Endometriosis -- The Silent Invader

Endometriosis is a common disorder that affects women of reproductive age. It occurs when normal endometrial tissue (the lining of the uterus) grows outside the uterus. This misplaced tissue may implant itself and grow anywhere within the abdominal cavity.

Many specialists feel that severe endometriosis is more likely to be found in infertile women who have delayed pregnancy - and for this reason, the condition is sometimes labeled a "career woman's disease".

Endometrial tissue, whether it is inside or outside the uterus, responds to the rise and fall of estrogen and progesterone produced by the ovaries during the reproductive cycle. Under the influence of the hormones, the misplaced tissue swells ; and when hormonal levels drop, the tissue may bleed. Unlike the normally situated endometrium, which is shed from the body as menstrual discharge, this blood and tissue has no outlet. It remains to irritate the surrounding tissue.

The disease is highly unpredictable. Some women may have just a few isolated implants that never spread or grow, while in others the disease may spread throughout the pelvis. Endometriosis irritates surrounding tissue and may produce web like growths of scar tissue called adhesions. The scar tissue can bind the pelvic organs and even cover them entirely. Many women who have endometriosis experience few or no symptoms. However, in some women, endometriosis may cause severe menstrual cramps, pain during intercourse, and infertility.

It is a disease which has been called an "enigma wrapped inside a mystery ", and there is a lot about it that we do not understand as yet.

What causes endometriosis?

Several theories exist as to how endometriosis begins. One possibility is retrograde menstruation, the backward flow of the menstrual discharge through the fallopian tubes into the pelvis. According to this theory, the endometrial cells may implant on the ovaries or elsewhere in the pelvic cavity.

What does it look like?

Early implants look like small, flat dark patches or flecks of blue or black paint ( "powder-burns" ) sprinkled on the pelvic surfaces. The small patches may remain unchanged, become scar tissue or spontaneously disappear over a period of months. Endometriosis may invade the ovary, producing blood filled cysts called endometriomas. With time, the blood darkens to a deep, reddish brown or tarry color, giving rise to the description "chocolate cyst." These may be smaller than a pea or larger than a grapefruit.

In some cases, bands of fibrous tissue called adhesions may bind the uterus, tubes, ovaries, and nearby intestines together. The endometrial tissue may also grow into the walls of the intestine - but although it may invade neighboring tissue, endometriosis is not a cancer.

Fig 1. Schematic, showing a chocolate cyst ( endometrioma) in the right ovary; and peritubal adhesions because of endometriosis

Fig 2. Laparoscopy, showing minimal endometriosis, in the form of " powder-burn" deposits. Fig 3 . Laparoscopy, showing a small chocolate cyst in the left ovary. This can be very easy to miss, so a careful multiple puncture laparoscopy is essential to make an accurate diagnosis of endometriosis.

What are the symptoms?

Progressively increasing dysmenorrhea (periods pains or menstrual cramping) may be a symptom of endometriosis. These are caused by contractions of uterine muscle initiated by prostaglandins released from the endometrial tissue. A puzzling feature of endometriosis is that the degree of pain it causes is not related to the extent of the disease. Some women with extensive disease feel no pain at all. A woman with endometriosis may notice that as the disease progresses her periods become more painful or that the pain begins earlier or lasts longer.

Endometriosis can cause pain during intercourse, a condition known as dyspareunia. The thrusting motion of the penis can produce pain in an ovary bound by scar tissue to the top of the vagina or in a tender nodule of endometriosis. Most women who have endometriosis report no bleeding irregularities. Occasionally, however, the disease is accompanied by vaginal bleeding at irregular intervals; or by premenstrual spotting.

How does endometriosis cause infertility? The relationship between mild (early) endometriosis and infertility is controversial. The most recent theories regarding the endometriosis-infertility link focus on the fact that endometriosis may lead to a form of mild inflammation within the pelvis. In some women with mild endometriosis, the levels of certain chemicals called cytokines ( released in response to inflammation) are increased in the abdominal cavity, and these hormones may have a negative effect on follicle and egg development, egg-sperm binding and fertilization, normal tubal function, and even
implantation. Sometimes, the endometriosis may be coincidental and unrelated to the fertility problem. In these patients, other factors may be involved in a couple's infertility, such as poor quality sperm or ovulation disorders- and the endometriosis is a "red herring". Some women who have the condition are able to conceive, while others may be infertile due to endometriosis or a combination of factors.

The disease may hinder conception in various ways - especially when it is severe. Endometriosis may inflame surrounding tissue and spur the growth of scar tissue or adhesions. Bands of scar tissue may bind the ovaries, fallopian tubes, and intestines together and thus interfere with the release of eggs from the ovaries or the ability of the tube to pick up the egg. Rarely, severe endomteriosis may cause the tubes to become blocked. The presence of chocolate cysts in the ovary may also impair ovulation.

