Helping Couples Fulfill the Highest of Lifes Goal

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ORIGINAL RESEARCH
Helping Couples Fulfill the BHighest of Lifes Goals^: Mate
Selection, Marriage Counselling, and Genetic Counseling
in United States
Devon Stillwell1
Received: 29 September 2014 /Accepted: 22 June 2015 /Published online: 13 August 2015
# National Society of Genetic Counselors, Inc. 2015
Abstract This article traces the history of modern genetic
counseling to mate selection and marriage counselling practices
of the early-20th century. Mate selection revolved around a
belief that human heredity could be improved and genetic diseases eradicated through better breeding. Marriage counselling,
though interested in reproduction, was also concerned with the
emotional and psychological well-being of couples. These two
practices coalesced most obviously in the work of well-known
geneticist Sheldon Reed. Even as marriage and genetic counselling diverged in the post-WWII period, vestiges of these practices remain in contemporary counseling experiences with family planning and genetic screening programs. Emphasizing
points of continuity between Bpositive^ eugenic ideologies
and modern genetic practices elaborates the diverse origins of
genetic counseling. It also exposes how genetic counselors have
become involved in genetic enterprises beyond standard clinical settings, and prods at key issues in the interaction between
genetic science and social values.
Keywords Genetic counseling . Mate selection . Marriage
counselling . Medical genetics . Eugenics
In 1987, medical geneticist Aubrey Milunsky published a
book titled How to Have the Healthiest Baby You Can. The
text, which explored prenatal care, chromosomal abnormalities, and pregnancy complications, was based on the premise
that, BAs a parent or parent-to-be, you want to have the healthiest child you can^ (p. 15). Milunsky intended for his manual
to help couples realize the Bchoices they can make and
chances they may not wish to take^ (Milunsky 1987, p. 15).
In September of that year, Melonie Krebs reviewed the book
in the National Society of Genetic Counselors newsletter,
Perspectives in Genetic Counseling. She suggested that the
manual would be a useful resource for counselors, but
objected to the books intent focus on the prevention of birth
defects. Krebs main concern was the emotional and psychological well-being of prospective parents. She worried that
Milunskys emphasis on the undesirability of deleterious traits
would make parents feel responsible and guilty for the appearance of Babnormal^ conditions in their children (Krebs 1987).
Krebs attempt to balance the prevention of birth defects and
the more holistic meanings of reproduction for family life represents a tension genetic counselors (or those who have performed
counseling functions) have negotiated for the past 100 years.
Throughout the 20th-century, geneticists, physicians, and others
whose professional expertise intersect with the science of human
reproduction have echoed Milunskys concern about the transmission of genetic conditions and diseases. Eugenics enthusiasts
in particular wrote manuals to educate Americans about reproduction and foster intelligent mate selection in the 1910s and 20s
(Davenport 1911). Krebs emphasis on the inner workings of the
family unit, instead of a primary focus on the health status of a
couples progeny, has a similarly lengthy history dating back to
marriage counselling philosophies of the 1930s.
Taking a long perspective on the history of medical genetics and its social implications, I suggest that both mate selection and marriage counselling practices converged in the genesis of modern genetic counseling. We can clearly see these
two ideologies in the work of Sheldon Reed, who coined the
term Bgenetic counseling^ in 1947, describing it as, Ba kind of
genetic social work without eugenic connotations^ (Reed
1974, p. 45; Paul 1995, p. 127; Resta 1997b). Reed
counseled his clients from a belief that human heredity could
* Devon Stillwell
stillwde@mcmaster.ca
1 Department of the History of Medicine, Johns Hopkins University,
Baltimore, MD, USA
J Genet Counsel (2016) 25:157165
DOI 10.1007/s10897-015-9853-5
be controlled and improved through informed reproduction designed to eradicate genetic disease. At the same time, his
counseling was explicitly concerned with the psychological
well-being and familial happiness of his clients. Meeting with
couples either before marriage, or with a married couple before
they attempted to conceive, Reed helped prospective parents
weigh their expectations for family life and reproductive options (Reed 1955; Fraser 1959; Ladd-Taylor 2003; Stern 2012).
