J Genet Counsel (2009) 18:551–566 DOI 10.1007/s10897-009-9241-0

ORIGINAL RESEARCH

Genetic Counselors’ Religiosity & Spirituality: Are Genetic Counselors Different from the General Population? Ryan T. Cragun & Amelia R. Woltanski & Melanie F. Myers & Deborah L. Cragun

Received: 21 February 2009 / Accepted: 29 May 2009 / Published online: 3 October 2009 # National Society of Genetic Counselors, Inc. 2009

Abstract Although there is evidence that the religious beliefs of genetic counselors (GCs) can induce internal conflict in at least some genetic counseling scenarios, empirical research on the religiosity of GCs is limited. This study compares genetic counselors to a representative sample of the adult U.S. population on multiple religiosity measures. After controlling for several sociodemographic factors the percentage of GCs who report having a religious affiliation is similar to the general U.S., but GCs are less likely to affiliate with conservative Christian religions and are more likely to be Jewish. GCs are significantly less likely than the general U.S. population to: believe in god, attend religious services, pray, and believe in an afterlife even after controlling for relevant sociodemographic fac-

R. T. Cragun Department of Sociology, University of Tampa, Tampa, FL, USA A. R. Woltanski Sanford Children’s Specialty Clinic, Sanford Health, Sioux Falls, SD, USA M. F. Myers College of Allied Health Sciences, University of Cincinnati and Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA D. L. Cragun (*) Department of Biology, University of Tampa, 401 W. Kennedy Ave, Tampa, FL 33606, USA e-mail: [email protected]

tors. Despite the lower levels of religiosity, a majority of GCs do report themselves to be moderately to highly spiritual. We explore potential reasons for religiosity differences as well as possible implications in the context of the GC scope of practice. Keywords Genetic counseling . Religion . Belief . Spirituality . Religiosity . Spiritual

Introduction Religiosity and spirituality remain important to many Americans, particularly when dealing with stressful life events (Bjorck and Thurman 2007; Pargament 1997; Zinnbauer et al. 1997), as is often the case in genetic counseling scenarios. Religiosity and spirituality may also play a role in the decisions individuals make regarding genetic testing (Schwartz et al. 2000; White 2006). Given that religious beliefs influence moral and ethical worldviews, religious beliefs may contribute to ethical conflicts that can occur between the personal and professional values of genetic counselors (Bower et al. 2002; Pencarinha et al. 1992; Veach et al. 2001; Woltanski et al. 2009; Wyatt et al. 1996). Furthermore, there is the possibility that genetic counselors will project their values onto their clients/patients during a counseling session, as has been documented among mental health workers and therapists (Burke and Miranti 1992; Kelly 1994). Because of the potential influences religion may have on genetic counselors, their patients/clients, and the genetic counseling process, the religiosity and spirituality of genetic counselors warrants investigation. About 80% of Americans report a religious affiliation (Kosmin et al. 2001). This is higher than the percentage of

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genetic counselors who reported a religious affiliation in three different studies. In a survey assessing values of genetic counselors, Pirzadeh et al. (2007) found that approximately 73% of genetic counselors reported a religious affiliation and 7% did not respond. The remaining 19% were categorized as “other”, though it is unclear whether everyone in this category is unaffiliated or whether some belong to religious groups that were not specified as any of the options. A study on spirituality assessment practices of genetic counselors found that 68% of genetic counselors reported a religious affiliation, 24% reported no religious affiliation, and 7.5% did not respond to the question (Reis et al. 2007). A third study on abortion attitudes of genetic counselors found that 76% of genetic counseling respondents reported a religious affiliation, while 24% reported no affiliation (Woltanski et al. 2009). Thus, it appears genetic counselors may be slightly less likely to have a religious affiliation compared to the general public. Whether there are differences between genetic counselors and the general public on other measures of religiosity is not well established, although one study mentions a significant difference in terms of religious service attendance (Woltanski et al. 2009). Among the general U.S. population, 40% report they attend religious services at least weekly, although actual attendance rates are closer to 25% (Hadaway et al. 1998). Woltanski et al. (2009) noted that women from the general U.S. population with similar levels of education report significantly higher rates of religious service attendance compared to female genetic counselors. Other prior studies of genetic counselors have obtained additional measures of religiosity, but these measures are not directly comparable to data from the general U.S. population. Wyatt et al. (1996) found that 46% of genetic counselors identified themselves as “religiously active.” Pirzadeh et al. (2007) found that slightly more than half of genetic counselors reported “practicing a religion.” And Lega et al. (2005) found that 47% of genetic counseling students reported that they currently “practice a religion.” Unfortunately, what is meant by “practice a religion” and “religiously active” is not clear and the wording is different from questions that are commonly asked among the general U.S. population. Valid comparisons of genetic counselors’ religiosity to that of other groups should also control for key demographic differences that have been shown to influence religiosity. Genetic counselors are almost exclusively white and female, both of which influence religiosity: whites are less religious than blacks and Hispanics, while women are more religious than men (Hoffmann and Bartkowski 2008; Hunt and Hunt 2001). Genetic counselors are also disproportionately Jewish and less likely to live in the South. Those who identify with the Jewish religion tend to report lower levels of religiosity, as measured by multiple

Cragun et al.

