J Genet Counsel DOI 10.1007/s10897-008-9177-9

ORIGINAL RESEARCH

Views on Abortion: A Comparison of Female Genetic Counselors and Women from the General Population Amelia R. Woltanski & Ryan T. Cragun & Melanie F. Myers & Deborah L. Cragun

Received: 28 March 2008 / Accepted: 20 June 2008 # National Society of Genetic Counselors, Inc. 2008

Abstract While literature characterizing individual genetic counselors’ abortion attitudes is sparse, the National Society of Genetic Counselors takes a clear stance for reproductive autonomy. To determine genetic counselors’ views, this study compared (1) genetic counselors’ abortion attitudes to those of women from the general population and (2) genetic counselors’ professional abortion attitudes to their personal abortion attitudes. Genetic counselors were invited to complete an online survey. Response rate was 44.3% (709/1,601). Compared to women from the general population, female genetic counselors were significantly more likely to agree abortion should be an option in all cases (p<.001). Controlling for other possible confounders, regression analyses revealed that being a genetic counselor, religious service attendance and age were significantly predictive of abortion attitudes. Although the vast majority of genetic counselors agree that abortion should be available, they are significantly less likely to personally consider abortion under all circumstances presented (p<.001), and

A. R. Woltanski (*) Sanford Children’s Specialty Clinic, Sanford Health, Sioux Falls, SD 57117-5039, USA e-mail: [email protected] R. T. Cragun Department of Sociology, University of Tampa, Tampa, FL, USA M. F. Myers College of Allied Health Sciences, University of Cincinnati and Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA D. L. Cragun Department of Biology, University of Tampa, Tampa, FL, USA

the percentage of genetic counselors who would consider terminating in the case of a severe birth defect is similar to studies of other women. Keywords Genetic counseling . Religion . Abortion . Belief . Attitude . Nondirectiveness . Ethics

Introduction Abortion Attitudes of Genetic Counselors and Other Health Care Professionals During their graduate training, genetic counseling students are often encouraged to explore their personal attitudes and beliefs about disabilities, abortion, religion, and other factors as part of a broader context of cultural awareness. However, genetic counselors are also trained to present information and facilitate decision making without letting their own religious or moral beliefs sway a client/patient in any particular direction. While the benefits and limitations of this philosophy, known as nondirectiveness, have been, and remain highly debated within the profession, it is still considered a primary tenet of genetic counseling (Bartels et al. 1997; Michie et al. 1997; Weil 2003; Weil et al. 2006; Wolff and Jung 1995) particularly when it comes to reproductive rights. The ethos of nondirectiveness and individual autonomy are clearly illustrated in two of the National Society of Genetic Counselors (NSGC) position statements: REPRODUCTIVE FREEDOM: The NSGC, as an organization, publicly supports a woman’s right to reproductive freedom, including her right to prenatal diagnosis and access to safe and legal abortion (Adopted 1987)

Woltanski et al.

DISCLOSURE AND INFORMED CONSENT: The NSGC supports an individual’s right to full disclosure of all appropriate medical options regarding reproductive testing and management of genetic diseases and birth defects. It is the care provider’s responsibility to provide effective communication of all available options and to obtain informed consent for procedures involving risk to the individual or fetus. (Adopted 1991) These statements make the NSGC’s position on abortion clear. However, little is known about genetic counselors’ personal attitudes toward abortion. Genetic counselors may differ in their personal opinions regarding abortion and in what situations they would personally consider it an option. Similarly, it is possible that not all genetic counselors agree with the NSGC’s position statements. Understanding genetic counselors’ personal and professional views toward abortion is important because, despite training in nondirectiveness, differences in attitudes toward abortion could impact how, or even if, all reproductive options are presented in a genetic counseling session. Wertz previously explored the level of nondirectiveness employed by genetic counselors as compared to geneticists (1996). Results suggested that more genetic counselors than geneticists would counsel nondirectively in 24 of 26 situations involving a decision about abortion. Examples of situations provided by Wertz included deaf parents pursuing prenatal diagnosis with the intention of selecting for a deaf child and a pregnant woman with untreated maternal phenylketonuria (PKU) who is making a choice about continuing the pregnancy. Wertz also found that in 20 of the 26 situations, fewer genetic counselors than geneticists would themselves choose to abort. A separate publication by Wertz reported that genetics professionals in the United States, including both genetic counselors and geneticists, would personally have an abortion for 13 of 24 conditions (Wertz 1998). The conditions presented were varied and included anencephaly, severe mental retardation with an early death, cleft lip or palate, and maternal rubella. The respondents from the genetic community were compared to a patient population in which the majority would personally have an abortion for only nine of the 24 conditions. Beyond Wertz’s work, no other studies were identified in the literature that specifically described attitudes toward abortion within the genetic counseling profession. Although few studies have examined genetic counselors’ attitudes toward abortion, there are a number of published studies that assess physicians’ attitudes, specifically regarding their willingness to perform or refer a patient for an abortion (Aiyer et al. 1999; Klamen et al. 1996; Miller et al. 1998). In the studies cited, more physicians were receptive to abortion for medically necessary reasons than for

