Chris Evans with Sue Stuart-Smith
Reference is Evans,
C. and S. Stuart-Smith (2000). "Mapping the complexity of the
transgenerational in the 21st century -- taking genograms onward." Context
49: 23-24.
Information and codes
Moving from millennial fever into the 21st century proper, the 3rd millennium of Christianity, it's probably easier than ever before to be aware of the multiple voices and cultures on our globe. As I'm an agnostic, recognising that I'm indexing time by reference to a particular religion jars and it puts this global discourse in focus. Who owns time? Who owns what? More and more of the people of the globe are communicating in forms of English on the Internet in a virtual tower of Babel. None of us owns English, none of us owns the Internet, but we all have the copyright of anything we write. Of course this new tower of Babel is "actually" a spherical pancake wrapped around much of the surface of the globe. It stretches a little into space with its reflecting team of satellites and yet is still also linked by ocean floor networks of conventional cabling like the old phone still linking the therapy room and the team room. Welcome to arbitrariness of coding and self-similarity within chaos. Welcome to network diagrams that make this all possible.
Four months into this new millennium the "human genome project" promises imminent delivery of the first completely mapped individual human's genetic code. It seems no accident that this comes in the middle of fights about ownership of that "intellectual property", competition between private industry funded, and public sector funded, components of the genome project. Who owns "our" code in this state of affairs and what becomes of transgenerational threads of identity? It's probably no accident that the ubiquitous Internet is there again as the likely vehicle for publication. If we can't sort out ownership perhaps it seems we can at least agree lines of communication.
Another development that has come about more slowly has been the increasing control over reproduction. Control of contraception through oral contraceptives probably shaped radical developments in attitudes to sexuality and to gender in the second half of the last century but that technology progressed little in the last thirty years. By contrast, the last thirty years brought dramatic developments in assisted conception. There has been some development in the ability to harvest and preserve sperm and artificial insemination has become a routine process. One set of public stories has concerned the potential for children to be born through "AIH" (Artificial Insemination by Husband" to use a dated acronym and a now almost defunct process) and "ICSI" IntraCytoplasmic Sperm Injection, the injection of a single sperm into an ovum. The particular fascination has been on the fact that the children might be conceived and born after their father has died. The routine use of that technology has become commonplace enough (and thankfully thus private again for most families). The remaining public controversy is again over "ownership", this time the right of a female partner to use sperm extracted and stored from a comatose partner without his consent between his becoming ill and dying.
Another area of dramatic development has been in promoting the release of ova, "harvesting" them, being able to fertilise them outside the womb, and their implantation into the womb of either the woman who created that ovum, or the womb of another. The developments in the ability to "assist" fertility by promoting release of fertilisable ova has led to many sorely wanted children as a quiet backdrop to tabloid stories about multiple pregnancies and births. However, most tabloid story telling and excitement has concerned ovum donation and surrogacy: carrying a baby for another.
And that brings us to the latest big wave of issues: what does it mean to be able to have one woman carry a child to term in her womb that is the product of someone else's egg, fertilised outside her body, perhaps by a stranger's sperm? A news theme of the last year has been that a gay (male) couple are suing the woman who gave birth to their twins for some alleged breach of the contract they and she had. Another concerns a British woman who went to Greece to allow her womb to be implanted with an embryo from a sperm from an unknown American man and British woman. The Italian father and Portuguese wife who were paying her discovered that the twins were girls and insisted she had an abortion. The surrogate mother refused, went to California, had the girls and gave them to a lesbian couple for adoption. We are in thick of issues about ownership, of the stories that people tell children and each other to help, contain and define ourselves. We are also in the difficult territory of the stories that are not told and profound questions about rights to know and responsibilities to tell.
We may be able to clone an embryo. We may have a full human genome sequence but "who did what with whom, where and why?" remain key stories. These are stories that define families, open or close options, cause or abate pain and the job of therapists is to work with these stories, these patterns and our work may come to be about stories that are not told and why.
At a very practical level we need to be able to put these things on a genogram. It behoves anyone who still draws a genogram (perhaps only in the privacy of one's own self-supervision) to be comfortable with a code for these things. I have been uncomfortable for some time about the practice of drawing adopted children onto a genogram essentially as genetic children, perhaps with an "A" or a note marking the adoption. While that may be fine at certain stages of the family's identity and the child's age, there is a seeming clash with the right, at 18 years in the U.K., to be informed of the genetic parents' identity, to the extent known, and the process of adoption. Adoption and fostering are hardly new phenomena: one of my father's memories of his childhood is that as he was a second child there was serious consideration of him being given to childless relatives who liked him and were better off than his own parents. Perhaps anxieties about openness in this area have been more within the classes who had more wealth to inherit, perhaps they have grown as we have appeared to take more and more technological control of reproduction.