variables such as belief in god, frequency of service attendance, and frequency of prayer (Lazar et al. 2002), while individuals who live in the South tend to report higher levels of religiosity (Chalfant and Heller 1991). Genetic counselors are relatively young compared to the U.S. population generally and they are more educated, both of which also influence religiosity. Younger people tend to be less religious (Stolzenberg et al. 1995), whereas education has mixed effects (Funk and Willits 1987; Johnson 1997; Lee 2002). Although closely related to religiosity, “spirituality” is a slightly different concept (Marler and Hadaway 2002). Zinnbauer et al. (1997) looked closely at how a convenience sample of individuals from various different churches and secular organizations distinguished between religiosity and spirituality. Using a forced choice question, they found that 93% of their respondents considered themselves spiritual, while only 78% considered themselves religious. The most common description of spirituality provided by their respondents pertained to a feeling of or experiencing connectedness. This is contrasted with the most common definition of religiousness or religiosity, which tended to include personal beliefs or faith related to organizational practices or activities. Reis et al. (2007) measured the spirituality of genetic counselors and found that 9.2% of genetic counselors reported being not at all spiritual (rating of 1 on a 5 point scaled item question), leaving 90.8% who reported being mildly to very strongly spiritual (rating of 2 to 5). This may suggest that genetic counselors are more similar to the general population in terms of spirituality than in terms of religiosity. However, differences in methodology and wording of the questions make adequate comparisons of these two studies difficult. Furthermore, based on their sampling methodology, data from Zinnbauer et al. are probably not representative of the U.S. population. Additionally, direct comparisons with genetic counselors, who are mostly female, are not possible because Zinnbauer et al. did not break their results down according to gender, although other research has found that females generally tend to be more spiritual than males (Hoffmann and Bartkowski 2008). Even though the studies mentioned above indicate some differences in genetic counselors’ religiosity, as compared to the general population, the details of how genetic counselors are different and possible reasons why they differ have not been thoroughly explored. Furthermore, the spiritual beliefs of genetic counselors have not been well characterized. The aims of the present paper are: 1) to further characterize the religious and spiritual beliefs of genetic counselors and 2) to examine how and possibly why genetic counselors appear to differ from the general public in terms of religiosity.

Genetic Counselors’ Religiosity

553

Methods

Data Analysis

Study Design and Participants

We generated descriptive statistics for responses from the demographic, religiosity, and spirituality questions. Bivariate analyses (chi-square or independent samples t-tests) were performed for all questions from the GSS comparing genetic counseling respondents with the sample of the general population. Differences in demographics between genetic counselors and the GSS general population samples were then controlled for using binomial logistic regression. Binomial logistic regression was used because these variables are all nominal/ordinal and they do not meet the assumptions of ordinary least squares regression. To perform the regressions, we used a dummy code for whether or not an individual is a genetic counselor. In addition, all of the multiple response variables were recoded into two categories: affiliation was re-coded into (1) affiliate or (0) non-affiliate; belief in god was re-coded as (1) know god exists or (0) not sure, higher power, or don’t believe/know; religious attendance was re-coded as (1) frequent attender (once a month or more) or (0) infrequent attender (several times a year or less); frequency of prayer was re-coded as (1) frequent prayer (once a week or more) or (0) infrequent prayer (less than once a week); belief in afterlife was already dichotomized as (1) yes and (0) no.

Primary data were collected through an online survey of genetic counselors in the fall of 2006. For further details on the survey methods and the respondents, see Woltanski et al. (2009). The secondary data used by Woltanski et al. for comparison with genetic counseling respondents differ from that used in the present study. Woltanski et al. compared genetic counselors to a matched sample of the general public: women with Master’s degrees or higher levels of education from the 1998–2004 waves of the General Social Survey (GSS).1 In this study, we use only the 2006 wave of the GSS (data that were unavailable when the original research was conducted by Woltanski et al.). Unlike Woltanski et al. (2009), we include both male (n=26) and female (n=654) genetic counselors2 in our comparison with a representative sample of the adult population in the U.S., as reflected in the 2006 wave of the GSS, (n=4,510). Instrumentation The questionnaire was divided into three sections. The first section assessed basic demographic information and additional questions that correspond with many found on the 2006 National Society of Genetic Counselors Professional Status Survey (PSS). The second section of the survey contained questions about religious beliefs taken directly from the GSS addressing basic information about participants’ religious affiliation, belief in god (or higher power), frequency of attendance at religious services, frequency of prayer, and belief in life after death. The second section also contained two separate questions asking genetic counselors to rate their overall religiosity and spirituality on a 10 point scale, with 1 being not at all religious/spiritual and 10 being very religious/spiritual. Lastly, section two included multiple questions designed to measure two hypothesized dimensions of secularism. These responses will be used in a different study to validate the questions as part of a secularism scale. However, they do help paint a more specific picture of the beliefs of genetic counselors; therefore many of them are included in the descriptive analysis portion of this study. Data from the third section on abortion attitudes were reported by Woltanski et al. (2009) and are not included as part of this study.

1 More information about the GSS can be found at http://www.norc. org/GSS+Website/ 2 Our sample size of female genetic counselors is larger than the sample from Woltanski et al because we include the 26 genetic counselors who answered the religion questions but not the abortion questions.

Results Religiosity Measures of Genetic Counselors and General U.S. Population Results of descriptive statistics and bivariate analyses are presented in Tables 1 and 2. Table 1 includes religious affiliation, belief in god, religious attendance, frequency of prayer, belief in an afterlife, sex, race (dummy coded as white vs. other), and a dummy code for region (south vs. non-south).3 When genetic counselors are compared to the general U.S. population sample from the GSS, there are statistically significant differences on all the variables (p< 0.001). Genetic counselors are significantly more likely to report having no religious affiliation, significantly less likely to believe in an afterlife, and significantly more likely to be agnostic and atheist when compared to the U.S. population sample. Among genetic counselors, ~7% report no belief in god (i.e. atheist) and 11–12% report that they “don’t know” (i.e. agnostic). In contrast, the same question revealed that ~2% of the general U.S. population holds 3 South includes the following states: Delaware, Maryland, West Virginia, Virginia, North Carolina, South Carolina, Georgia, Florida, District of Columbia, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Oklahoma, Louisiana, and Texas.

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Cragun et al.