nonmedical reasons. This breakdown of reasons for abortion into medical and nonmedical (i.e., social-psychological) is well documented (Jelen and Wilcox 2003). Medical reasons are generally thought to include such cases as endangerment of the mother’s health or a birth defect in the fetus. Abortions performed because of an unwanted pregnancy or inability to provide for an additional child, are examples of nonmedical reasons. Regardless of the reason for the abortion, physicians can present barriers to obtaining abortion services. The results of a study by Curlin et al. (2007) suggest that “when patients request morally controversial clinical interventions [including abortion], male physicians and those who are religious will be most likely to express personal objections and least likely to disclose information about the interventions or to refer patients to more accommodating providers” (p. 600). This view, in which physicians can and do decide which reproductive options should be offered to their patients, is the opposite of the nondirective ethos expressed in the NSGC position statements. As a result of their training in nondirectiveness, one would expect that genetic counselors are more likely than physicians to feel abortion should be presented as an option for patients. However, genetic counselors’ attitudes toward abortion have not been examined in detail. Associations between Religion, Education, and Attitudes toward Abortion Most studies have found that religious variables are the most important social predictors of attitudes toward abortion (Jelen and Wilcox 2003). The association of religious variables and attitudes toward abortion among the general population depends on the particular religion and the strength of an individual’s association with that religion. Judaism is consistently rated as the most liberal regarding abortion, followed by mainline Protestants, those with no affiliation, black Protestants, Catholics, and lastly, evangelical Protestants (Bolzendahl and Brooks 2005; Strickler and Danigelis 2002). Black Protestants are becoming more liberal over time while evangelical Protestants are becoming more conservative over time (Bolzendahl and Brooks 2005; Evans 2002). According to Evans (2002), Catholics have the widest internal variation regarding acceptability of abortion. More recent research has begun to examine the abortion attitudes of those practicing Islam, which traditionally has restrictions on abortion; however, it has also been noted that abortion attitudes may be influenced by the level of acculturation into Western society as compared to traditional Arabic society (Awwad et al. 2008). There are conflicting findings in the literature about the influence of education on measures of religiosity. One study

Views on Abortion

suggests that differences in religious convictions due to education are artifacts of the differences in religious convictions of different genders and races, with males and whites generally being less religious (Iannaccone et al. 1998). Other studies have suggested that there is a general change in religious affiliation and/or religious convictions during a student’s time in college (Funk and Willits 1987; Hastings and Hoge 1981; Lee 2002). Johnson claims that there is a shift away from a belief in God that can be directly correlated to educational level (Johnson 1997). Both Johnson (1997) and Lee (2002) state that it seems to be those with lesser degrees of conviction to begin with who have the most change. In addition, being Catholic tends to lessen the liberalizing effects of education (Jelen and Wilcox 2003).

attendance, are consistently found to be better predictors of abortion attitudes (Jelen and Wilcox 2003). Purpose of the Present Study Our study is designed to answer two main research questions: (1) Do differences exist between female genetic counselors’ personal and professional attitudes toward abortion? (2) How do female genetic counselors’ professional attitudes toward abortion compare with women in the general population who have a similar level of educational attainment? By comparing genetic counselors to a matched general population sub-group, differences that exist with respect to attitudes toward abortion, and any associations of religious beliefs and practices with those attitudes, can be delineated.

Influence of Abortion Knowledge and Exposure to Abortion on Attitudes toward Abortion Methods Knowledge about abortion itself has been shown to be positively correlated with more accepting attitudes toward abortion. Esposito and Basow (1995) studied 454 college students and found that respondents who scored significantly higher on an Abortion Knowledge Test also tended to indicate approval of abortion on an abortion attitude scale, though knowledge was a weaker predictor than religiosity, religion, and age. Exposure to individuals who have had abortions has reportedly been associated with more permissive attitudes. Results from a 1977 study of nurses by Allen et al., suggest that increased experience or even the potential for experience with abortion patients tended to increase the favorableness of attitudes toward this issue, though this study failed to account for a number of potential confounders (Allen et al. 1977). Knowledge about abortion is not something we can control for in our study. However, one can assume that genetic counselors have been exposed to individuals who have had or are considering having an abortion and one can also assume genetic counselors know significantly more about abortion compared to the general population. Influence of Geographical Region on Attitudes toward Abortion Several studies have examined the effect of geographic region on a respondent’s abortion attitudes (Combs and Welch 1982; Hall and Ferree 1986; Wilcox 1992). Overall, those residing in the South were found to have more conservative abortion attitudes compared to those in the North. We therefore include geographic region in our analysis even though other socio-demographic variables we control for, such as education, age, and religious

Study Design and Participants The institutional review boards of Cincinnati Children’s Hospital Medical Center and the University of Cincinnati approved this study in the winter of 2006. The genetic counseling participants were identified through the NSGC membership directory. Both the 2006 online version and the 2005–2006 paper version of the directory were used to gather contact information of potential participants. Genetic counselors who were full members of the NSGC, worked in the United States, and had an email address available in the online or paper directory were considered eligible for participation. Genetic counselors not meeting these criteria were excluded. Beginning in February, 2007, cover letters were emailed to 1,838 eligible genetic counselors inviting them to participate in an online survey. A link to the online survey was included in the email. Participants were informed that the survey was voluntary and anonymous. All genetic counselors received a second email as a reminder two weeks later. A third email, sent 4 weeks after the initial request, included a deadline for completing the survey. General population data were obtained from the General Social Survey (GSS) for use as a comparison group. The GSS is a biennial survey of households in the United States. It began in 1972 and since that time has collected over 45,000 total responses. The survey is conducted in-home by trained interviewers and takes over 90 minutes to complete. Questions cover a broad range of topics including religious practices and attitudes toward abortion. The data are available free of charge to the public. The questions are designed by experts in the field of sociology and are pretested and validated. Not all questions on the GSS are

Woltanski et al.