Despite his prominent place in the history of genetic counseling as the fields modern originator, I emphasize that Reed is
neither where this story begins nor ends. Instead, tracing mate
selection and marriage counselling to contemporary genetic
counseling brings into focus points of continuity between
century-old perspectives on the science of heredity and the meanings of intelligent reproduction, and more recent practices in
reproductive and community genetics. A focus on continuity
builds on historian Nathaniel Comforts (2012) argument that
the field of medical genetics has always revolved around the
two goals of human betterment and the eradication of hereditary
disease. Tracing moments of continuity exposes historical precedents for contemporary professional and ethical issues facing
genetic counselors, as well as the fields more obscure points of
origin. Aspects of genetic counseling can be traced to the
American eugenics movement, most famous for Bnegative^ eugenic measures (including segregation and sexual sterilization)
intended to reduce the incidence of defective traits in the
American population. I elaborate, rather, the work of Alexandra
Minna Stern, Molly Ladd-Taylor, and Wendy Kline by following
the movements Bpositive^ strand (Stern 2005; Ladd-Taylor
2001; Kline 2001). This paper connects the work and beliefs of
eugenicists like Charles Davenport, Charles Fremont Dight, and
Paul Popenoe to the post-WWII genetic counseling performed
by Sheldon Reed at the Dight Institute. The history of mate
selection and marriage counseling then intersects with more contemporary genetic screening programs for Tay-Sachs and sickle
cell anemia, and modern family planning technologies designed
to control our offsprings genetic heritage.
Following this thread allows us to think through central themes
in the history of heredity, reproduction, and kinship that are obscured if we focus on the more famous, sensational aspects of
eugenics. This history also elucidates how contemporary counselors have become involved in a host of genetic enterprises outside the standard clinical forum. The extension of genetic counseling beyond the one-on-one client-counselor relationship prods at
some of the broader issues involved in negotiating genetic science
and technologies within contemporary social settings.
Early 20th-Century Eugenics and the Genetic
Interest in Mate Selection
BPositive^ eugenics was an integral aspect of the American
program for human betterment, and a necessary adjunct to the
anti-immigrationism and sterilization programs of the early20th century that have captured the minds of historians for
decades (Ludmerer 1972; Kevles 1985; Reilly 1991; Largent
2008). Positive programs were essential to eugenicists
double-pronged approach of discouraging breeding amongst
the Bunfit,^ while encouraging reproduction between desirable individuals of sound personal and familial health. The
production of eugenically-fit children was promoted through
educational exhibits at state fairs and in major museums; in
BBetter Babies^ and BFitter Families for Future Firesides^
contests; and through calls for better education around mate
selection and marriage (Stillwell 2012; Rydell 1993, p. 3861;
Kline 2001, p. 731).
BFather of eugenics^ Francis Galton showed interest in
informed mate selection and its benefits in Hereditary
Genius (1869). He proposed based on his evaluation of the
relations of 400 Billustrious men^ that Ba mans natural abilities are derived by inheritance,^ (p. 1) and was particularly
struck by the heritability of Bgenius^ throughout the ages as it
appeared in judges, statesmen, scientists, artists, and the like.
Galton hoped his readers would understand Bhow largely natural intellectual gifts are the birthright of some families,^ yet
how through Bjudicious marriages,^ it would be plausible to
produce a Bhighly-gifted race of men^ over a few generations
(p. v-1, 72; Bulmer 2003, p. 46-56). Galtons work often reads
as an exemplary manual for accomplishing such a feat by
providing, in exceptional detail, both pedigrees and prose
demonstrating the patterns of intermarriage amongst various
kinship groups. Moreover, he performed some prototypical
genetic counseling by statistically estimating the chances of
a particular union furnishing eminent progeny. BWhat expectations,^ Galton wondered, Bhas [the son of a judge] that his
own sons will become eminent men, supporters of his
family?^ (Galton 1869, p. 84). Assuming the sons own eminence, he calculated that Bout of the 226 judges previous to
the present reign, 22 whose sons have been distinguished
men22 out of 226 gives 10 in 100 as to the percentage of
the judges that have had distinguished sons^ (p. 8485).
Galtons point of emphasis was primarily the inheritance of
a desirable characteristic in ones offspring through smart marriages and matings.
Charles Benedict Davenport, Americas most famous eugenicist, also promoted careful Bmarriage matings^ through better
education in the principles of heredity (Davenport 1911, p. iii;
Comfort 2012, p. 36-45). Davenports ideas and work at the
Eugenics Record Office (ERO) can be seen as a precursor to the
heredity counseling performed by Sheldon Reed. Indeed, Reed
himself noted that Davenport Bundoubtedly did some bona fida
[sic] genetic counselingthough he didnt use that term^
(Reed 1974, p. 2; Paul 1995, p. 123; Reilly 2008). In his work
Heredity in Relation to Eugenics (1911), Davenport defined
eugenics as Bthe science of the improvement of the human race
by better breeding,^ (p. 1) being particularly concerned with the
158 Stillwell
production of fit offspring. Happiness in marriage was of slight
importance since eugenics was concerned with Btraits that are in
the blood, the protoplasm^ (p.1). A successful marriage was
Bmeasured by the number of disease-resistant, cultivable offspring that come from it^ (p. 1). He professed in this treatise
that, BThe general program of the eugenist is clear it is to
improve the race by inducing young people to make more
reasonable selection of marriage mates; to fall in love
intelligently^ (p. 4). This approach relied on peoples Bgood
sense^ when thinking about marriage, and whether their relationship would produce Bhealthful, mentally well-endowed
offspring^ (p. 4). To promote good and avoid bad matings,
Davenport implored the American public to record their heritage in the form of a pedigree. Keeping a record of ones family
history would help produce children Bof the best quality in
respect to inborn capacities,^ and was deemed a Bpatriotic
duty^ of crucial value to the health of the nation (p. iv-v,
239249).