Table 1 Descriptives and Chi-square Tests of Demographic and Religious Variables for the General Population and Genetic Counselors variable

general population

genetic counselors

n

n

Religious Affiliation Protestant Catholic Jewish None

4,484 2,328 1,114 78 739

Other Belief in God don’t believe don’t know higher power believe sometimes doubt know god exist Religious Attendance Never Less than once a year Once or twice a year Several times a year About once a month 2-3 times a month Nearly every week Every week Several times a week

225 2,966 66 129 294 128 473 1,876 4,491 1,020 302 571 502 308 380 240 839 329

Frequency of Prayer Several times a day Once a day Several times a week Once a week Less than once a week Never Belief in an Afterlife No Yes Sex Male Female Race (white vs. other) White Other Region (south vs. other) South

2,971 926 863 332 192 342 316 2,629 452 2,177 4,510 2,003 2,507 4,510 1,226 3,284 4,510 2,765

not-South

1,745

(%)

(51.9) (24.8) (1.7) (16.5) (5.0) (2.2) (4.3) (9.9) (4.3) (15.9) (63.3) (22.7) (6.7) (12.7) (11.1) (6.8) (8.4) (5.3) (18.6) (7.3)

680 286 136 68 161 29 678 49 77 105 50 147 250 681 93 (89) 111 128 34 60 65 91 10

(38.6) (61.3)

172

(17.2) (82.8) (44.4) (55.5) (72.8) (27.1)

df

p-value

177.79

4

<0.001

194.39

5

<0.001

149.10

8

<0.001

318.82

5

<0.001

68.89

1

<0.001

408.85

1

<0.001

119.94

1

<0.001

31.23

1

<0.001

(%)

678 73 85 130 60 162 168 656 208 448 679 26 654 681 53 628 656 460

(31.1) (29.0) (11.1) (6.4) (11.5) (10.6)

Chi-Square

(42.1) (20.0) (10.0) (23.7) (4.3) (7.2) (11.4) (15.5) (7.4) (21.7) (36.9) (13.6) (13.0) (16.3) (18.8) (4.9) (8.8) (9.5) (13.3) (1.4) (10.7) (12.5) (19.1) (8.8) (23.8) (24.7) (31.7) (68.3) (3.6) (96.3) (92.2) (7.7) (27.2) (72.7)

a

Sample sizes (n) for the GSS vary substantially because not all respondents were asked all of the questions. Sample sizes for GCs vary because some GCs did not answer certain questions.

b

Chi-Square analyses compare responses of GCs to the GSS general population sample using two categories formed by collapsing response options.

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Table 2 Comparison of Means for the General U.S. Population and Genetic Counselors on Age and Education

General adult pop.

GCs v. adult pop.

n

mean

sd

n

mean

sd

t

4510 4499

47.35 13.29

17.18 3.23

676 679

36.18 18.06

9.15 0.40

16.59 −38.48

atheistic beliefs and 4% to 5% are agnostics. Genetic counselors also attend religious services and pray significantly less often than the general population sample. Not surprisingly, genetic counselors are more disproportionately white and female. Finally, genetic counselors are less likely to live in the Southern U.S. than the general U.S. population. Table 2 presents the means and comparison of means t-tests for two interval/ratio variables: age and educational attainment. Genetic counselors are significantly younger, yet they are substantially more educated on average than the representative sample from the U.S. population (18+ years vs. 13+ years of education). Figure 1 illustrates frequency of prayer for genetic counselors and the general population sample. Genetic counselors clearly report praying less frequently than the general population. Responses are not normally distributed in either group. The distribution is skewed for the GSS general population sample with a trend toward bimodality, while the distribution for genetic counselors is clearly bimodal. Also of note is the fact that the skew among the general population is in the opposite direction of the peaks of the genetic counselors. Figure 2 shows frequency of attendance at religious services for genetic counselors and the general U.S. sample. Again, responses are not normally distributed. Figure 2 shows bimodality/multimodality for both groups. Parametric and non-parametric tests indicate significant differences in frequency of attendance between genetic counseling respondents and the general population (results not shown). Table 3 presents a breakdown of the self-reported religious affiliations of genetic counselors alongside those of the general adult population in the U.S., as reported in the ARIS 2001 and Pew 2008 studies4. Almost ¼ of genetic counselors report no religious affiliation. There are also slightly fewer Roman Catholic genetic counselors than one would expect given their representation in the general public. Jews make up a much larger percentage of the genetic counseling population than the general population (six to eight times as large). Mainline Protestants are also

p-value <.001 <.001

over-represented among genetic counselors while conservative Protestants are substantially under-represented. Based on the above findings, we can assert with confidence that genetic counselors are significantly different from the general population in their frequency of religious service attendance, frequency of prayer, belief in an afterlife, belief in god, and probability of reporting a religious affiliation. On all measures, genetic counselors exhibit lower levels of religiosity. However, genetic counselors are also significantly different with respect to demographic characteristics that are known to influence religiosity. To determine whether demographic differences account for the religiosity differences, we performed five binomial logistic regressions. Table 4 presents the results of the five regressions. The first regression of religious affiliation on the genetic counseling dummy code and the demographic control variables illustrates the utility of the regressions. Without controlling for demographic differences, genetic counselors are significantly different in their probability of having a religious affiliation. But once age, sex, race, education, and living in the South are controlled, the odds of having a religious affiliation are not significantly different (p=0.107). However, in all of the other regressions, the genetic counseling dummy code is statistically significant and in a direction that indicates lower levels of religiosity. Thus, even after controlling for age, sex, race, level of educational attainment, the disproportionate number of Jews among genetic counselors, and the lower likelihood of living in the 35

Percentage of Individuals in Each Response Category

Age Education

GCs

30 25 20 15 10 5 0

4

These two surveys are used for comparison here because they report more detailed information about religious affiliation then the GSS. Additional information about these studies can be found at http:// religions.pewforum.org/affiliations and http://www.gc.cuny.edu/faculty/ research_briefs/aris.pdf

Several times Once a day Several times Once a week Less than once a week a day a week

adult pop. (GSS 2006)

Never

GCs

Fig. 1 Frequency of Prayer Among Genetic Counselors and General U.S. Population.