asked of every participant in every survey year. To be representative of the US Census data, a full probability sampling design is used. The GSS is conducted by the National Opinion Research Center at the University of Chicago and is primarily funded by the National Science Foundation.1 The GSS collects the highest educational degree completed. Because a career in genetic counseling requires a Master’s degree, we included only those respondents who participated in the GSS from 1998–2004 who had a graduate degree in the comparison group dataset to reduce possible confounders associated with educational attainment. In addition, due to the small numbers of males in the genetic counseling profession, only females were included when comparing results from the GSS survey to our online survey. In the final GSS sample, there were 478 females with a graduate degree. Although the GSS data we included were obtained over a six year period, there were no statistically significant differences between year of participation and attitudes toward abortion or religious beliefs, suggesting abortion attitudes and religious beliefs were fairly stable. Instrumentation The questionnaire was divided into three sections. The first section assessed basic demographic information (i.e. gender, age, ethnicity, geographic location) as well as year of graduation, degrees held, whether the participant counsels patients, and if so, in which primary setting. These demographic questions corresponded to those found on the 2006 NSGC Professional Status Survey (PSS) so we could determine whether our survey was representative of genetic counselors in general (NSGC 2006). The Professional Status Survey is conducted by the NSGC during even numbered years. As part of the PSS, full members of the NSGC are surveyed about their practice, salary, and other professional issues. Although NSGC membership is not required of genetic counselors, it is the only professional membership organization for genetic counselors and the majority of practicing genetic counselors are NSGC members. The PSS provides the best available description of the genetic counseling profession. The second section of the survey contained questions addressing basic information about religious beliefs and practices. These questions were taken directly from the GSS to allow direct comparison of genetic counseling respondents with a gender and education matched sample from the general population (Davis and Smith 2007).

1 More information about the GSS can be found at http://www.norc. org/GSS+Website/

Questions pertaining to religious beliefs included assessing participants’ religious preference, frequency of attendance at religious services, and belief in life after death. Five options for religious preference were given: Protestant, Catholic, Jewish, other, and none. All participants were asked how often they attend religious services. Response options were 1=never through 9=several times a week. All participants were also asked whether they believe in life after death. Response options for this question were yes and no. Section three of the survey addressed attitudes toward abortion using questions taken directly from the GSS. Participants were asked whether it should be possible for a woman to obtain a legal abortion under seven different circumstances including: the presence of a serious defect in the baby, the woman does not want any other children, her own health is seriously endangered, the family cannot afford any more children, the pregnancy was the result of rape, the woman is not married and does not want to marry the man, and the woman wants it for any reason. Response options were yes/no/do not know. The responses to the seven situations were considered to be reflective of the genetic counselors’ professional views toward abortion. Female genetic counseling participants were then asked whether they would personally consider an abortion under the same seven circumstances. We considered responses to the second set of abortion questions reflective of genetic counselors’ personal attitudes toward abortion. Although the GSS does not include this second set of questions, we chose to include them to examine whether genetic counselors’ personal and professional attitudes differ. In line with previous research on abortion attitudes (Jelen and Wilcox 2003), a factor analysis revealed these seven variables load on two factors, which can be categorized as “medical” and “psychosocial” reasons for abortion.2 Medical reasons include abortion if the woman’s health is endangered, there is a serious defect in the baby, or the pregnancy was the result of rape. The remaining four scenarios: the woman does not want any other children, the family cannot afford any more children, the woman is not married and does not want to marry the man, and the 2

Factor analysis is not shown but is available upon request. Rape is included as a medical reason because, based on previous studies and our factor analysis, most people’s view about the acceptability of abortion in cases of rape falls in line with their views about abortion in cases of birth defects and endangerment of the mother’s life. Interestingly, factor analysis using only data from genetic counselors revealed that rape was split nearly fifty-fifty between the two factors. Although this suggests that genetic counselors evaluate rape from both “medical” and “psychosocial” perspectives, grouping rape with the medical reasons was consistent with previous research and our comparison group. Additionally, including the rape variable in the psychosocial scale reduced the scale’s reliability while inclusion of rape in the medical reasons scale increased the scale’s reliability.

Views on Abortion

woman wants it for any reason we considered psychosocial reasons for abortion. We created two scale measures out of the seven variables—one for the medical reasons and one for the psychosocial reasons. By coding a positive response (yes) as “1” and a negative response (no) as “0,” then adding up the various variables, we were able to turn these nominal variables into interval-like scale measures that allow for finer discrimination regarding attitudes toward abortion. The medical scale ranges from 0 to 3; the psychosocial scale ranges from 0 to 4. Higher values indicate more permissive attitudes toward abortion.

This left a total of 1,601 possible respondents. Of the 791 individuals who viewed or participated in the survey, 82 were excluded because there were fewer than five questions answered. The resulting response rate was 44.3% (709 out of 1,601).3 Further reductions were made to the genetic counseling sample by excluding all male genetic counselors (n=26) and those genetic counselors who did not specify a gender (n=29). The exclusions based on gender resulted in a genetic counseling sample of 654.

Data Analysis

Bivariate analyses and descriptive statistics are presented in Tables 1, 2, and 3. Nominal variables for both the general female population and for genetic counselors are presented in Table 1 and include the region in which participants live, their belief in an afterlife, their religious affiliation, and their age. Age is the only demographic variable for which a significant difference between the general female population and genetic counselors was found (χ2 =267.63, df=3, p<.001). Data from the genetic counseling sample indicate that age of genetic counselors skews toward younger ages (genetic counselor sample mean is 35.98 years; 25th percentile is 29 years; 75th percentile is 41 years) while the GSS comparison group skews toward older ages (GSS sample mean is 49.56 years; 25th percentile is 38 years; 75th percentile is 59.25 years). To limit any effects due to skewing in age, four age categories were established for comparison purposes: 24 through 34 years, 35 through 45 years, 46 through 60 years, and those over 60. There are many more genetic counselors in the youngest age group (24–34) and many more women from the general population in the oldest age group (61+). For analysis, we converted age, which is typically a ratio variable, into several dummy coded age groups. Recoding age this way compensates for skew in our multivariate analysis (see below) and also allows for detection of any nonlinear effects of aging. Tables 2 and 3 present descriptive statistics for the interval/ratio variables. Table 2 compares genetic counselors to the general population using independent t-tests on three variables: religious service attendance, attitudes toward abortion for psychosocial reasons, and attitudes toward abortion for medical reasons. The higher the mean on attendance, the more frequent the attendance. Our data suggest genetic counselors attend religious services significantly less frequently than do women in the general

