Brave New Families: Modern Health Technologies and Family Creation

Dianne M Bartels. Handbook of Contemporary Families. Editor: Marilyn Coleman & Lawrence H Ganong. Sage Publication. 2004.

Health care technologies can extend life, decrease disability, and expand reproductive options. With technical assistance, members of families can often survive life-threatening illnesses. Infants can survive when born at increasingly earlier stages of gestation. Couples experiencing infertility can have biologically related children.

Families faced with decisions to use or to bypass these technologies are likely to encounter profound psychosocial and ethical challenges (McDaniel, Hepworth, & Doherty, 1992). In these deliberations, families consider not only survival but also the quality of life that will be possible following technological intervention. Nowhere are these challenges more evident than in making choices about the use of reproductive and genetic technologies. These health care interventions can change family structure, family functioning, and even how we define family (Bartels, 2002).

In this chapter, I will describe the role of reproductive technologies and genetic testing in family creation. I will address available data on how people make decisions about using technologies and how these methods of family creation have affected children, families, and family relationships. Finally, I will discuss theoretical underpinnings and research strategies that have been, and could be, used to expand our knowledge about these modern-day families.

The Nashes are one family that faced a series of technologically related health decisions to aid in the survival of one child while creating another. Their situation exemplifies the power of new technologies and the possibilities they afford. Molly Nash was born with Fanconi’s anemia (FA), a rare genetic disorder that affects all bone marrow elements, resulting in anemia. Without treatment, the person with FA will develop a life-threatening leukemia (Online Mendelian Inheritance in Man, 2000). The Nash family became the subject of national media attention when the parents chose to have another child using reproductive technologies and genetic testing. They requested that embryos be tested before implantation in the mother’s uterus so that one could be selected that would not be affected with FA. Additionally, they asked their physician to test the embryos in order to select one that could be a stem cell donor for Molly. Their hope was that by transplanting stem cells from the umbilical cord of their next child, they could ameliorate the progression of Molly’s illness. The Nashes’ second child was born healthy as a result of these interventions, and his stem cells were used for a bone marrow transplant procedure for Molly.

The Nashes’ situation is quite rare in that they used reproductive technology (in vitro fertilization [IVF]), genetic diagnosis, and bone marrow transplantation in an effort to have one healthy child and to offer treatment to another. More typically, couples use reproductive technologies and genetic testing to enhance fertility and to increase the likelihood that they will have a healthy child.

Creating Families Using Reproductive and Genetic Technologies

Reproductive Technologies

Childbearing and child rearing are inherent parts of family development and in many cases are inherent parts of one’s personal identity. Because this is so, the inability to have children has been described as both an individual and a family crisis (Hammer Burns & Covington, 1998). Societies have created a myriad of approaches to addressing the crisis of infertility. These approaches have included changes in social relationships (e.g., divorce, adoptions) as well as spiritual and medical interventions (Rosenblatt et al., 1973). Today, couples experiencing infertility will most likely turn to the health care system in their quest for answers. IVF is the primary remedy used to address infertility problems.

IVF is a medical intervention that has helped thousands of couples annually to have biologically related children (Society for Assisted Reproductive Technology & American Society of Reproductive Medicine, 2002). First successfully used in the birth of Louise Brown in 1972 (Edwards, 1980), the procedure involves combining an egg and a sperm in a laboratory dish, then implanting developing embryos into the womb (Strong & DeVault, 1992). Donor eggs (ova) and donor sperm can also be used to increase the likelihood of becoming pregnant.

For women who cannot conceive or who cannot carry a pregnancy, there is an option of contracting with another woman to carry the pregnancy in her womb until birth. The surrogate mother (also called a gestational carrier) may donate her eggs, or she may carry a fetus that is a product of the contracting couple’s egg and sperm. Couples initiating these relationships assume that the surrogate mother will relinquish parental rights at birth so they can adopt the child (Bartels, 1990). With all of these options available, children could potentially have two social (adoptive) parents who raised them, two other biological parents (an egg donor and a sperm donor), and a surrogate mother involved in their creation.