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Cragun et al.

Percentage of Individuals in Each Response Category

25

20

15

10

5

0 Never

Less than once About once or Several times a year twice a year a year

About once a month

2-3 times a month

adult pop. (GSS 2006)

Nearly every week

Every week

Several times a week

GCs

Fig. 2 Religious Attendance Among Genetic Counselors and General U.S. Population.

South, genetic counselors are still significantly less likely to believe in god (OR=0.540), significantly less likely to frequently attend religious services (OR=0.690), significantly less likely to pray frequently (OR=0.297), and significantly less likely to believe in immortality (OR=0.314). Snapshot of Religiosity and Spirituality of Genetic Counselors Figure 3 presents the responses of genetic counselors on two 10-point scale measures of self-rated religiosity and spirituality. Religiosity, unlike spirituality, is bi-modal among genetic counselors. In fact, while the mean is 6.65, the most frequently reported rating on the 10-point religiosity scale is 1, indicating “not at all religious” (n= 125), followed by 8 (n = 106). Approximately equal percentages of genetic counselors fall into each half of the religiosity scale. Spirituality on the other hand, is not bimodal. In this case, the mean (8.16) is a useful representation of the scores on the spirituality scale as it is close to being normally distributed. About 64% of genetic counselors report moderate to high levels of spirituality (based on a score of 6 or higher on the 10 point scale). The two figures in Appendix A and B provide additional information on the religious and spiritual views of genetic counselors based on other, more specific, scale item questions.

Discussion Religiosity of Genetic Counselors Our findings that genetic counselors are less religious than the general public on all of the widely used measures of

religiosity including, frequency of prayer, frequency of religious service attendance, belief in god, and belief in an afterlife, were not simply due to differences in demographic variables. Although genetic counselors differ from the general adult U.S. population in that they are significantly younger, substantially more likely to be women, more likely to be white, have higher levels of education, and have an under-representation of people living in the South, after controlling for these demographic variables all of the religiosity differences remain significant with the exception of religious affiliation. However, as Table 3 illustrates, the types of religions to which genetic counselors are affiliated are very different from the general population. Possible explanations for the lower levels of religiosity include: (1) there is something about the profession of genetic counseling that influences the religiosity of genetic counselors, (2) highly religious individuals are more likely to drop out of the profession, or (3) religious differences already exist between those who enter the profession and the general population. The first explanation mentioned above is theoretically consistent with an early theory in the sociology of religion. Berger (1967) suggested that increased exposure to alternative worldviews has the effect of secularizing individuals. Berger argued that exposure to alternative worldviews leads to questioning one’s own worldview. If someone you encounter really believes what he/she claims and you really believe what you claim, how do you know who is right? Berger argued that people who recognize this epistemological dilemma often resolve it by becoming more ecumenical or accepting of other people’s worldviews. Berger’s idea has been criticized by some scholars who suggest that lack of exposure to alternative worldviews due to people’s generally closed social networks prevents this from occurring (Putnam 2001) or that pluralism may in fact have the

Genetic Counselors’ Religiosity Table 3 Religious Affiliations of Genetic Counselors and the General U.S. Population

a

These columns do not sum to 100 because these surveys report additional religious groups that are not found among the GC population. See the respective reports for the missing groups: http://religions.pewforum.org/ affiliations and http://www. gc.cuny.edu/faculty/research_ briefs/aris.pdf b

Percentages for these broad religious categories consist of the total sum of the specific denominations listed in the indented rows below each. Also, other Christian, non-denominational, and unspecified Protestants are often grouped with conservative Protestants. That is what the Pew study did, which is why the Pew study is missing a value for that broad category and also explains why the numbers from the Pew study are higher for conservative protestants.

557 Specific religious group

% GCs

No religious affiliation Roman Catholic

23.2 20.1

14.1 24.5

16.1 23.9

Jewish b Mainline Protestant Presbyterian (unspecified, PCUSA, PCA) Methodist (United and unspecified), Wesleyan Lutheran (unspecified, ECLA, Missouri Synod) Episcopalian, Anglican United Church of Christ Disciples of Christ Congregational Quaker Dutch Christian Reformed, Reformed Christian Mennonite b Conservative Protestant Baptist (unspecified) Assemblies of God b Other Christian, Non-Denominational, and Unspecified Protestants Unspecified Protestant Non-Denominational Unspecified Christian (includes “evangelical” and “fundamentalist”) Orthodox (Eastern, Greek, etc.) Unitarian, Unitarian Universalist LDS, Mormon

10.0 26.3 6.9 6.8 5.6 4.1 1.3 0.4 0.3 0.3 0.3 0.3 2.6 2.5 0.1 10.9

1.3 17.7 2.7 6.8 4.6 1.7 1.2 <.1 0.7 <.1 <.1 <.1 16.8 16.3 0.5 10.2

1.7 18.1

5.9 3.2 1.8

2.2 1.2 6.8

0.6 2.5 0.1

<.1 0.3 1.3

0.1 1.0 0.1 0.4 0.6 0.7 0.3 0.1 0.1 681

<.1 0.4 <.1 <.1 0.5 0.5 <.1 <.1 2.3 50,281

Wiccan Hindu, Vedanta, Sikh Taoist Spiritual Muslim Buddhist Baha’i Unclear No response Total N

opposite effect and increase religiosity (Stark and Finke 2000). Genetic counseling is a profession where exposure to alternative worldviews is not uncommon, allowing for an informal test of Berger’s hypothesis. Genetic counselors find themselves empathizing with people whose beliefs and values may be substantially different from their own. Additionally, genetic counselors are trained to approach such situations with an open-mind, as the goal of the practice is often to help people through challenging situations by drawing upon whatever cultural resources the patients/ clients have. Considering genetic counselors are less religious than the adult population of the U.S., even after