After excluding 82 respondents who answered fewer than five questions, demographic information from the remaining 709 genetic counseling respondents were compared to the 2006 PSS to determine if they were representative of the genetic counseling profession. A number of variables were compared including gender, ethnicity, age, degrees held, US region, and years in the field. Comparisons of means and proportions tests revealed no significant differences between our data and the PSS, indicating our data are as representative of the genetic counseling profession as are the data from the PSS. Following these tests, 29 individuals who did not specify a gender along with the 26 male genetic counselors who responded to our survey were dropped from the dataset to limit potential confounders in subsequent analyses. Additionally, 24 years was used as a lower age cutoff, resulting in no genetic counselors being excluded and only one 19 year old in the GSS comparison group being excluded. Bivariate analyses (chi-square and independent t-tests) were performed to identify differences in demographics, religious beliefs and practices, and abortion attitudes between genetic counselors and the GSS comparison population. Paired t-tests to examine differences between genetic counselors’ professional and personal attitudes about abortion were also performed. Multivariate analysis (ordinary least squares regression) was performed to control for any confounding effects of age, geographic region, religion, and being a genetic counselor and to determine which of these variables significantly influence attitudes toward abortion. The two scale measures, abortion for medical reasons and abortion for psychosocial reasons, were analyzed independently.

Descriptives and Bivariate Comparisons

Results 3

Of the 1,838 emails sent to genetic counselors, 233 were returned as undeliverable. Four genetic counselors identified themselves as no longer practicing and were excluded.

This response rate is a conservative estimate given that the actual number of people receiving the emailed cover letter is probably less than 1,601 since email addresses change frequently and other technological complications (e.g., spam filters) can result in people not receiving the invitation to participate in the survey.

Woltanski et al. Table 1 Demographics of Female Genetic Counselors versus a General Female Population Comparison Group

Age groups

South vs. non-south West vs. non-west Belief in afterlife Judaism Catholicism Religious affiliation

24–34 35–45 46–60 61+ Non-south South Non-west West No Yes Non-Jew Jew Non-Catholic Catholic Affiliated Not affiliated

General population

Genetic counselor

Total n

(%)

n

(%)

n

(%)

Chi-Square

446 294 269 115 777 309 910 176 274 626 1,023 99 906 216 876 246

(40) (26) (24) (10) (72) (28) (84) (16) (30) (70) (91) (09) (81) (19) (78) (22)

81 123 162 108 332 146 403 75 75 196 434 35 385 84 377 92

(17) (26) (34) (23) (69) (31) (84) (16) (28) (72) (93) (07) (82) (18) (80) (20)

365 171 107 7 445 163 507 101 199 430 589 64 521 132 499 154

(56) (26) (16) (01) (73) (27) (83) (17) (32) (68) (90) (10) (80) (20) (76) (24)

267.63

p ***

1.83

ns

0.17

ns

1.40

ns

1.86

ns

0.93

ns

2.51

ns

***p<.001; ns=not significant

population (p<.001). On the abortion attitudes scales, higher values indicate more permissive attitudes toward abortion. Genetic counselors have significantly more permissive attitudes toward abortion than does the comparison subsample of the general population on both abortion attitudes scales, though the difference is not quite as large on the attitudes toward abortion for medical reasons scale (p<.001 for both scales). Table 3 compares genetic counselors’ professional attitudes toward abortion to their personal attitudes using paired t-tests. On both scale measures, genetic counselors are significantly more permissive in their professional attitudes than in their personal attitudes (p<.001 for both scales). The difference in personal and professional attitudes is larger on the psychosocial abortion scale than it is on the medical abortion scale. The GSS did not ask participants whether they would personally consider having an abortion under different circumstances. However, Learman et al. (2005) compared opinions from 1,082 diverse pregnant women about the availability of abortion and whether or not the women would personally consider termination in various situations.

These results are listed in Table 4 along with the data we obtained from genetic counselors in our study. The participants in the Learman et al. study had the following demographic characteristics: mean age of 33 years (range 16 to 47 years), 31.4% were White, 72.5% practiced a religion, and 44.3% had a Bachelor degree or more education. Predictors of Attitudes toward Abortion for Medical Reasons Table 5 presents the results of a stepwise ordinary least squares (OLS) regression analysis. The dependent variable is all participants’ (genetic counselors and the general population combined) attitudes toward medical abortion. Model 1 in Table 5 includes only the demographic variables—age (in groups) and the two geographic regions. As noted earlier, age was categorized into four groups; only three are shown in the model. The fourth age group, individuals over 60, is reflected in the constant. The coefficients for age in the model reflect the difference between each age group in the model relative to the oldest age group. In Model 1, only

Table 2 Comparisons of Religious Attendance and Abortion Attitudes between Groups General population

Religious attendance Psychosocial abortion Medical abortion

Genetic counselor

n

Mean

SD

n

Mean

SD

471 233 235

4.85 2.38 2.66

2.805 1.839 0.808

654 554 620

4.29 3.52 2.96

2.358 1.277 0.272

Difference 0.56 −1.14 −0.30

p <.001 <.001 <.001

Views on Abortion Table 3 Comparison of Genetic Counselors’ Professional and Personal Attitudes toward Abortion Professional attitudes