Davenport was primarily interested in physical traits, diseases, and specific talents (as opposed to Galtons more ephemeral interest in Bgenius^) including height and stature, anomalies of the extremities, albinism, cancer, diabetes, chorea, and
giftedness in math, art, and mechanics (Davenport 1911, p. ivv; Comfort 2012, p. 40-42). He outlined for his (primarily
white, middle- to upper-class) readers basic Mendelian hereditary principles, the theory of independent unit characters, and
the interaction of Bdeterminers^ in the union of the mother and
fathers Bgerm plasm^. He offered a chart or pedigree outlining
the statistical likelihood of a given match producing the condition under review. Though he refrained from giving advice
about the advisability of parenthood in many cases, he strongly
cautioned against marriage and reproduction for the sisters of
hemophiliacs (an X-linked disease), couples where both partners have low resistance to tuberculosis, and individuals with
diabetes, deaf mutism, and chorea (Davenport 1911, p. 101,
157168). Davenport advocated knowledge of ones family
history, better education in heredity, and intelligent matings as
part of a eugenic program intended to benefit posterity and the
larger gene pool.
Eugenics enthusiasts at the state level also promoted mate
selection including Dr. Charles Fremont Dight, Minnesotas
foremost campaigner for human betterment. Despite being
remembered primarily for devoting his life to enacting statelevel sterilization legislation (Ladd-Taylor 2005; Phelps
1984), Dight also advocated for mate selection as a necessary
adjunct to the surgical procedure. He considered the prevention of reproduction amongst persons of Bundesirable traits^
or Bmental defects^ as only the second goal of eugenics; the
first was Bto promote marriage matings between persons both
of whom carry in the chromosomes of their reproductive cells
the determiners of desirable traits^ (Dight 1936, p. 86). He
was guided by his belief in the individual childs Bright to be
well born, to be born of normal parents,^ (Dight 1936, p. 91)
but also from a wider sense of social responsibility and conviction that only by matings amongst those free from hereditary defects could Ba better human stock be bred^ (Dight
1936, p. 86).
Dight (1936) sought to foster desirable unions by giving
young Americans pride in their heredity. He preached,
BYoung Man! Young Woman! It matters greatly whom you
marry. Your choice is a choice of a parent for your children^
(Dight 1936, p. 92). Mate selection would determine whether
a child would be Bmentally subnormal^ or intellectually superior, an honor to their family or an incredible burden (Dight
1936, p. 92). Casting aside romantic views on marriage, he
suggested that the Bgreat purpose^ of choosing a mate is to
Bperpetuate the race^ (Dight undated essay, b, p. 3). Dight
provided examples to illustrate the advantages in seeking what
was in fact heredity counseling when choosing a spouse. He
conveyed the case of a Bvery intelligent young woman^ who
visited Dight for advice about a prospective marriage partner.
Her potential husband suffered from epileptic seizures and
was dismissed from the Armed Forces because of his illness.
She confided to Dight that knowing this, Bshe doubts the
wisdom of marrying him,^ (Dight 1923, p.1) believing that
she would always be anxious that she had Bmade a serious
mistake that might wreck her happiness and result in epileptic
and defective children^ (Dight 1923, p. 1).
Like many who wrote or visited Dight, this woman worried
about her mating decisions and their impact on her future
family life. Her concern about heritable disease was echoed
by Dight, who stressed the importance of knowing ones disease history and investigating the family pedigree of a prospective partner (Dight undated manuscript, p. 114). He
sought to educate his clients on the inheritance of diseases like
Huntingtons chorea, keratosis, presenile cataracts, and general Bsoundness in mind and body,^ (Dight undated essay, a, p.
1) but also character traits like the tendency to be secretive, too
cautious, combative or destructive, sober, and industrious
(Dight 1936, p. 169). Dight, and other eugenicists interested
in mate selection, therefore performed some pseudocounseling functions between the 1910s and 1930s,
elements of which are evident in contemporary clinical
practice.