% General pop. ARIS 2001a

% General pop. Pew 2008a

33.2

–

0.6 1.7 0.4

0.6 0.7

0.8 35,556

controlling for demographic differences, it would seem as though genetic counselors might support Berger’s hypothesis. However, to test this ad hoc hypothesis we regressed each of the dichotomized religiosity variables on an additional variable in our data set — time since degree — while controlling for age (results not shown). Age was a significant predictor in all of the regressions, but time since degree was only a significant positive predictor for religious affiliation: people who have been genetic counselors for a longer period of time are slightly more likely to have a religious affiliation, but otherwise they are no different from other genetic counselors with regard to other religiosity variables. This would seem to suggest that

1.875 2.003

logodds 0.297 1.016 2.997 0.589 0.971 0.377 1.857 1.801

0.629 0.695

Prayer (n=3,582) b −1.216

0.016 1.098

−0.530 −0.030 −0.976 0.619 0.588 (.47, .73) (.94, 1.00) (.25, .56) (1.55, 2.21)

(1.01, 1.02) (2.50, 3.59)

95% CI (.23, .38)

(1.58, 2.21)

(1.01, 1.03) (1.45, 1.99) (.52, .77) (.95, 1.00)

<.001 *** .053 * <.001 *** <.001 *** .021 * 3703.548 0.120 0.175

<.001 *** <.001 ***

p-value <.001 ***

0.045 0.075

<.001 *** .002 ** 4477.086

<.001 *** <.001 *** <.001 *** .095

1.177 1.041 0.368 1.502 2.866

0.990 1.538

−0.010 0.430 0.163 0.041 −0.999 0.407 1.053

logodds 0.314

1.008 2.249 0.532 0.896 0.371 2.051 4.284

0.540

logodds

Afterlife (n=3,222) b −1.159

0.008 0.811 −0.630 −0.109 −0.991 0.719 1.455

−0.615

1.024 1.704 0.635 0.978

.107

0.024 0.533 −0.453 −0.023

(.63, 1.04)

0.813

−0.207

* p<.05; ** p<.01; *** p<.001

White (=1) Education Jewish (=1) South (=1) Constant -2 Log Likelihood Cox & Snell R2 Nagelkerke R2

Genetic counselor (=1) Age Female (=1)

Genetic counselor (=1) Age Female (=1) White (=1) Education Jewish (=1) South (=1) Constant -2 Log Likelihood Cox & Snell R2 Nagelkerke R2

b

p-value

logodds

b

95% CI

God (n=3,577)

Affiliation (n=5,102)

Table 4 Results of Logistic Regression for Each of the Religiosity Variables

(.93, 1.47) (1.01, 1.07) (.23, .56) (1.23, 1.82)

(.98, .99) (1.25, 1.87)

95% CI (.23, .41)

(1.00, 1.01) (1.92, 2.63) (.44, .64) (.87, .92) (.23, .57) (1.75, 2.39)

(.427, .684)

95% CI

.157 .013 ** <.001 *** <.001 *** <.001 *** 3075.709 0.039 0.062

<.001 *** <.001 ***

p-value <.001 ***

0.136 0.183

.001 *** <.001 *** <.001 *** <.001 *** <.001 *** <.001 *** <.001 *** 4329.192

<.001 ***

p-value

0.016 0.407 −0.536 0.055 −1.137 0.498 −1.615

−0.371

b

1.016 1.503 0.585 1.056 0.321 1.645 0.199

0.690

logodds

(1.01, 1.02) (1.33, 1.69) (.50, .67) (1.03, 1.07) (.21, .48) (1.46, 1.85)

(.56, .85)

95% CI

Attendance (n=5,094)

0.055 0.074

<.001 *** <.001 *** <.001 *** <.001 *** <.001 *** <.001 *** <.001 *** 6733.274

<.001 ***

p-value

558 Cragun et al.

Genetic Counselors’ Religiosity

559

Percentage of Counselors in Each Response Category

25

20

15

10

5

0 1

2

3

4

5

6

7

8

9

10

10 Point Scale spirituality

religiosity

Fig. 3 Genetic Counselor’s Self-rated Spirituality and Religiosity.

Berger’s hypothesis does not provide an explanation for our results and exposure to alternative worldviews during training and genetic counseling sessions does not appear to make genetic counselors less religious. The second possibility, highly religious genetic counselors drop out of the discipline, is also not supported by the available evidence. The regressions described in the previous paragraph illustrate that there is not a higher or lower number of highly religious genetic counselors relative to their length of time in the profession. This leaves the third hypothesis; Individuals who pursue careers as genetic counselors are less religious than individuals from the general population. Our findings appear to support this hypothesis as do the observations in three separate studies, which found that the number of genetic counseling students who “practice a religion” is very similar to the percentage of genetic counselors who reported “practicing a religion” and was almost identical to the percent of genetic counselors who reported “being religiously active” (Lega et al. 2005; Pirzadeh et al. 2007; Wyatt et al. 1996). Although religiosity does not appear to differ between genetic counselors and students who are entering the profession, what is not known at this point is whether individuals self-select into the genetic counseling profession or whether there is bias against highly religious individuals by genetic counseling program administrators who select applicants. Woltanski et al. (2009) suggested that as people become acquainted with what it is genetic counselors do, it may be the case that the job requirements discourage some from pursuing a career as a genetic counselor. In particular, religious conservatives, who tend to be the strongest opponents of abortion (Emerson and Hartman 2006; Hunsberger et al. 1996), are unlikely to want to pursue a career in which they will be required to present abortion as an option in cases where a fetus is found to have a genetic condition. Anecdotally, one of the authors remembers being questioned during one of her graduate school interviews about her involvement in a religiously