Psychosocial abortion Medical abortion

Personal attitudes

n

Mean

SD

n

Mean

SD

307 439

3.15 2.96

1.609 0.287

307 439

1.73 2.83

1.768 0.615

the youngest age group is a significant predictor of attitudes toward abortion for medical reasons, suggesting that, relative to the oldest age group (over 60), individuals between 24 and 34 years of age have significantly more permissive attitudes toward abortion. Living in the South is a significant predictor of less permissive attitudes toward abortion. Combined, these control variables only account for a small amount of the variation in attitudes toward abortion, around 2% (reflected in the R2 measure at the bottom of the table). Model 2 introduces the religion variables into the regression equation. Only one of the religion variables, frequency of religious attendance, significantly altered general attitudes toward abortion for medical reasons: the more frequently one attends religious services, the less permissive one’s attitudes toward abortion for medical reasons (p<.001). As expected, Catholics have less permissive attitudes and Jews have more permissive attitudes, but these relationships are not significant when controlling for the other variables in the equation. Additionally, the age and geographic region variables are no longer significant. The addition of the religion variables increases the variation explained in attitudes toward abortion for medical reasons to 11%.

Difference 1.42 0.13

p <.001 <.001

Model 3 introduces another dummy-coded variable indicating whether or not a person is a genetic counselor. Being a genetic counselor is significantly associated with more permissive attitudes toward abortion for medical reasons (p<.001). Being a genetic counselor increases a person’s permissiveness score on the attitudes toward abortion for medical reasons scale by 0.37 points out of a total of 3 points (12%). Religious attendance remained a significant predictor after controlling for being a genetic counselor (p<.001). Intriguingly, age becomes a significant predictor, but in the opposite direction than was found in Model 1. In Model 3, the younger the individual relative to the 61+ age group, the less permissive the attitudes toward abortion. The addition of the genetic counseling control variable increases the variation explained in attitudes toward abortion for medical reasons to 18%. Respondents who did not answer any one of the questions used in the regression analysis were excluded leading to variability in our sample sizes. While analyzing our data we noted that genetic counselors who reported being more religious, based on the religiosity questions, were less likely to respond to the questions about attitudes toward abortion. Since more religious genetic counselors

Table 4 Abortion Attitudes of Genetic Counseling Respondents and Pregnant Women from a Study by Learman et al. Percentage who agree with each scenario

Overall availability of abortion Abortion should never be allowed for any reason You would personally consider an abortion under certain circumstances Abortion should be limited to cases where maternal or fetal health are endangered Medical reasons one would personally consider an abortion If their life is in danger due to the pregnancy If the pregnancy resulted from rape If the fetus had a chromosome abnormality like Down syndrome If the fetus had a mental disability If the fetus had a physical disability If there was a strong chance that the fetus had a serious birth defect Psychosocial reasons one would personally consider an abortion Don’t want more children Cannot afford another child Parentheses indicate those who responded “don’t know” Percentages are calculated using only those women who would ever consider an abortion b Question was not included in the study a

Genetic counselors

Pregnant women

<0.05% >95% 10%

8% 72% 33%

99% (0.06%) 93% (3.5%)

a

b b b

84% 84% a 76% a 73% a 70% a

73% (11%)

b

21% (19%) 35% (25%)

a a

39% 25%

.433 .700 .877 .454 .350

−0.242 −0.201 −0.176 −0.020 0.004 (−.40, (−.36, (−.33, (−.10, (−.01,

−.08) −.04) −.02) .06) .01)

95% CI −0.242 −0.175 −0.143 −0.018 0.025

Beta

3.100 (2.94, 3.26)

0.026 0.035 −0.035

.000*** 0.111

0.314

0.370 (.28, .46) 3.032 (2.88, 3.19)

0.031 0.012 −0.037

0.033 (−.05, .12) 0.020 (−.10, .14) −0.047 (−.13, .04)

.527 .345 .344

0.059 0.026 −0.010 −0.028 0.035

b

0.028 (−.06, .12) 0.058 (−.06, .18) −0.044 (−.14, .05)

.21) .18) .14) .05) .02)

p-value

.000*** −0.059 (−.08, −.04) −0.292

(−.09, (−.12, (−.17, (−.11, (−.01,

Beta

−0.064 (−.08, −.05) −0.314

0.059 0.030 −0.012 −0.031 0.005

95% CI

Model 3 (n=721)

−0.268 −0.213 −0.191 0.000 0.005

b

(−.44, (−.38, (−.35, (−.08, (−.01,

Beta

−.11) −0.276 −.06) −0.189 −.04) −0.158 .08) 0.000 .02) 0.033

95% CI

0.046 (−.04, .13) −0.007 (−.13, .11) −0.030 (−.12, .06)

0.045 −0.004 −0.025

.290 .907 .495

.000***

.001*** .009** .016* .990 .368

p-value

0.392 (.30, .50) 0.327 .000*** −0.218 (−.59, .17) −0.054 .258 .000*** 3.037 (2.88, 3.20) .000*** 0.182 0.192

.000***

.437 .740 .294

.000*** −0.054 (−.07, −.04) −0.273

.003** .013* .027* .622 .478

p-value

Model 4 (n=694)a

a

*p<.05; **p<.01; ***p<.001 The parameter estimates in Model 4 (b and p-value) come from the Heckman model without the weighting; the confidence intervals come from the Heckman model with the weighting

Demographic variables 24–34 year old 0.164 (.03, .30) 0.160 .015* 35–45 year old 0.133 (−.01, .27) 0.114 .062 46–60 year old 0.058 (−.09, .20) 0.047 .428 Live in South (=1) −0.086 (−.17, −.00) −0.075 .039* Live in West (=1) 0.011 (.00, .02) 0.070 .055 Religion variables Attendance (higher more frequent) Believe in immortality Jewish (=1) Catholic (=1) Independent variable Genetic counselor (=1) Response bias correction Constant 2.785 (2.63, 2.89) .000*** 0.023 R2

p-value

b

Beta

b

95% CI

Model 2 (n=721)

Model 1 (n=809)

Table 5 Demographic, Religion, and Genetic Counseling Variables as Predictors of Attitudes toward Abortion for Medical Reasons

Woltanski et al.