Paul Popenoe, the American Institute of Family
Relations, and Marriage Counselling in California
By the 1930s, Paul Popenoe, who, like Dight and Davenport,
was a well-known eugenics crusader, began developing his
interest in marriage counselling. Popenoe championed hereditary education and intelligent relationships through
Californias Human Betterment Foundation and later through
the American Institute of Family Relations (AIFR). Like
Dight, Popenoe was an enthusiastic participant in his states
Mate Selection, Marriage Counselling, and Genetic Counseling 159
sterilization program, which sterilized approximately 20,000
individuals (Stern 2005, p. 84). But Popenoe and his mentor,
E.S. Gosney, understood sterilization primarily as a means of
Bclearing the way for, a positive program of eugenics^
(Gosney and Popenoe 1929, p. xiii, 135; Kline 2001, p.
142). Popenoe worked, beginning in the 1930s, to establish
marriage counselling as an institution to promote Bbetter offspring everywhere,^ believing that, Bsome needed fewer children but many more needed more and better offspring^
(Popenoe 1977, p. vii).
Popenoes marriage counselling philosophies resembled, in
many ways, Dights belief in mate selection. He was convinced that Bthe production of children is the goal of all life,
^ and described marriage as Ba scientific choice^ (Popenoe
1925, p. 42, 175). Popenoe wrote extensively on biological
issues in reproduction and sought to educate couples on hereditary mechanisms. He performed risk calculations using a
Bcheckerboard^ Punnett square to demonstrate dominant and
recessive inheritance, and how a couples genes might interact
in a given mating. Moreover, he counseled his AIFR clients to
balance their characteristics in their choice of mate, and on a
host of problems related to conception, pregnancy, and childbirth in his clinical encounters and writings (Popenoe 1925,
1926, 1930, 1943).
Despite obvious similarities, however, Popenoes encouragement of intelligent mate selection differed from Dights
campaign in several key ways. Though intended to curb the
spread of hereditary disease and encourage the propagation of
Bnormal^ children, Popenoes marriage advice was also designed to help couples achieve emotional and psychological
stability in their relationships in order to uphold and celebrate
traditional family values. For Popenoe, the institution of marriage was seemingly under attack with the receding of
Victorian gender roles and what he estimated to be 400,000
divorces a year in the U.S. (Popenoe and Disney 1960, p. xviii;
Popenoe 1943, p. 3; Ladd-Taylor 2001, p. 308; Kline 2001, p.
124-125). A successful relationship and happy marriage
depended on men and womens fulfillment of their proper roles
as husband and wife, and pre-marital education in finding the
ideal mate. He therefore advised that young people seek a partner based on mutual age, race, socio-economic class, religion,
and other factors likely to foster long-term compatibility (Stern
2005, p. 150-181; Kline 2001, 141-156). Ultimately, Popenoes
counseling philosophy revolved around what Ladd-Taylor described as a Btherapeutic approach to personal happiness, and
the elevation of family togetherness^ (Ladd-Taylor 2001, p.
305). The stability and wellness of the family unit was important for a couples relationship, but also for their reproductive
life and the well-being of their future progeny.
Popenoe, in many ways, bridges the gap between early20th century ideologies and practices in hereditary advising,
and the post-WWII genetic counselor. The AIFR was similar
in its operation to mid-century heredity clinics (Stern 2005,
p. 150181). The Institute was divided into three departments
devoted respectively to education, research, and Bpersonal
service.^ The latter helped couples deal with familial issues
including sex, marriage, heredity, and parenthood to Bpromote
successful family life in every possible way^ (Popenoe 1943,
p vii-ix; Popenoe and Disney 1960, p. vii). Couples seeking
premarital education met with a counselor (often Popenoe
himself) who assessed the clients personal and family histories, and medical personnel who performed a physical examination. Popenoe also stressed the impact of heredity on marital happiness, and implored his clients to interrogate their
family history (Popenoe 1943, p. v, 46; Kline 2001, p. 145).