affiliated adoption helpline and whether or not she agreed with some of their policies that limited discussion of abortion. While we found no substantial evidence that program administrators actively screen out highly religious individuals or individuals belonging to conservative religions, it could potentially be a contributing factor that warrants further investigation. Genetic counseling is not the only profession where levels of religiosity have been found to be lower among individuals in the profession compared to the general U.S. population. A survey of 489 randomly selected clinician members of the American Psychological Association found that, when compared to Gallup poll data from the general U.S. public, clinical psychologists are significantly less likely to be religious on a number of variables including: religious affiliation, religious service attendance, and belief in god (Delaney et al. 2007). Although it should be noted that the researchers did not control for demographic differences, a number of these reported differences were substantial; for instance, 25% of the psychologist respondents indicated that they either do not believe in god or don’t know if there is a god. The religiosity of physicians was explored in a survey using a stratified sample of 2,000 practicing U.S. physicians (Curlin et al. 2005). In this study, notable similarities and differences were reported between physician responses and GSS population data. When compared to the general U.S. population, physicians were equally likely to have a religious affiliation, but more likely to belong to a religion that is less common in the U.S. Although these are very similar to our findings, it should be noted that Curlin et al. (2005) did not control for demographic differences between the general population and physicians. In contrast to what we found with genetic counselors, Curlin et al. (2005) found that physicians are more likely than the general population to attend religious services regularly. Physicians were less likely than the general population to apply their religious beliefs to other aspects of their lives, to rely on god when making decisions, or as a means of coping. Physicians were also less likely than the general U.S. population to report having a belief in god, but the difference was not statistically significant. Physicians were significantly less likely to believe in an afterlife compared to the general population. Unlike in our study of genetic counselors, where we found no evidence that religiosity differed according to area of practice, such as prenatal counselors versus cancer counselors (data not shown), there is evidence that levels of religiosity may differ by physician specialty. Pediatricians and general practitioners tend to be very similar in religiosity to the general population and they are more religious than physicians in other subspecialties, whereas psychiatrists have consistently been found to be significantly less religious than other physicians (Curlin et al. 2005; Curlin et al. 2007).

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Spirituality of Genetic Counselors Similar to trends seen in other studies (Zinnbauer et al. 1997), genetic counselors are more likely to report being spiritual than they are to report being religious. The 10 point scale we used in the present study allows for finer discrimination, but also means our data do not directly compare with data from Reis et al. (2007). Nevertheless, examination of the data reveal that 9.8% of genetic counselors in our study report a low level of spirituality (1–2 on a 10 point scale), which is similar to the 9.2% of genetic counselors who reported being not at all spiritual (1 on a 5 point scale) in the study by Reis et al. The main differences between the studies occur at the other end of the scale; 14.8% of genetic counselors in our study reported a high level of spirituality (9–10 on a 10 point scale), compared to only 9.2% reporting “very high levels of spirituality” (5 on a 5 point scale) in the study by Reis et al. We suspect differences in wording may help explain some of the difference in spirituality ratings. Study Limitations Studies that focus on religiosity and spirituality (spirituality in particular) are often limited due to the varied ways people interpret these terms (Zinnbauer et al. 1997). A major strength of our study was that we were able to capture a number of specific dimensions of religiosity and directly compare our data with that obtained from a representative sample of the general U.S. population. However, we could not identify a representative sample of the general U.S. population to which our genetic counseling data on spirituality could be validly compared. Additionally, spirituality is much more difficult to measure or even define. During the data collection portion of this study we had a handful of genetic counselors email us asking what we understood by “spirituality.” Our response was always the same, “Whatever you interpret spirituality to mean.” We purposely did not define the term spirituality or religiosity with regard to the two single item rating questions for the following reasons: 1) we wanted to avoid bias toward any particular religious traditions, and 2) we wanted to determine which of the additional scale item questions correlated with how people rate themselves on the general single item 10 point spirituality and religiosity scales. While it is true that people have very different understandings of spirituality, Zinnbauer et al. (1997) did find that there are some common meanings associated with the term. Spirituality generally refers to feeling or experiencing connectedness or personal beliefs regarding a higher power. While we did not provide these definitions for the single item spirituality scale, variations in definitions were implied to some extent in the additional questions that are included

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in the appendix. Even so, the lack of clarity in defining terminology is a limitation of this study as it is with other studies that explore religiosity and spirituality. An additional limitation is present in both our data and the secondary data we used for comparison. Religious activities, such as church attendance and frequency of prayer, were not measured directly, but were self-reported. Although self-reported data reflect actual behaviors to some extent, such responses have been found to be inflated (Hadaway et al. 1998). Implications for Clinical Practice and Future Research Whether or not genetic counselors’ religious and spiritual beliefs influence genetic counseling practice was not directly addressed in this study, but merits discussion. Based on our results, we can only speculate about the possible impact that lower levels of religiosity among genetic counselors could have on counseling sessions. Secular people tend to be more tolerant and less prejudiced than moderately and highly religious people (Allport 1966; Allport and Ross 1967). Secular people are generally more accepting than religious people of: various different religious groups (with the exception of religious fundamentalists), alternative sexualities, different political views, and other racial and cultural backgrounds (Bolce and De Maio 1999; Hunsberger 2006). Secular individuals also tend to be less authoritarian in their outlooks (Altemeyer 2003; Duck and Hunsberger 1999; Hunsberger 2006; Hunsberger et al. 1996). Highly authoritarian individuals generally do not value autonomy (Duck and Hunsberger 1999). Thus, a lower level of religiosity among genetic counselors is more likely to bode well for client/patient autonomy and tolerance for various worldviews. Coupled with the training genetic counselors receive to develop cultural competencies, it is likely that genetic counselors exhibit high levels of tolerance and cultural sensitivity in counseling sessions. However, observational studies would be required to verify that these training practices are actually translated into routine practice. There have been a couple of studies where religiosity or spirituality measures were compared with self-reported behavior of genetic counselors. One study, published only as an abstract, examined the influence of genetic counselors’ religious views on their counseling practice (Wyatt et al. 1996). As part of this study, genetic counselors completed a seven page survey containing questions that explored the effect of their personal religious convictions on what was presented or discussed in their counseling sessions. Although 95% felt that their personal beliefs did not affect their ability to remain “nondirective” within the counseling session, 64% of counselors felt there were situations that conflicted with their religious convictions. Despite these conflicts, only a few differences were reported