Views on Abortion

also tended to be less permissive toward abortion, in Model 4 we controlled for the possibility of response bias using a Heckmann correction (Heckman 1979). The Heckmann correction uses two variables to predict how someone would have responded on the questions they did not answer and adjusts the weights of the cases in the analysis to better reflect what the analysis would look like if we did not have missing data.4 As can be seen in Model 4, the Heckmann correction coefficient is not significant, which indicates there is little or no effect from the response bias on attitudes toward abortion for medical reasons. Predictors of Attitudes toward Abortion for Psychosocial Reasons Table 6 replicates the analyses from Table 5, but the dependent variable is all participants’ general attitudes toward abortion for psychosocial reasons scale. Model 1 again introduces just the demographic variables. Four of the variables in this model are significant. Individuals in the two youngest age groups have significantly more permissive attitudes than individuals over 60 (p<.001 for both age groups). Additionally, individuals who live in the South have significantly less permissive attitudes (p<.05) while individuals who live in the West have significantly more permissive attitudes (p < .05). These control variables explain slightly more variation in attitudes toward abortion for psychosocial reasons than they did for medical reasons, around 4%. Model 2 introduces the religion variables. Only frequency of religious attendance is a significant predictor of participants’ general attitudes toward abortion for psychosocial reasons (p<.001). The more frequently a respondent attended services, the more restrictive the attitude toward abortion for psychosocial reasons. The religion variables increase the variation explained in attitudes toward abortion for psychosocial reasons to 23%. Model 3 introduces the genetic counselor dummy variable. Being a genetic counselor is a significant predictor of attitudes toward abortion and increases permissiveness toward abortion 1.23 points on a 4 point scale (p<.001), which is a difference of almost 31%. Frequency of religious service attendance remains significant when the “genetic counselor” variable is introduced in the model (p<.001). Additionally, the same inversion of the signs for the age 4 The two variables used to predict the probability of response were participants’ race (dummy coded as 0=non-white and 1=white) and frequency of prayer (1=several times a day; 6=never). The Lambda for the Heckmann correction was also calculated using race and frequency of attendance with very little difference in the resulting models. We chose to use the Lambda calculated using frequency of prayer to reduce the collinearity between the Heckmann correction coefficient and frequency of attendance.

groups takes place, and all three age groups are significantly different from the 61+ group. The variables in Model 3 account for 32% of the variation in attitudes toward abortion for psychosocial reasons. Model 4 introduces the Heckmann correction and finds that the response bias is significant, meaning that individuals predicted to hold more restrictive attitudes toward abortion for psychosocial reasons were significantly less likely to respond to the abortion questions (p<.001). Collinearity diagnostics for this model reveal that the Heckmann correction is substantially collinear with religious attendance: 67% of the variation accounted for by religious service attendance overlaps with the variation accounted for by the Heckman correction. This indicates that those genetic counselors who did not answer the abortion questions also attend religious services more frequently. Another indicator of collinearity is the decline in the religious attendance coefficient (from −.391 in Model 3 to −.296 in model 4). Of note in the final model is the finding that being Catholic is significantly associated with psychosocial attitudes toward abortion: when response bias is accounted for, Catholics have significantly more restrictive attitudes toward abortion for psychosocial reasons than do non-Catholics (p<.05). Two additional noteworthy analyses were performed, though the results are not shown in our tables. We initially included race as part of the regression models, but dropped it because it had no effect (possibly due to the limited racial and ethnic diversity among genetic counselors). Separate bivariate analyses were also performed to determine whether a genetic counselor’s primary area of practice was correlated with attitudes toward abortion (data not shown). We found no relationship between abortion attitudes and whether or not a genetic counselor does any prenatal counseling or whether or not the counselor’s primary area of practice is prenatal versus other.

Discussion We had two main objectives with this research project. We wanted to better understand how individual female genetic counselors think about abortion by comparing their personal and professional attitudes. We also wanted to see how female genetic counselors compare to the general female population with regard to abortion attitudes. Regarding the first objective, our results show that genetic counseling respondents are significantly less likely to personally consider having an abortion even though they feel abortion should be an option for women in general. This finding is not surprising given previous research that suggests genetic counselors are more likely to counsel nondirectively, but less likely to personally consider termination compared to

(2.18, 2.97)

(.34, 1.17) 0.239 (.35, 1.21) 0.217 (−.02, .87) 0.112 (−.61, −.10) −0.101 (.00, .07) 0.079

.000*** 0.041

4.158 (3.68, 4.63)

0.018 −0.072 0.345

1.234 (.97, 1.50)

−0.034

−0.391

−0.208 −0.117 −0.111 −0.047 0.017

Beta

0.590 (−.25, .44) 0.036 (−.55, −.02)

.000*** 3.963 (3.51, 4.41) 0.234

.178 .061

0.048 −0.068

0.382 (−.36, .14)

0.247 (−.11, .61) −0.270 (−.55, .01)

(−1.12, −.18) (−.88, .04) (−.87, .03) (−.40, .07) (−.02, .04)

.343

0.006 0.073 0.066 0.170 0.622

95% CI

−0.039

.092 .143 .565 .086 .448

b

−0.128 (−.39, .14)

0.119 0.094 0.036 −0.062 0.027

p-value

.000*** 0.000 (−.29, −.20)