The possibility for human cloning may be the most controversial issue on the reproductive technology horizon. Cloning involves replacing the female genetic material of an unfertilized egg with a nucleus from a different cell. Thus, the genetic material in the nucleus will be identical to that of the donor, essentially creating a twin born at another time (Gurdon & Colman, 1999). Cloning, unlike other reproductive technologies, has been the focus of much legislative oversight and restriction.

The availability of reproductive techniques has fundamentally changed the ways families are created (Golombok, MacCallum, & Goodman, 2001). People who in the past might have remained childless or sought other alternatives like adoption (e.g., single adults, gay and lesbian couples) are now able to have biologically related children (Fasouliotis & Schenker, 1999). Success in cloning would eliminate the need for a sperm donor in the reproductive process. These reproductive techniques, in combination with testing to predict genetic traits, can also determine the structure and membership of entire families.

Genetic Research and Family Creation

During the 1950s, genetic researchers developed techniques that made it possible to detect prenatal chromosomal abnormalities associated with medical problems ranging from malformation and retardation to infertility and reproductive failure (Thompson & Thompson, 1986). In the United States today, pregnant women over 35 years of age are routinely advised by their physicians to have prenatal testing to detect potential chromosomal problems like Down’s syndrome because the risk increases with the age of the mother. Family members concerned about passing on familial genetic conditions to their children can also use prenatal testing to see if a fetus is affected.

In seeking genetic and reproductive technologies, most expectant parents hope for a perfect babyone with maximum health and minimum defects (Hammer Burns, 1999). Although most people receive reassurance that a chromosome problem is not present, when testing reveals there is a problem, couples may face a decision about whether to continue or to terminate the pregnancy. A decision to terminate appears to have psychological consequences similar to having a miscarriage, including grief, loss, sadness, and depression (Hammer Burns & LeRoy, 1998). Preimplantation genetic diagnosis (PGD), as used in the Nash case, allows detection and selection of healthy embryos before implantation. Some couples prefer this option because it avoids the need to consider terminating pregnancy.

Advances in molecular biology, especially the discovery of recombinant DNA techniques during the 1970s, have further increased medicine’s ability to analyze human hereditary material. In hopes that genetic research will lead to treatments and preventive strategies for common as well as rare genetic disorders, both the private and public sectors have invested heavily to develop genetic technologies. The success of these efforts means that we can now identify many genetic conditions before symptoms arise (Center for Bioethics, 1999). Genetic prediction will become a major tool for health care management (Collins, 1999). Physicians will use genetic tests to predict future health conditions and will make treatment plans based on identified genetic susceptibilities (Doukas, 1993). These predictive abilities will expand the range of medical problems that can be detected prenatally as well.

The combination of reproductive technologies and genetic tests creates powerful tools to enhance abilities to have healthy children and even to save children’s lives. Many questions have been raised about the impact of these technologies on families, and some questions have been answered. The following section describes what we have learned about families’ use of reproductive and genetic technologies in family creation.

Studies Addressing Family Responses to Reproductive and Genetic Technologies

Family scholars and health professionals have taken a variety of approaches to exploring the impact of technologies, including (a) describing how people make decisions about whether to have prenatal testing or to use reproductive technologies, (b) describing outcomes of reproductive technologies in terms of children’s health and family relationships, and (c) addressing genetic and reproductive technologies in the context of the health care system and the broader society.

Making Decisions about Reproductive Technology and Genetic Testing

Potential parents might decide to have no children, to have biological children, to adopt, to request prenatal testing, to use reproductive technologies, or to pursue a combination of alternatives in the process of creating their families. Initial studies focused on outcomes following prenatal genetic testing and on factors that related to decisions about whether to have testing.