Genetic Counselors’ Religiosity

between religious and non-religious respondents in this study. The 5% of counselors who indicated their religion influences their practice were more likely to report that they mention adoption as an option for a lethal disorder. Nonreligious respondents were more likely than religious respondents to mention adoption as an option when the diagnosis of a non-lethal birth defect is made; they were also more likely to make a referral to a religious leader. Respondents who identified themselves as religious reported a greater level of comfort praying with a patient. Because these were the only differences between religious and nonreligious counselors, the study concluded that genetic counselors “maintain the standards of professional practice against the backdrop of a wide diversity of personal religious beliefs and practices” (Wyatt et al. 1996). This conclusion is also supported by findings from the study by Reis et al. (2007), that neither religious affiliation nor self-rated spirituality influenced whether genetic counselors reported performing spirituality assessments during counseling. Caution should be used when interpreting the findings of the above studies because self-reported and actual behaviors are not always congruent. Furthermore, genetic counselors are increasingly recognizing that being neutral with regard to values and remaining “nondirective” is not realistic (Bartels et al. 1997; Pirzadeh et al. 2007; Veach et al. 2001; Weil et al. 2006) Some studies appear to indicate that religious and spiritual beliefs do impact the practice of genetic counselors and other healthcare practitioners. Salamone (2002) found that genetic counselors who were themselves less religious or spiritual were less comfortable with topics related to these issues. The literature on physicians has found that those who are not spiritual or religious are less likely to engage in conversations on religious and spiritual issues and less likely to report that patients bring up these topics (Curlin et al. 2007). It is notable that psychiatrists appear to be an exception to this generalization; despite being less religious than other physicians, psychiatrists are more likely to report encountering, asking about, and addressing religiosity/spirituality issues (Curlin et al. 2007). Spirituality may be extremely important to some patients/ clients and may even contribute to their satisfaction with healthcare. For example, having their spiritual needs met was positively correlated with increased satisfaction with care among patients surveyed in an oncology clinic (Astrow et al. 2007). Unfortunately, the question asked in this study did not allow the researchers to determine how the patients’ spiritual needs were being met, specifically whether or not these needs were being met by healthcare practitioners. This brings us to a final, but important consideration: To what extent should genetic counselors be involved in discussing religiosity/spirituality and should they help identify and/or actively participate in religious/spiritual interventions (i.e. prayer, contemplation/ meditation, reading sacred

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writings, forgiveness, repentance, and participation in worship services or rituals)? Answers to these questions are not straightforward and dissenting views are likely, but exploration of these questions may benefit from the following critical analysis of the available evidence and how it relates to the Genetic Counseling (GC) Scope of Practice that was approved by the National Society of Genetic Counselors in 2007. Although the patient/client population seen for genetic counseling may not be representative of the general adult U.S. population, our findings suggest that there is a good chance that the genetic counselor is less religious than many of his/her patients/clients. Even if a genetic counselor were to share many of the same religious and/or spiritual beliefs as their patient/client, most individuals lack significant knowledge about their own religion (Kosa and Schommer 1961). Thus the following statement from the GC scope of practice is particularly relevant: “Recognize personal limitations in knowledge and/or capabilities and seek consultation or appropriately refer clients to other providers.” Recognizing one’s limitations does not mean that spiritual/religious issues should be ignored. Indeed, the idea that performing a spirituality assessment is appropriate is largely accepted by a majority of genetic counselors (Reis et al. 2007; Salamone 2002) and such an assessment appears to be in line with other responsibilities laid out in the GC scope of practice. Those responsibilities particularly relevant to our discussion are listed below: “Identify individual client and family experiences, behaviors, emotions, perceptions, values, and cultural and religious beliefs in order to facilitate individualized decision making and coping.” “Promote client-specific decision making in an unbiased non-coercive manner that respects the client’s culture, language, traditions, lifestyle, religious beliefs and values.” “Identify the client’s psychological needs, stressors and sources of emotional and psychological support in order to determine appropriate interventions and/or referrals.” “Use knowledge of psychological structure to apply client-centered techniques and family systems theory to facilitate adjustment to the occurrence or risk of occurrence of a congenital or genetic disorder.” Although a spirituality assessment may appear to be a benign extension of a psychosocial assessment, making the assumption that one should perform a religiosity/spirituality assessment suggests a pro-religiosity or pro-spirituality bias (Sloan 2008). Furthermore, devoting a disproportionate