Popenoes marriage counselling, in emphasizing autonomous decision-making, drew on a comparable patient ethos
as that adopted by later genetic counselors. Epitomized in
humanistic psychotherapist Carl Rogers Bperson-centered^
and Bnon-directive^ counseling philosophies, this theory emphasized the need for counselors to view patients as generators
of meaning within a session, and cautioned counselors against
becoming directly involved in the therapeutic subjects
decision-making process (Rogers 1942, p. 34; Rogers 1965,
p. 29; Stern 2005, p. 162 ; Stern 2012, p. 126-128). Popenoe
articulated a commitment to this ethic in response to clients
concerns that marriage counselors would tell them to get a
divorce, or label them Bcrazy,^ saying, BNo counselor ever
intends to make any decision for a client^ (Popenoe and
Disney 1960, p. xvi). He maintained that the counselors role
was Bto guide the client into thinking through his own problem more carefully, so that he can make his own decision on
the basis of all the evidence, not on the basis of ignorance or a
momentary whim^ (Popenoe and Disney 1960, p. xvi). This
language and understanding of counselling reinforced
Popenoes commitment to ensuring marital harmony and a
healthy family life by allowing clients to make a decision that
was compatible with their long-term aspirations (Popenoe and
Disney 1960, p. xvi-xvii). This vision of counselling helped
modify eugenicistsstrict focus on mate selection in ways that
better reflected the ideologies of genetic counselors since the
1960s.
Sheldon Reed, the Dight Institute, and Genetic
Counseling at mid-Century
The origins of genetic counseling are most often traced to
Sheldon Reed, a geneticist and zoologist who took over the
Dight Institute for the Promotion of Human Genetics in 1947.
The Institute was established in 1941 at the University of
Minnesota under Clarence P. Oliver with $75,000 from
Charles Fremont Dights estate with the purpose of furthering
Bbiological race betterment^ (Comfort 2012, p. 101,
111;Notice of fund establishment 1944, Last Will and
Testament 1936). The Dight Institute provided public
160 Stillwell
education in human genetics and eugenics; collected and preserved family histories and pedigrees on various traits; and
acted as a clinic where people could obtain Bgenetic and eugenic interpretations^ (Oliver 1943, p. 12; Resta 1997b).
Reeds interest in providing clients with these interpretations
is a central aspect of his career and major legacy within the
field of genetics. Indeed, Reed believed that Bthe desire for a
happy family of normal children is one of the strongest human
motivations^ and the Bhighest of lifes goals^ (Reed 1955, p.
225). In an era before the development and standardization of
prenatal technologies, the counselor met with couples with a
known family history of hereditary disease who were either
contemplating starting a family or who already had a child
with a genetic condition (Fraser 1959, p. 78). In this medical
encounter, the counselor provided information and mathematical risk estimates about the probability of such Bdefects^ occurring in future offspring.
In his seminal text Counseling in Medical Genetics (1955),
Reed suggested that counselors needed a firm background in
genetics and, to this end, explored the inheritance of Bmental
retardation^, clubfoot, and Bnervous system malformations,^
skin color, epilepsy, twinning, disputed paternity, consanguinity, and schizophrenia, amongst others conditions. But counselors also required the ability to teach heredity from a Bdeep
respect for the sensitivities, attitudes and reactions of the
client^ (Reed 1955, p. 8, 1112). Integral to his heredity
counseling was an emphasis on autonomy in reproductive
decision-making, and the importance of genetic counseling
for an individuals psychological well-being. Genetic counseling could make parents Bpsychologically forearmed if the next
child does prove to have an abnormality^; it could also help,
once a child was born, to Breorganize their psychologic
shambles^ (Reed 1955, p. 1314, 225).
Reeds brand of counseling was not intended to recommend or advise patients about whether or not to have children;
rather, it aimed to provide couples with an education in genetics on which to base informed reproductive decisions
(Johnson 1958; Reed 1955, p. 1116). He summarized a philosophy that strongly resembled the concept of nondirectiveness so central to the later profession, explaining that,
BThe parents often ask us directly whether they should have
more children,^ but that B[t] his question is one that we do not
answer because we cannot^ (Reed 1955, p. 14; Stern 2012, p.
129-132). Since the counselor can never fully understand a
couples unique family situation, they must Bexplain thoroughly what the genetic situation is, but the decision must
be a personal one between the husband and wife, and theirs
alone^ (Reed 1955, p. 14). He maintained that counselors
focused exclusively on Bwhat is good for a particular family,
^ and not Bthe country as a whole^ (Reed 1974, p. 45; Jordan
1981, p. 20).
Even as Reeds philosophy embraced a holistic view of
family health and life, he simultaneously evidenced attitudes
that resonated strongly with proponents of mate selection.
Reeds counseling, despite emphasizing an ethos of patient
autonomy, presumed that given the necessary information,
couples would make rational decisions about their childbearing that was not only good for themselves, but which Bseems
correct to society as a whole^ (Reed 1951, p. 67; LaddTaylor 2003, p. 74). He anticipated that counseling would
Bserve the individual first^, but that the state would also enjoy
the fringe benefits of individual improvement. As Diane B.