Rational choice models have been used to describe factors that influence decisions about using prenatal testing and/or reproductive planning in the face of genetic risks. Those who come for prenatal testing are often white, upper-middle-class, and highly educated couples (Burke & Kolker, 1993). Couples who have a child with a genetic problem also may be likely to pursue testing to ascertain their genetic risk for having another child with problems. Couples who have no children may accept a risk of genetic disease rather than remain childless (Evers-Kiebooms, Denayerr, & Van Den Berghe, 1990). In one study, the birth of a child with cystic fibrosis had a major influence on reproductive planning (Evers-Kiebooms et al., 1990). For these parents, the risk of recurrence played the most important role in postponing or deciding against further progeny.

Rates of pregnancy termination following nearly 26,000 amniocenteses (prenatal genetic tests) increased with the severity of the health effects of the chromosome problem (Vincent, Edwards, Young, & Nachtigal, 1991). However, when Frets et al. (1990) interviewed couples with a history of genetic problems 2 or 3 years after genetic counseling, they found that 70% of couples opted to have children despite the risk. They surmised that the couple’s interpretation of risk, rather than actual risk, and their desire to have children were the paramount factors influencing reproductive planning. People who had a child, sibling, or spouse affected with a genetic condition also described guilt feelings as they considered their options. This was more true of people who had a sibling with a genetic condition than of those who had an affected child (Frets et al., 1990).

Couples who have experienced infertility may be ambivalent about genetic testing. The potential for a genetic diagnosis may be seen as further evidence of flaw or failure that could precipitate feelings of shame, embarrassment, guilt, deficiency, and inadequacy (Hammer Burns & LeRoy, 1998).

Parents who decided to continue a pregnancy in the face of a prenatal genetic diagnosis indicated that they did not actively decide; rather, a decision was made in a more subtle process that occurred over time. Factors that influenced the final outcome included religious and personal beliefs, past experiences, and uncertainty about outcomes with a specific diagnosis. These parents said they needed informational and emotional support from family, friends, and health professionals; a lack of emotional support from parents and grandparents was particularly troubling during this time (Redlinger-Grosse, Bernhart, Berg, Muenke, & Biesecker, 2002).

Couples asked about their process for making decisions about continuing or terminating a pregnancy indicated that rather than using logical models to make decisions, they created scenarios to help limit uncertainty and to decide. They imagined various future scenarios with a disabled child, then asked themselves whether they could cope or manage (Lippman-Hand & Fraser, 1979). These scenarios were influenced by prenatal history and whether they already had a healthy child, as well as consideration of what they had experienced as a person or relative of a person with a genetic condition, what the early death of a child might mean to them, and how others outside family might react to their situation. Other factors (e.g., religion and career commitments) also influenced reproductive decisions. Ultimately, these decisions centered on profound social meanings and imagined social consequences rather than on biomedical data or abstract principles (Beeson & Golbus, 1985).

As the U.S. population diversifies, investigators looking at systemic influences have found substantial variation of opinion about prenatal screening and diagnostic testing. Western-culture couples are more likely to see genetic testing as providing hope and promise, and they may be more sensitive to social criticism for foregoing testing than are couples from non-Western cultures (Hammer Burns & LeRoy, 1998). Mexican American women, who refuse prenatal testing at high rates, do so because of their general attitude toward doctors, medicine, and prenatal care, as well as their personal assessment of risk and uncertainty (Browner, Preloran, & Cox, 1999). In a culturally diverse group of women, factors influencing their views included available resources, feelings about a child with Down’s syndrome, moral beliefs, family and social influences, perceptions of one’s own health, the difficulty of becoming pregnant, and willingness to put a fetus at elevated miscarriage risk (Moyer et al., 1999). These findings suggest that policies for recommending testing should go beyond medical indications and must be more sensitive to how ethnic minority clients make choices.

