Counselling has become an increasingly central – and sometimes mandatory – part of the provision of infertility treatment services in the UK, although its role is not always clearly defined. In a recent research project, we interviewed 66 staff, with different roles at 20 clinics that provide infertility treatment services (around one quarter of the total). Our research offered some interesting insights into the role of counsellors in this process.
First, while the role of counsellors varied between clinics, it swiftly became apparent that their role was often not well defined (1). Typically, besides providing 'therapeutic counselling' and 'implications counselling' (for the purpose of support and exploration of the issues raised by treatment), counsellors were also sometimes asked to conduct 'assessment counselling' of patients who have triggered the need for further investigation due to concerns regarding the welfare of children who might be conceived as a result of treatment. While a small number of clinics were able to provide more than one counsellor to maintain a distinction between 'therapeutic' and 'implications' counselling on the one hand, and 'assessment' counselling on the other, this was unusual. This created tensions.
As one counsellor told us: 'This [involvement in the welfare of the child assessment] is completely away from my counselling side... you use your counselling skills to elicit information to see what's going on, to see what's not being said, but the patient considers you to be kind of a judge in a sense and, really, to a certain extent you are, because you then determine whether or not something else comes of this matter'.
Second, we were interested to learn that most clinics treated counselling as mandatory for those patients who made use of donated gametes. This is not legally required: clinics are merely charged that they must offer a 'suitable opportunity to receive proper counselling' (our emphasis) (2). Supplementary guidance issued by the Human Fertilisation and Embryology Authority (HFEA) makes it even more clear that the decision of whether or not to accept the counselling should properly lie with patients, stating that 'the centre should allow enough time before treatment starts for patients to consider the offer and to take up the opportunity of counselling if they so choose' (3).
Practice in clinics, however, has evolved to be far more prescriptive. All of our interviewees displayed a strong awareness of an obligation to provide treatment in a way that was non-discriminatory towards particular social groups, and operated in accordance with a presumption that treatment should be provided, even in the presence of initial 'welfare concerns' unless these concerns cannot be resolved through further investigation. While no exception to this principle, treatments involving gamete donation were generally nonetheless regarded as raising a complex set of issues, which left patients in need of guidance.
At one clinic, an embryologist explained that: 'For example, people who need to have sperm donation, we force them to delay for a few months so that we make sure that they've had to time to think through that option rather than jumping into it because it has huge implications, doesn't it?'
Further, patients requiring donated gametes were, in all but one of our 20 sample clinics, talked of as needing to undergo at least one session of 'implications counselling'. Such counselling was described as providing an opportunity for patients to consider a number of issues that could potentially arise from the use of donated gametes. This tended to be described as being 'mandatory' or 'compulsory', with interviewees sometimes stating an erroneous view that HFEA guidance requires that patients undergo counselling.
Others reported that counselling was a mandatory requirement imposed by the clinic, with yet others noting that while making it a formal requirement had been opposed, patients seeking donated gametes would be 'pretty strongly invited' to have implications counselling. Another said that while counselling was not compulsory it would be 'more of an offer they can't refuse'. As such, it is clear that in many clinics receiving counselling is being treated as a precondition of being accepted for treatment.
We are grateful to the ESRC, Economic and Social Research Council, for funding this study (RES-000-22-4291), further details of which can be found at the website: Centre for Parenting Culture Studies