If we are not perhaps as comfortable drawing genetic parents of adopted children onto genograms as we might be, I am struck that we don't have any agreed notation for sperm donation, ovum donation or surrogate pregnancy. I suspect this reflects some normative assumptions and discomfort within the profession about these issues and I'm suggesting that we should draw genetic parents on genograms. (Clearly only with the permission of the adoptive parents for children under 18 if this is a genogram shared with the family). In the UK we have the prospect that in 2008 it will become a right for children born through IVF to know their genetic parents but a problem that the records kept may contain only physical descriptors of donors. Sweden has a different approach: sperm donation and hence AID and donation of sperm to IVF is only legal if the donor is willing for his identity to be known (ovum donation is illegal there). We are in a globalised world but still have many national differences.
If we are drawing genetic parents onto genograms I think we need symbols to reflect the different routes of "parentage" (if that is the best word, perhaps it isn't). In the fictional genogram below I have used dotted lines for donation of sperm and ova with the head of the line a diamond for sperm and a filled small circle for an ovum. I have suggested a continuous line and a cross and open circle at the head for surrogacy or womb donation. I think the full line catches something of the months of gestation and the circle and cross catch both the conventional symbol for female and also something of the convention of a line across a link indicating a separation.
These lines may seem new, alien, technological. However, we have long known that one's genetic father is harder to determine confidently than one's mother. (A classic study much referred to in medical textbooks, but which I've never found, is said to have shown that blood typing children born in a London hospital in the 50s showed that between 25 and 40% couldn't have been fathered by the man on the birth certificate.) We have a tension between this uncertainty and our traditions of patrilineal names and ideas about property and other inheritance. Clearly different cultures have different inheritance systems but patrilineal systems are, I believe, commoner than matrilineal.
But what about surrogacy and gamete donation and is all this as new as it seems? Well, the millennium marks a virgin birth narrative but other strikingly pertinent stories abound in the Mahabharata (e.g. Rajagopalachari, 1990<1951>). The five Pandavas at the core of the great battle with their cousin and his allies are good examples. They are not born to Kunti and Madri, the wives of their father Pandhu, by intercourse, as Pandhu had been cursed to die if he had intercourse, but by Kunti's invocation of her blessing to be able to bring about conception and instant birth of children by divine intervention. Something she did for both herself and for Madri. Whilst the story clearly identifies all the Pandavas as the sons of Pandhu there is also clear implication of other, divine, donation to their conception. The core of the Mahabharata concerns the enmity that develops between the Pandavas and their cousins, the Kauravas (all one hundred of them, born to the same mother and father). The Mahabharat culminates in the almost genocidal battle between the two forces at Kurukshetra. Themes of family, identity, ownership and the power of stories run through the saga in a way that seems extraordinarily relevant in the 21st century. One of the Pandavas' most terrifyingly dangerous rivals, Karna, is, unknown to anyone but Kunti, their half-brother born again without intercourse. Karna was born to Kunti by the sun god when, as an adolescent, she first invoked her boon just to see if it were true. Karna is one of many children in the Mahabharata adopted and unaware of his genetic (and often divine) origins. Much of his anger comes from his shame about his adoptive parents' low social status. Krishna, a god in human form in the saga is an exception. His counsels to Arjuna (one of the Pandavas) during the battle form the Bhagavad Gita and concern duty, love, affection and pain. He is unusual in that he is an adoptee through a divine donation but he is omnisciently aware and proud of his adoption and origins. There are stories here aplenty for families needing something beyond the technological.
We may not have complexity and celestial richness of origins of the Mahabharata, but on any skeletal genogram, much can be drawn. In the fictional example given, the genetic family of origin of the adopted son could be elaborated to three generations perhaps. The links, and the social worker(s) involved in the adoptive/genetic parent contacts (or lack of) might be drawn on. The lines in I've drawn for the new biological options are just the skeleton of a genogram but they seem worth catching and coding. Many transgenerational family stories gain stiffness from a skeleton of this sort be they problem, resource or solution focused — as with the Internet, there may be no simple answers about ownership, perhaps there shouldn't be, but we need the network diagrams if we are to communicate.
Sue Stuart-Smith is an
specialist registrar in psychotherapy who got me thinking about surrogacy and
kept me on the straight and narrow about what is currently possible in
fertility treatment.
TGFT is mounted for access on the WWW at: http://www.psyctc.org/tgft/
References
Rajagopalachari, C. (1990<1951>) Mahabharata (C. Rajagopalachari, Trans.) (31st edn). Bombay: Bharatiya Vidya Bhavan.
Relates to
diagram 21stcent.jpg (21stcent.wmf
gives you better version for incorporation into Word or other word processing
files) diagram and to two genograms from the Mahabharata: Mahab1.jpg
and Mahab2.jpg (or Mahab1.wmf
and Mahab2.wmf).