In summary, these investigations have identified a broad range of factors influencing prenatal decisions and have shown that rational choice models cannot capture the entirety of reproductive decision making. Researchers have generally not addressed decision situations in the context of the family, the health care system, and the broader society, although health care practitioners’ beliefs and values also are likely to influence whether clients accept or decline testing (Anderson, 1999). Post hoc interviewers appear to have presumed that couples’ voices were united throughout the decision-making process, although health care professionals have reported major couple disagreements in the context of making these decisions (McCarthy Veach, Bartels, & LeRoy, 2001). The studies just described addressed prenatal planning and testing in situations that focused on whether the risk of genetic health problems would be avoided by not having children. In the late 1990s, investigators began to look at the outcomes of assisted reproductive techniques that had been used both to enhance fertility and, in some circumstances, to avoid transmitting genetic conditions.

Impact of Assisted Reproduction on Children

Research efforts to address the effects of reproductive techniques focused on whether the infants, children, and adolescents conceived using reproductive technologies varied from those who were naturally conceived. These studies addressed concerns about the unintended effects of new technologies and growing unease about potentially negative consequences for children. Some concerns related to residual effects of distress related to infertility and its treatment (Golombok, MacCallum, Goodman, & Rutter, 2002). Other researchers worried that parents who had had difficulty conceiving might be overprotective and emotionally overin-vested in their children (Montgomery et al., 1999). Overall, these studies focused on the early years of development and found no deleterious effects for children conceived using reproductive technologies. A study of infant attachment at 12 months postpartum showed “predominantly secure attachments” and no significant differences in interaction during play between children conceived through the use of technologies and children whose parents did not use them (Gibson, Ungerer, McMahon, Leslie, & Saunders, 2000, p. 1015). Behavioral observations of mother-child interactions and self-rated questionnaires also found no significant differences related to means of conception in children 24 to 30 months old (Colpin, Demyttenaere, & Vandemeulebroecke, 1995). Children ages 6 to 10 years performed equally well in school (Olivennes et al., 1997), and children at age 12 who had been born after donor insemination were well adjusted in terms of social and emotional development when compared with adopted and normally conceived children (Golombok et al., 2002). Additionally, Montgomery et al. (1999) reported normal psychological development and no adverse effects in school-age children who had been conceived by IVF when compared to control groups. Similar findings were true for IVF-conceived adolescents (Golombok et al., 2001). Finally, a meta-analysis found no significant differences in terms of emotions, behavior, self-esteem, or children’s perception of family relationships between children conceived with reproductive assistance and children of parents who had not used technology (Hahn, 2001).

Impact on Family Relationships

One outcome of IVF is an increased rate of multiple births. One preliminary study suggested that parents who had twins following IVF experienced more stress than those who had naturally conceived twins (Cook, Bradley, & Golombok, 1998) but that the stress did not affect parenting or child behaviors. Overall, a lack of genetic relationships does not lead to difficulties in the parent-child relationship. In fact, greater psychological well-being has been found among mothers and fathers where there is no genetic link between mother and child (Golombok, Murray, Brinsden, & Abdallah, 1999).

Regarding specifically families who used donor insemination, the only things that distinguished them from others were mothers who exhibited greater expressive warmth and fathers who were less involved in discipline than in families where the social father was the biological father (Golombok et al., 2002). Conclusions from an examination of literature from 1980 to 1995 were similar; the quality of parent-child relations was better with the donor insemination group than in naturally conceived families (Brewaeys, 1996). Similar conclusions were derived from a meta-analysis of the literature from 1980 to 2000; mothers of children born with artificial reproductive technologies reported less parenting stress and more positive mother-child and father-child relationships than was true of mothers of naturally conceived children (Hahn, 2001).

All of these studies of children and parent-child relationships suggest that parents who embark on creating children using reproductive technologies can be optimistic about the likely outcomes (Hahn, 2001). Overall, reproductive technologies are not more likely to lead to problems in terms of child health outcomes, co-parenting, or parent-child relationships. However, because these technologies are so new, we do not yet have empirical evidence of how adults who were born using reproductive technologies were influenced.