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amount of time or larger number of questions to religiosity and spirituality, as opposed to other beliefs, traditions, values, influences, and/or activities that could have an impact on decision making and coping, may be interpreted by patients/clients to mean religious/spiritual issues should play a more prominent role in their decision making and/or coping (Sloan 2008). Even without performing a spirituality/religiosity assessment, these issues can be discovered during broader discussions. Religious and spiritual issues may surface while exploring a variety of both positive and negative emotions, including: peace, purpose, guilt, sadness, etc. Religious/spiritual topics may also arise when helping patients/clients identify social support networks, and/or potential coping mechanisms. Based on the aforementioned responsibilities laid out in the scope of practice, genetic counselors should help patients/clients identify the support networks, coping strategies, and factors that are most important and helpful to the individual patient/client. These may or may not be related to the particular religious or spiritual views of the individual. Although genetic counselors do not need to complete a spirituality assessment to fulfill the responsibilities laid out in the GC scope of practice, it is clear that genetic counselors should not ignore religious/spiritual issues. Religion is a component of culture and, as such, training regarding various religious/spiritual beliefs should be included in the curriculum of genetic counseling programs, as part of an effort to promote competency in multicultural counseling (Lewis 2002). Regardless of their own personal beliefs and practices, genetic counselors should be able to empathize in ways that are sensitive to the religious/ spiritual or nonreligious/nonspiritual worldviews of each individual patient/client. The extent to which religious/spiritual needs can or should be addressed in the genetic counseling session remains ambiguous. Part of this ambiguity may be attributed to a lack of knowledge regarding what is meant by spiritual needs. One study identified the following spiritual/existential needs among cancer patients: relaxation, meet similar patients, help with sadness, help to share feelings, help with family worries, finding meaning in life, finding hope, overcoming fears, talking about meaning of life, discussing dying and death, and finding peace of mind (Moadel et al. 1999). Based on this list, many genetic counselors are probably already assisting patients/clients in meeting their spiritual needs even if the counselors do not consider these needs to be part of a spiritual framework. The only data we found regarding the extent to which patients/clients desire religious/spiritual needs to be addressed in genetic counseling sessions have been published in abstract form only (Fick 2006). In this study, which took place in a large academic hospital in the

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Midwest, the percentage of patients who perceived spirituality to be relevant to a genetics session was 22.5%. More detailed information regarding this question is available in the context of other healthcare settings. Critical analyses of the handful of published studies addressing what patients want suggest that the majority (50–75%) have the desire for their physician to be aware of and/or discuss religious/spiritual matters, yet the demand tends to be overstated and is dependent on how the questions are worded (Sloan 2008). In a study, involving 1,033 randomly selected participants from the Southern U.S., just over 2/3 indicated they would want to discuss religious and spiritual matters with regard to serious illness/injury, but most reported their number one preference would be to speak with religious leaders and only 3% preferred to hold this type of discussion with a physician as opposed to a religious leader or other (Mansfield et al. 2002). Furthermore, time in clinic is often limited and a study that took this into account when asking about preferences found that only 10% of respondents would want their physician to discuss spiritual issues if it meant less time would be spent discussing medical issues (MacLean et al. 2003). Supposing these findings can be generalized to genetic counseling, they would support the idea that, when religious/ spiritual issues arise, genetic counselors should generally defer to individuals who are specifically trained to deal with these issues (i.e. chaplains, priests, pastors, rabbis, mullahs, etc.). Making such a referral would fulfill obligations laid out in the GC scope of practice while still helping the patients/ clients meet their spiritual/religious needs. Directly helping clients meet their spiritual needs through more in-depth discussion of religious/spiritual issues and/or aiding the client in the identification and perhaps even the implementation of religious/spiritual interventions, such as prayer, contemplation and meditation, reading sacred writings, forgiveness and repentance, or participation in worship services or rituals, would also fulfill the same obligations outlined in the GC scope of practice. It is not known whether exploring religious/spiritual beliefs during genetic counseling is beneficial or detrimental to patients/clients. Nor can we suggest whether a religious or secular genetic counselor might be better at exploring such issues since the religiosity/spirituality of the genetic counselor could interact with the religiosity/spirituality of the patient/ client. Thus, before any recommendations can be made, further research should be done to determine the impact of incorporating religious/spiritual counseling interventions into genetic counseling. Acknowledgements We wish to thank all the genetic counselors who took the time to participate in this survey. We also owe a debt of gratitude to David J. Maume and the Kunz Center in the Department of Sociology at the University of Cincinnati for hosting the survey and providing technical support.

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Appendix A. Genetic Counselors’ Views on Religion

0%

10%

20%

30%

40%

50%

41%

25%

There is a god.

18%

7% 9%

13%

When making important decisions in my

27%

life,

20% 19% 21%

I rely on the teachings of my religion

strongly agree agree

31% 27%

When considering death,

neutral

14% 14% 14%

I take comfort in my religious beliefs.

strongly disagree disagree

9%

I believe religion holds the answers to

18%

solving

22% 25% 26%

many of the world's problems.

19% 19%

Going to religious services is

14%

an important part of my life.

29% 20%

15% 28%

Science is a better way of arriving at truth than is religion.*

42% 2% 13% 6% 16%

Organized religion is more of a

25%

hindrance to humanity than a help.*

15%

37% 7% Religion provides for ultimate truth.

11% 28% 28% 27% % of Genetic Counselors in Each Likert-Scale Response Category

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Appendix B. Genetic Counselors’ Views on Spirituality

0%

10%

20%

30%

40%

50%

60%

37% 33%

I believe there is a higher power

15%

that influences our lives.

7% 8% 30%

47%

I feel a spiritual connection to the world around me.

Humans do NOT have a spiritual side.*

16% 5% 3% 1% 1% 5% 42%

51% 24%

49%

There is truth in many religions.

19% 6%

3% strongly agree

18%

38%

We are all part of a higher power.

28%

neutral

10%

7%

disagree

6% I am NOT on a spiritual journey.*

agree

strongly disagree

14% 26% 31%

24% % of Genetic Counselors in Each Likert-Scale Response Category

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