.80) .79) .59) .03) .05)

Beta

−0.258 (−.31, −.21) −0.414

.000*** 0.371 (−.06, .000*** 0.339 (−.12, .061 0.135 (−.33, .007** −0.216 (−.46, .037* 0.013 (−.02,

95% CI

Model 3 (n=660)

−0.592 −0.290 −0.321 −0.134 0.010

b (−1.10, −.14) (−.78, .17) (−.79, .14) (−.36, .12) (−.02, .04)

95% CI

.000*** 0.319

.000***

.740 .294

.437

.000*** 0.324

.000***

−2.927 (−4.22, −1.49) −0.189 4.593 (4.06, 5.20)

.000***

.651 .043*

.625

.000***

.014* .223 .167 .257 .531

p-value

0.309

−0.016 −0.071

−0.080 (−.45, .27) −0.275 (−.56, −.02) 1.127 (.87, 1.46)

0.020

−0.296

−0.195 −0.082 −0.086 −0.039 0.022

Beta

0.064 (−.20, .34)

.000*** −0.180 (−.25, −.14)

.003** .013* .027* .622 .478

p-value

Model 4 (n=630)a

a

*p<.05; **p<.01; ***p<.001 The parameter estimates in Model 4 (b and p-value) come from the Heckman model without the weighting; the confidence intervals come from the Heckman model with the weighting

Demographic variables 24–34 year old 0.755 35–45 year old 0.780 46–60 year old 0.423 Live in South (=1) −0.354 Live in West (=1) 0.037 Religion variables Attendance (higher more frequent) Believe in immortality Jewish (=1) Catholic (=1) Independent variable Genetic counselor (=1) Response bias correction Constant 2.577 R2

p-value

b

Beta

b

95% CI

Model 2 (n=660)

Model 1 (n=745)

Table 6 Demographic, Religion, and Genetic Counseling Variables as Predictors of Attitudes Toward Abortion for Psychosocial Reasons

Woltanski et al.

Views on Abortion

geneticists (Wertz 1996). Genetic counselors’ personal and professional attitudes differed more with regard to psychosocial reasons for abortion than for medical reasons for abortion. This too is not surprising given that most individuals in the United States hold more permissive views toward abortion for medical reasons and many religions have exceptions that permit abortion for medical reasons, such as in cases of rape or endangerment of the mother’s health. The second objective of this project was to understand if genetic counselors differ from the general population in their attitudes toward abortion. The Betas from our linear regression model provide an idea of the relative influence each variable has on the model, with a higher beta indicating that the variable is a better predictor of abortion attitudes. As shown in Table 5, whether or not a woman is a genetic counselor is a better predictor of attitudes toward abortion for medical reasons than the two other significant predictors, religious service attendance and age. Assuming all other variables included in the model are held constant, being a genetic counselor translates into a 13% increase in permissiveness of attitudes toward abortion for medical reasons.5 Being a genetic counselor is associated with an even larger increase in permissiveness (28%) on the abortion for psychosocial reasons scale. However, even after controlling for being a genetic counselor, religious attendance remained the best predictor of abortion attitudes for psychosocial reasons and being Catholic was associated with a decrease in permissiveness of nearly 8% on the psychosocial abortion scale. Why differences in abortion attitude between female genetic counselors and women in the general population remain significant even after controlling for possible confounding factors such as level of educational attainment, age, religious service attendance, or religious beliefs, is not perfectly clear from our analyses. Perhaps differences in abortion attitudes arise as genetic counselors incorporate the ethos of nondirectiveness and patient autonomy expressed in the NSGC position statements. Differences may also result from the increased knowledge about abortion and embryonic and fetal development that genetic counselors likely attain as a result of their training and practice. Beyond knowledge of abortion, genetic counselors may also be influenced by seeing the “whole picture,” including the outcome of birth defects and how they impact 5

This is calculated using the slope coefficient for being a genetic counselor, .392, found in Table 5. Being a genetic counselor actually increases one’s permissiveness on the scale of attitudes toward abortion .392 points. As it is a 3-point scale, dividing .392 by 3 gives .13, or 13%. In other words, there is a 13% difference in attitudes toward abortion between genetic counselors and non-genetic counselors on average.

different families. On the other hand it could simply be that women who hold more permissive views about abortion are more likely to become genetic counselors. Theoretically, it is also possible that program admission is more often extended to those with permissive views on abortion than those with restrictive attitudes regarding abortion. Although our study clearly indicates that genetic counselors are more likely to hold permissive attitudes with regard to the availability of abortion for women in general, it is not as clear how genetic counselors compare to other women regarding their intentions to personally consider terminating a pregnancy. A comparison with Learman’s study (Table 4) reveals similarities in the percentages of pregnant women who would consider terminating for a chromosome abnormality, mental disability, and physical disability with the percentage of genetic counselors who would consider terminating if the baby had a serious birth defect. A number of other studies have found that approximately 65–80% of women would consider terminating for various types of serious birth defects or genetic disorders (Blendon et al. 1993; Finley et al. 1977; Rice and Doherty 1982; Roberts et al. 2002; Robinson et al. 1975; Velie and Shaw 1996). The number of women who actually terminate due to serious fetal anomalies (mostly common trisomies) tends to be even higher than 80% (Forrester et al. 1998; Glover and Glover 1996; Vincent et al. 1991; Williamson et al. 1996). These studies lend further support to the finding that genetic counselors are probably not that different from other women with regard to personal abortion attitudes. This is not too surprising if we consider the findings by Roberts et al. (2002), that neither the level of general knowledge about disabilities nor the level of knowledge about specific conditions was related to women’s intention to continue or terminate a pregnancy among a group of women who were generally well educated. However, the picture is complicated by a finding from the same study that women with more knowledge about available resources for people with disabilities were moderately less likely to consider terminating a pregnancy. Although we corrected for the response bias in our regression analyses, it is not clear why genetic counselors who attend religious services more frequently were significantly less likely to answer the abortion questions. Perhaps this sub-population of genetic counselors found it uncomfortable to answer questions about a topic in which their personal beliefs are perceived to be in conflict with either the ethos of the genetic counseling profession or the teachings of their religion. It is also possible that genetic counselors chose not to respond after realizing that they did not have a well defined distinction between their personal and professional attitudes. Overall, our results seem to indicate that genetic counselors are permissive in their professional attitudes