It should be noted that European scholars have conducted most research on reproductive outcomes, and similar data about U.S. children and their family relationships are not available. The reasons for this are not clear. We might speculate that it relates to reproductive autonomy and donor confidentiality, which are highly prized in the United States. U.S. legislators have taken a much more “hands off” position and been less supportive financially to reproductive technology researchers than in Canada and the United Kingdom, where federal commissions have long provided oversight and support of new reproductive technologies. There is much to learn about U.S. families using reproductive technologies, and approaches examining whole family systems, rather than just children, parent-child, and couple relationships, need to be undertaken. For instance, one may wonder about the responses of other children in the family, about family communication and relationships over time, and about families in other societal contexts.

Families in the Health Care and Societal Context

Most decisions about whether and how to use reproductive and genetic technologies occur in the context of the health care system, yet few studies have addressed the experiences of families in that context. In one study, clinicians described families who experienced distress, including feelings of blame, shame, guilt, and responsibility for passing on a genetic condition to a child and concluded that one partner may blame the other for being the carrier who passed on a condition to a child. In some instances, couples divorced following a disagreement about whether to have prenatal testing or whether to terminate a pregnancy (Bartels, 2002). Clinicians also expressed concern about family secrets that could prevent a child from knowing about his or her genetic heritage. These secrets included revelations of false paternity (i.e., the social father not being the biological father) and parents who chose not to tell their children about genetic problems that could affect them. Professionals believed that children ought to have data that might be relevant for their own health care and for making reproductive decisions.

Clinicians were most concerned about requests from parents who wished to select traits in their future children. These requests might be to select an embryo that could be a bone marrow donor, as in the Nash case, but more troubling for clinicians were requests for sex selection or decisions to terminate a pregnancy for a condition that did not involve a threat to the future child’s health (Bartels, 2002; McCarthy Veach et al., 2001).

Concern has been registered about “tentative pregnancies” and about a “technology of quality control” that turns the process of having children into a production process where only certain products are acceptable (Katz Rothman, 1993, p. viii). Although supposedly giving women more freedom of choice, these technologies may, in the long run, constrain choices by societal insistence on prenatal testing. Children could come to be seen as products of conception, with abortion as an integral part of using the new technology (Katz Rothman, 1993). Clinicians who interacted with families were also concerned about societal judgments of parents who make difficult reproductive decisions (Bartels, 2002).

Like any new technology, new reproductive technologies raise controversial psy-chosocial and ethical concerns. For example, people who do not believe in abortion would repudiate all genetic testing and reproductive interventions that destroy embryos. Disability advocates have expressed concern about the availability of prenatal testing that provide parents with a choice about whether to have a child with disabilities, and some believe that offering this choice will lead to greater intolerance of existing people with disabilities (Asch, 1999).

An additional concern relates to resource allocation and disparities in who has access to new technologies. In 1992, IVF costs averaged $60,000 to $114,000 for young couples and $800,000 for older couples (Hahn, 2001). Most of these procedures were not covered by insurance, leaving many people unable to afford them. This disparity raises many policy questions that need to be addressed in the context of families, the health care system, and broader society.

Nondisclosure to Children

Another expressed concern is that many parents do not plan to disclose means of conception to their children (Bartels, 2002; Brewaeys, 1996; Golombok et al., 2002; Oliviennes et al., 1997; McWhinnie, 2001). This could be problematic for children in view of the expectation that health care in the future will be premised on genetic data (Collins, 1999; Doukas, 1993). To benefit from genetically based health care, a person needs to know his or her biological makeup. Children who are not told about the involvement of egg or sperm donors in their conception will make inaccurate assumptions about their health history and genetic risks. Unlike adopted children, who now are generally told about their origins, these children could be surprised to find out as teens or adults about their donor conceptions (Golombok, 1999). Children might discover information about their conception from genetic test information or from more routine tests like blood typing, or they could figure it out in a biology class where they learn about patterns of genetic inheritance. Furthermore, without reliable information about their family history, they cannot make predictions about whether they might pass on genetic disorders to their children. Most parents who withhold information about conception from their children indicate that they told other friends or relatives about their attempts to solve problems of infertility (McWhinnie, 2001). Such disclosures increase the chances that children will learn from other people who know about the parent’s use of reproductive technologies.