Paul has noted, Reed and other Cold War geneticists believed
that certain genes were Bunreservedly bad^, and that medical
genetics was Bgood eugenics^ guided by the admirable intention of alleviating the burdens of genetic diseases (Paul, 1995,
p. 124127). Moreover, Reed took for granted that having a
Bnormal^ family was the key to marital happiness. Believing
that Bretardation^ was primarily hereditary, Reed supported
the institutionalization of people with disabilities as they
threatened a familys normalcy through their lack of conformity to kinship ideals of the 1950s (Reed and Reed 1965;
Reed 1955, p. 100101; Ladd-Taylor 2003, p. 7679; Stern
2012, p. 8081). Here, the ideals of mate selection are
reflected in the assumed undesirability of any abnormal trait
in ones offspring. Popenoes perspectives are, however, also
evident by tying family happiness to conservative expectations about normal children as integral to the nuclear family
and a successful marriage in the 1940s and 50s.
Modern Overlaps in Genetics, Marriage,
and Reproduction
By the 1960s, marriage counselling and genetic counseling
had formally diverged and established themselves as independent disciplines. Popenoes counselling paradigm lost momentum as the currency
of Victorian models of woman- and man-hood. Marriage
counselling became increasingly affiliated with religious authorities and, due to its conservative expectations of family
life, found itself marginalized in contemporary discussions
about marriage (Ladd-Taylor 2001, p. 320; Stern 2005, p.
162). Genetic counselors, for their part, developed Masterslevel professional programs starting with Sarah Lawrence
Colleges inaugural effort in 1969. The handful of counseling
programs that cropped up across the U.S. throughout the
1970s emphasized Mendelian and molecular genetics, human
physiology, and developmental biology (Marks 1993, p. 17
18; Stern 2012, p.113-120). The ever-greater reliance of clinical genetics on techno-scientific expertise created a professional gap between genetic and marriage counsellors. At the
same time, links between marriage counselling and genetic
counseling remained as programs formalized Carl Rogers
principles and the psychosocial approaches evident in earlier
counselling practices. Between the 1970s and 2000s, the
Mate Selection, Marriage Counselling, and Genetic Counseling 161
definition of genetic counseling evolved considerably to reflect the growing emphasis on personal support and the psychological well-being of families. The 1974 definition described the field in medical terms, and discussed communication strategies, means of gauging parental attitudes, and the
psychodynamics of counseling (Fraser 1974). By 2006, genetic counselors were defined primarily as communicators
responsible for interpreting family histories, educating people
about various conditions, and counseling Bto promote informed choices and adaption^ to their new health status
(Resta et al. 2006, p. 79). As these definitions shifted, so did
professionals understandings of the importance of unbiased
support in a couples or individuals decision-making process.
Even as genetic counseling professionalized and cemented
its commitment to patient-centered care, the field continued to
confront its relationship to mate selection through its contemporary position at the interstices of genetics, reproduction, and
family life. A prominent example of this ongoing relationship
relates to Tay-Sachs disease (TSD) prevention in the
American Ashkenazi-Jewish community. First discovered in
the 1880s, TSD results in early decline and death during childhood, and lacks effective treatment or cure. Despite its prevalence in other ethnic groups, TSD is intimately associated with
the Ashkenazi community because of its involvement in statesanctioned testing and prevention efforts beginning in the
1970s. Religious and community leaders promoted genetic
education and testing on the basis of BJewish self-preservation,^ and encouraged married and unmarried individuals to
consent to genetic testing and counseling for TSD (Wailoo
and Pemberton 2006, p.16-17).
By the 1980s, following the success of genetic screening
initiatives, the Ashkenazi community developed the Dor
Yeshorim (DY): a registry of genetic information on which
individuals could base their marital and reproductive decisions. Spearheaded by Rabbi Josef Ekstein, a religious leader
from Brooklyn, NY, the program evolved from UltraOrthodox opposition to abortion following prenatal
diagnosis as a means of avoiding genetic disease. The DY
was intended to make TSD carriers aware of their risk status
and enable them to make informed marital and reproductive
decisions. As it evolved, the DY also provided this information for additional diseases including cystic fibrosis, Fanconi
anemia, familial dysautonomia, and Gauchers disease (upon
request), amongst others. While knowing ones genetic status
could be empowering in the matchmaking process by giving
couples a sense of certainty about their reproductive futures,
the DY could also reproduce a sense of stigmatization.
Additionally, members of the Ashkenazi community could
face increased pressure to test due to the expectation that prospective parents would take advantage of genetic counseling
and preventive measures in making decisions about their family life. Genetic counseling then found itself at the center of a
community genetics program with significant personal and
cultural repercussions (Wailoo and Pemberton 2006, 3150;
Raz 2010; Mozersky 2013).