Woltanski et al.

toward abortion for medical reasons, as would be expected based on the profession’s position statements indicating access to prenatal testing and abortion should be available to all women. However, some genetic counselors professionally feel abortion for psychosocial reasons should not be available to women. In addition, when considering their own personal decisions with regard to abortion for various reasons, genetic counselors’ attitudes about abortion are much more conservative than their professional attitudes and they do not appear to be that different from the personal attitudes of other groups of women.

Limitations Our attempt to find a good comparison group resulted in some limitations. First, we were unable to capture differences in attitudes about first versus second trimester abortions because the questions, taken directly from the GSS, do not specify a gestational age at which the abortion would occur. This may influence the results because previous research has shown that women are significantly more likely to report permissive views about abortion for psychosocial reasons when it is specified that the abortion occurs in the first trimester than when the timing is not specified (Bumpass 1997). Furthermore, although the questions about abortion from the GSS were intended to capture an individual’s opinion about whether abortion should be possible for women in general, rather than an opinion about what they would personally do in certain situations, this distinction may not be clear. Genetic counselors may be more likely than the general population to have considered this distinction as a result of their training in nondirectiveness, or because after being asked the general abortion questions from the GSS they were then asked similar questions about their personal attitudes. Post hoc comparisons of genetic counselors’ personal attitudes about abortion with personal attitudes of women from other studies are complicated by several factors. There are a number of demographic differences between the studies for which we cannot control, each study worded the questions on abortion differently, and the studies assessed different types of birth defects. Given how difficult it is to predict human attitudes, studies that have assessed socio-demographic predictors of attitude toward abortion (including the present study) have been unable to explain the majority of the variation in abortion attitudes. The R2 values in our two final regression models indicate that 19.2% of the variance in attitudes toward abortion due to medical reasons and 32.4% of the variance in attitudes about abortion due to psychosocial reasons can be explained by the socio-demographic variables we measured. Our greater ability to explain the

variance for the psychosocial scale is probably due to the fact that views vary more with regard to psychosocial reasons for abortion, while most women in our study agree that abortion should be available for medical reasons. The amount of variance explained in our models is similar to other studies on socio-demographic predictors of abortion attitudes (Esposito and Basow 1995; Harris and Mills 1985; Legge 1983; Wilcox 1992). However, a direct comparison with any of these studies is misleading because our sample population included only highly educated, mostly white women and therefore none of the variation in our model is due to gender, race, or education, whereas one or more of these variables accounts for a significant portion of the variation in abortion attitudes in the aforementioned studies of diverse populations in the U.S. Additional studies on predictors of abortion attitudes have been able to explain approximately 10% more of the variation by adding scales that assess attitudes, such as beliefs about euthanasia and/or appropriate sexual behavior (Strickler and Danigelis 2002; Woodrum and Davison 1992). However, the addition of these attitudes introduces some methodological problems. Other variables not included in our model, such as political affiliation, whether a woman has previously had an abortion, accurate knowledge about abortion, and parental attitudes toward abortion, may contribute to abortion attitudes but are not consistently reported in the literature and/or found to be very strong predictors compared to those variables included in our model (Esposito and Basow 1995; Jelen and Wilcox 2003; Learman et al. 2005; Legge 1983).

Future Research and Implications for Genetic Counseling Practice and Training In order to understand why genetic counselors have more permissive attitudes toward the availability of abortion compared to other women, further studies are needed. A qualitative study could examine how genetic counselors establish and distinguish their personal and professional attitudes toward abortion, while a longitudinal study would be useful to determine when attitudes toward abortion are established among genetic counselors and whether they fluctuate with training and practice. Determining the impact of the current findings on genetic counseling practice is beyond the scope of this study and remains highly speculative. However, if we extrapolate the finding that physicians who had less permissive views about abortion were less likely to provide all available options or make a referral to another practitioner (Curlin et al. 2007), it stands to reason that genetic counselors are more likely to discuss abortion as an option. However, any fears that women will be unduly

Views on Abortion

influenced by genetic counselors to have an abortion based solely on these findings are unfounded because genetic counselors are just as likely to report a religious affiliation as other highly educated women in the US, genetic counselors themselves do not appear to be more likely than other groups of women to personally consider termination in cases of serious birth defects, the personal attitudes of genetic counselors are more conservative than their professional attitudes, and the profession continues to uphold the values of nondirectiveness and autonomy. If genetic counselors’ personal attitudes influence the counseling session, it is probably more likely to be a subtle influence such as variations in the amount and type of information presented. Our study illustrates that genetic counselors are not as homogeneous in their personal attitudes toward abortion as one might assume based on the NSGC position statements, and this opens the door to further research into the possibility that differences in genetic counselors’ personal abortion attitudes and religious beliefs influence the genetic counseling session. Acknowledgements We are indebted to all the genetic counselors who took the time to participate in this survey. This project was completed as part of the requirements of the University of Cincinnati Genetic Counseling Program. Thanks go to that program as well as the Cincinnati Children’s Hospital Medical Center for the support, time, and space necessary to complete a Master’s thesis. 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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