Only a few investigators have directly addressed the issue of nondisclosure. Brewaeys (2001) described three reasons parents gave for withholding this information: (a) concern for the well-being of the child, who could feel confused or insecure with this knowledge, (b) a desire to protect the social father, for fear the child might feel less attached if the lack of a genetic relationship were known, and (c) uncertainty about what information to share or when to talk about it. Other reasons for withholding information included social stigma related to infertility or to the use of reproductive technologies, as well as attempts to preserve family harmony and to protect the feelings of the infertile husband (Landau, 1998). Unlike adoption, which is a well-known, accepted practice, use of reproductive technologies, especially gamete (egg and sperm) donation, is more controversial (Brewaeys, 1996). Parents who disclosed the use of biological donors did so because of their understanding of negative effects on adopted children who found out later in life. Deciding to share this information did not solve all of their problems, however. Concerns remained about what to tell their children about the sperm donor when they were teens or adults, given that anonymity precludes obtaining genetic information (Brewaeys, 2001).

Data about opinions of adults who were born following gamete donation have come from people participating in support groups or communicating with one another via Internet chat lines (McWhinnie, 2001). A look at these exchanges revealed that people who learned about their origin later in life wished they had been told much earlier. Their feelings of anger and resentment were similar to those of adults who had been adopted and had not been told. They also wanted information about their donor’s appearance, education, interests, and personality. These concerns, however, were unlikely to be resolved. Unlike adoption, records of gamete donation are not generally available to families, nor are they kept for later availability (McWhinnie, 2001). Policies for donations were designed to protect the anonymity of the donor and the privacy of infertile adults (McWhinnie, 2001). However, there is growing consensus that adult children should have access to the identity of their genetic parents (Caulfield, 2002; Eichler, 1996). What that information would mean to children has yet to be determined.

How Have Technologies Changed Families?

The introduction of new reproductive technologies in the 20th century constituted a fundamental change in the way in which families can be created (Golombok et al., 2001). Technologies make it possible to have healthy children and even to save lives. Eligibility to have children is no longer limited primarily by biological parameters. Edwards (1991) discussed how the advent of medical technologies, especially genetic and reproductive technologies, created a need to reconsider the prevailing model of the familynuclear family with heterosexual parents and gender-specific roles (Gates & Lackey, 2000). Clearly, static definitions of family are much too narrow to encompass the range of relationships and structures that make up what we are coming to know of families in this age of advancing technologies.

Family scholars have suggested some of the likely effects of these technologies on families. First, family relationships and family structure will become more complicated as family creation is mediated by technologies (Edwards, 1991). Families who have genetic testing may face moral decisions that revolve around individual rights versus collective responsibility. Specifically, families will need to address (a) decisions about secrecy, confidentiality, and disclosure; (b) feelings of despair and hope; (c) life cycle choices; and (d) family roles and relationships (Taswell, 1999).

With expanding reproductive options, we will need much more analysis to begin to understand what these technologies mean to families. We might learn by applying what we already know about families facing similar challenges in other contexts. Weil (2000), a family therapist, has reminded us that although genetic and reproductive sciences create new options, these options will be applied to human experiences that are age old. “The science is contemporary, but the hopes, fears, and anxieties surrounding genetic disorders and birth defects remain, in many respects, unchanged” (p. vii).