Experiences with genetic testing for sickle cell anemia
(SCA) in the African American community furnish another
example of the contemporary relationship between genetic
counseling, marital choices, and reproduction. Sickle cell, like
TSD, was targeted by state-level genetic testing legislation in
the 1970s; the program, however, received little involvement
from a black community suspicious about government motives in testing for what can be treated as a chronic condition
(Cowan 2008; Wailoo 1997). Geneticist Linus Pauling shored
up these fears in 1968, suggesting that ones carrier status
Bshould be tattooed on the forehead of every young person^
(Wailoo and Pemberton 2006, p. 130). He expected that genetic counseling would play a crucial part in control of the
disease and, echoing Popenoe and Dights calls for a scientific
choice of mate, hoped that by identifying one another early in
life, carriers Bwould recognize this situation at first sight, and
would refrain from falling in love with one another^ (Wailoo
and Pemberton 2006, p. 131). Paulings sentiments were formalized in state laws enacted regarding SCA: three states
mandated genetic counseling services affiliated with testing,
while nine states refused to grant marriage licenses to couples
unless they had undergone testing. Outside of the American
context, the Republic of Cyprus and the Turkish Republic of
Northern Cyprus have mandated blood testing and genetic
counseling before marriage in order to stem the transmission
of -thalassemia (Cowan, 208, p. 165, 181). Marriage proposals have also been affected in countries like Bahrain,
Tunisia, and Jordan by the promotion of premarital carrier
screening and genetic counseling focused on families and
communities for hemoglobinopathies (Bittles 2012, p. 195).
Genetic screening, then, has brought counselors into contact
with modern incarnations of social issues around mate selection and marriage counselling that would be familiar to early20th century practitioners.
Many recently-developed genetic services bear some resemblance to the DY program in their broad goals, but are
offered to the general American public without necessary religious implications. These services, often accessed online,
provide another forum through which Americans can investigate their genetic makeup with the express purpose of preparing to start a family. A company called BCounsyl^ offers a
Family Prep Screen to help you BLearn about diseases that
could impact your future family.^ The site offers carrier
screening, which features Bcouple reporting^ to simultaneously screen both partners and issue a shared report on diseases
with shortened life expectancy, little or no treatment, effective
treatment with early intervention, and conditions resulting in
cognitive disabilities (Counsyl Family Prep Screen, https://
www.counsyl.com/services/family-prep-screen/). Counsyl
suggests that the information gleaned from the screen Bhas
the potential to influence pivotal choices in your life,^ and
162 Stillwell
that screening before pregnancy allows couples to Binvest into
making choices that are consistent with your values^ (Counsyl,
Personal Stories, https://www.counsyl.com/services/familyprep-screen/choices/). The website advises that based on
screen results, couples might prepare for a child with a
disability, consider fertility treatments like preimplantation
genetic diagnosis, or pursue prenatal diagnosis. On the one
hand, Counsyl has appropriated the role of the genetic
counselor in the fashion of many direct-to-consumer testing
companies. On the other, however, these tests offer new forums
for genetic counselors to interface with Americans interested in
managing their genetic risks. In many cases, the tests will be
ordered for an individual or couple by a health care provider
who may be a genetic counselor. In either case, the website
perpetuates the broad assumptions evident in earlier hereditary
advising: that genetic defects can imperil a happy family life.
The mate selection initiatives pursued by Davenport and
Dight also find contemporary corollaries in modern sperm
banks. The selection of sperm donors demonstrates recent
overlaps between genetics, reproduction, and a happy family
life that are not necessarily tied to marriage. Since the 1970s,
sperm banks have offered single women, same-sex couples,
and individuals with fertility issues the ability to fulfil their
reproductive goals (Swanson 2014, p. 198237). Today, companies like GenePeeks offer their clients the chance to assess
potential donors based on physical characteristics and personal accomplishments, but also their genetic attributes. The company claims to be able to identify 500 pediatric conditions, and
is especially focused on Bsilent risk^ (recessive traits).
GenePeeks Matchright Purchase (their premium package,
which costs just under $2000) includes information about a
donor that ranges from physical attributes, personality traits,
and educational and professional backgrounds, to health histories and a Bpersonalized, risk-screened donor catalogue
based on your unique genetic signature.^ The company, which
asserts that BProtecting your baby is in your DNA,^ offers a
genetic profile for both you and your potential sperm donor to
Bbetter protect your future baby from rare genetic conditions.^
Here, the language of protection echoes back to the early-20th
century calls of eugenicists for Americans to protect themselves (and, by extension, the gene pool) through intelligent
mate selection. GenePeeks offers counseling services to help
clients navigate the services they offer, once again placing
genetic counseling at the cross-section of genetics and family
life (GenePeeks website, https://my.genepeeks.com/
genepeeks/displayhome.do; see also Almeling 2011).
Using the Past to Think Through Contemporary
Health Issues
Genetic counselors have been, and continue to be, active participants in negotiating their professions relationship to the
new technologies affecting marital and reproductive practices.
At the 2011 NSGC Annual Education Conference, for example, GenPath Womens Health announced a single genetic
screening test that could detect 600 mutations implicated in
160 different diseases. Time magazine reported that counselors generally felt the test was beneficial by Bencourag
[ing] women to better understand how their genetic makeup
could impact their children^ (Rochman, 2011). Then-NSGC
President Karen Dent, however, also articulated the professions view that testing should be mediated by a counselor,
and that sometimes counselors professional ethics means
Bnot testing because the patient would not benefit^ from the
results (Rochman, 2011). Counselors have continually evaluated their professional and ethical responsibilities in relation to
genetic screening of the general population for genetic disorders like cystic fibrosis; genetic testing for adult-onset conditions in children; and (Stevens 1991/92; Lwiwski et al. 2008; McConkie-Rosell
and Spiridigliozzi 2004; Hawkins and Ho 2012). They have,
since the 1990s, also reconsidered the psychological impact
and effectiveness of Bnon-directiveness^ on the families they
counsel, and held protracted discussions on alternative models
(Kessler 1992; Resta 1997a, 2010).
This paper elucidates how genetic counseling has mediated
discourses and practices surrounding marriage and family life
throughout the 20th-century. In so doing, it contextualizes some
of the more recent issues facing the field that reach beyond the
ethics of non-directiveness. Indeed, recent examples of the interaction between genetic counseling, marriage counselling,
and mate selection indicate the need to question not just how
counselors practice (from what ethical standpoint), but the variety of programs and forumsthrough which genetic counseling
has lived socio-cultural impact beyond the medico-scientific
realm. This history demonstrates the influence of genetic
counseling far beyond the private client-counselor relationship
and individual reproductive decisions. Genetic counseling
clearly has meaningful socio-cultural, political, and sometimes
religious repercussions that exceed Sheldon Reeds description
of counseling as solely concerned with Bwhat is good for a
particular family^ (Reed 1974, p. 45).
Tracing historical moments in which genetic science has
encountered reproductive practices is important for exposing
connections to values that persist despite major politico-legal,
technological, and professional changes. Vestiges of Bpositive^
eugenics remain in contemporary health policies, and raise
questions about issues of choice and coercion in utilizing genetic technology; priorities in medical care; definitions of disease; and the importance of heredity to everyday life (Schoen
2005). This story demonstrates that peoples awareness of the
importance of genetics and concepts of heredity often begins
long before pregnancy or encounters with medical professionals about reproduction. Rather, an inter-generational understanding of family life influences how people think about their
Mate Selection, Marriage Counselling, and Genetic Counseling 163
relationships, marriage, kinship, and overall health throughout
their adult lives. Genetic counselors, then, have quite a considerable sphere of influence and a wide array of opportunities to
shape reproductive discourses. Moreover, this history suggests
that while the impetus to control hereditary disease and use
family planning and reproductive technologies has come from
medical professionals, Americans have also shaped scientific
intentions and policies as potential parents and consumers.
Contemporary corollaries to mate selection and marriage
counseling, then, have often emerged from a kind of conversation between genetics specialists and everyday people, and
are conditioned by both medical and social values.
Biomedical understandings of hereditary disease certainly influence the development of family planning technologies and
how hereditary disease is defined and conceptualized. At the
same time, however, personal aspirations for family life and
social values dictate how (or if) people actually use genetic
technologies to plan their reproductive futures.
Thinking about the ongoing relationship between genetic
counseling, marriage counselling, and mate selection reveals
the significance of considering more than personal, family,
and medical histories in genetic counseling sessions. The public contexts in which individuals and couples make private
choices, as well as the history of these contexts, can help
counselors truly appreciate the ways in which the clientcounselor encounter is a key site through which Americans
make intimate personal choices with profound and widereaching consequences.
Acknowledgements I would like to thank the reviewers for their very
insightful suggestions. Parts of the research presented in this article appear in my doctoral dissertation, Interpreting the Genetic Revolution: A
History of Genetic Counseling in the United States, 19302000, completed at McMaster University in 2013. My doctoral research was sponsored
by a Social Sciences and Humanities Research Council (SSHRC) Doctoral Fellowship. This article was written while pursuing a SSHRC Postdoctoral Fellowship under the supervision of Nathaniel Comfort at Johns
Hopkins University, and with resources provided by the Department of
the History of Medicine.
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