Summary of Where We Have Been

A focus on reproductive decisions has identified a number of issues of consequence for families, therapists, and researchers. Family scholars and therapists have previously addressed many of the issues family decision making and handling of grief, guilt, and family secretsin other contexts. That knowledge could be incorporated into approaches for family counseling about genetic testing and reproductive decision making. We have some knowledge about factors that influence who uses reproductive technologies and why. We are just beginning to listen to women’s voices, to recognize diversity, and to look at the contexts in which both decisions and technologies occur. We have yet to listen to the voices of potential fathers or other family members who would also be affected by reproductive decisions. Reproductive technologies and genetic tests have solved many problems for people wishing to have children. The last 20 years of investigation indicate that parents planning to use reproductive technologies can be reassured that there are no devastating health effects or major disruptions in parent-child and parent-parent relationships (Hahn, 2001). Findings have suggested that children’s psychological adjustment may be less influenced by family structure than by warm, supportive relationships (Fasouliotis & Schenker, 1999).

We have much more to learn about genetic and reproductive health care. We have not yet looked at families who use these interventions as systems acting together or in the context of other systems (e.g., health care, schools, broader society). We know that health professionals have identified a number of challenges that families face in the health care context. However, we do not know what families would say about themselves in terms of psychosocial and ethical challenges that they encounter in the health care system or in other societal systems in which they participate. Studies have been driven by questions of interest to researchers; families have not generally been involved in developing research questions and/or research methods.

Reproductive and genetic technologies have expanded the need to explore definitions of families that are not dependent on biological relationships. Families and users of medical technologies, generally, are increasingly diverse, yet most outcome studies have described families headed by two middle-class, heterosexual parents (Hahn, 2001). More attention could be paid to the relative influences of family structure and family relationships by including other families (i.e., single parents, gay and lesbian couples) and by including more racial and ethnic diversity in samples (Golombok, 1999; Hahn, 2001). Perhaps most striking is the disconnection between medical and family researchers. Family scholars have suggested a number of issues that could be examined, although research thus far has focused primarily on medical decisions and health outcomes.

What Might the Future Hold?

One thing about which we can be certain is that family forms and options for creating them will continue to evolve and to bring new challenges for family scholars and practitioners. Embryo adoption will offer new possibilities to infertile people seeking to have children. Artificial wombs might give women the option to forego pregnancy, and human cloning could eliminate the need for gamete donors (Weaver, Umana-Taylor, Hans, & Malia, 2001). A growing understanding of the role of genetics in common diseases may create options for in utero treatment of genetic diseases or for preselection of embryos that will not be affected by them.

Lessons from family scholars in past decades can add depth and breadth to future investigations. To explicitly state the theoretical assumptions that guide research would provide focus and could link findings to other family data. In the research reviewed here, research questions were usually explicitly stated, whereas theoretical underpinnings were less explicit. As new technologies raise new questions, new theoretical approaches may be needed.

More collaboration among family science and health sciences practitioners and scholars could address a number of concerns that have been raised. For instance, adoption studies could potentially tell us a lot about families who are not biologically related and could predict outcomes of disclosure related to gamete donation or gestational carriers (surrogate mothers). Adoption scholars have found that many of the concerns initially raised about openness in adoptions were unfounded. As a result, adoption practices have become increasingly open. Not only do parents disclose relationships to their adopted children, but many families have arrangements where the biological mother continues a relationship with the child after adoption (Grotevant & McRoy, 1998). Looking at family processes rather than family structures could help us to look at strengths and resources rather than potential deficits and threats. Indeed, one might learn about parenting skills from parents who have been intentional about having children and who have spent time, money, and effort in creating these technologically mediated families (Weaver et al., 2001).

Most importantly, we will want to avoid judging what is normal from what is typical and assuming that what differs from the norm is pathological. In past decades, we have witnessed much anxiety over diverse families (e.g., single-parent families, stepfamilies, gay and lesbian families, ethnically diverse families), yet a focus on family functioning has revealed unique strengths in these families (Walsh, 1993). Families created using genetic and reproductive technologies can be seen as an additional type of diversity with similar challenges and resources.