Diagnosis

Endometriosis cannot be diagnosed from symptoms alone. While a physician may suspect the disease if an infertile woman complains of severe menstrual cramps or pain with intercourse, many patients with the condition have no discomfort at all. The diagnosis can be confirmed only by a laparoscopy

Laparoscopy enables the doctor to look inside the pelvis and inspect the reproductive organs to confirm the presence of endometriosis. In fact, since endometriosis is often without symptoms, many doctors advise laparoscopy as part of the diagnostic study for all infertile women.

Looking through the laparoscope the surgeon can see the surface of the uterus, tubes, ovaries, and other pelvic organs. He can visually confirm the presence of the endometriosis and gauge its extent. If desired, a small piece of tissue can be removed for microscopic examination (biopsy). It is easy to miss early endometriosis if the laparoscopy is not performed carefully. The entire ovary should be inspected carefully; and if it is enlarged, it should be punctured to look for "chocolate" cysts.

In most cases, the surgeon will treat the endometriosis during laparoscopy. If so, he makes other small abdominal incisions through which additional instruments are introduced for operative laparoscopy. The surgeon may vaporize the lesions with a laser beam , or destroy them with an electric current called diathermy. Ovarian cysts can be excised ( removed) or opened and drained ( marsupialised) and their inner lining destroyed.

Fig 4. Operative laparoscopy, for removal of a chocolate cyst of the ovary ( endometrioma)

Other imaging technologies, such as ultrasound, computerized tomography or magnetic resonance imaging may be used to get more information about the extent of the disease. These procedures are useful only for identifying endometriotic cysts in the ovary.

Hormone medication

The goal of hormonal treatment is to simulate pregnancy or menopause, two natural conditions known to inhibit the disease. In each case, the normal endometrium is no longer stimulated to grow and regress with each monthly cycle, and menstruation ceases. The growth of misplaced endometrial tissue usually will suppressed as well.

To simulate the hormonal environment of pregnancy, birth control pills are prescribed. To be effective against endometriosis, the pills must be taken continuously without pausing for withdrawal bleeding. This state is sometimes called pseudopregnancy.

The hormone derivative danazol is the medication most frequently used to treat endometriosis. During treatment with danazol, estrogen levels are reduced to the low levels characteristic of natural menopause. This state is sometimes called pseudomenopause. Danazol is an expensive medication which is usually prescribed for six months or more. Unfortunately, large endometriotic cysts of the ovary are generally resistant to the drug.

Analogues of GnRH, the gonadotropin releasing hormone, are the newest class of hormones used for endometriosis treatment. These analogues switch off production of FSH and LH from the pituitary, thus inducing a menopausal state. These analogs can be given in the form of special injections called depot preparations, which release small quantities of the drug daily, allowing administration at monthly intervals.

Medical therapy used to be prescribed in the hope that it would cause the endometriosis to shrink sufficiently so that it would no longer interfere with conception after the treatment is stopped. However, since pregnancy cannot occur during the medical therapy of endometriosis, and because the treatment has been shown not to be helpful in improving fertility, medical therapy for endometriosis is no longer advised for infertile patients.

Surgery

Treating endometriosis with medicines has definite limitations. Medication usually controls mild or moderate pain and may eliminate small patches of the disease. But large chocolate cysts in the ovary are less likely to respond, and drugs cannot remove scar tissue. This is why surgery may be needed to improve fertility by removing adhesions, lesions, nodules or endometriomas.

As described earlier, laparoscopy can be used as a therapeutic tool. For example, fluid can be drained ; adhesions freed; and patches of endometriosis destroyed using a laser or electrical current. Even large endometriomas can be removed through the laparoscope by a skilled surgeon, so that today most cases can be successfully treated through the laparoscope. Open surgery ( laparotomy) is needed only very rarely.

IVF

Treatment cannot "cure" endometriosis - but it can control it. If an infertile woman with endometriosis fails to conceive even after surgical treatment, the next option is superovulation with intrauterine insemination, since the fallopian tubes in these patients are usually open. If this fails, then IVF ( in vitro fertilization ) can be very useful. However, the ovarian response in some of these patients can be poor, especially if they have large chocolate cysts, or have had surgery for these cysts. Fertilisation rates in some patients with endometriosis can be a little lower than for other patients, perhaps because of an intrinsic oocyte abnormality.

Endometriosis is a disease affecting millions of women throughout the world. For many, the condition goes unnoticed. But for others it demands professional attention, especially when fertility is impaired. The best strategy to maximize chances of conception is to select a specialist who is familiar with the latest developments in endometriosis management.

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Openness in adoption In most jurisdictions, the adoption process begins with the decision of the birth mother (or in some cases, both parents) to place the child for adoption. Birth parents may be able to choose what family will adopt their child. Depending on jurisdiction and local law, they may already know of a family that want to adopt, or they may find people who want to adopt by going to a lawyer, social services, or by finding a private or state adoption agency (though privately arranged adoptions are illegal in some jurisdictions). The birth parents may have the option of choosing whether they want an open, semi-open, or closed adoption. They may be given Parent Profiles to look at and choose from, or the agency may choose a family for them. In addition, some states have passed laws allowing birth mothers to leave their unwanted infants at any nearby hospital, fire department, or police station within 10 days after birth, with no questions asked. However, such laws have been criticized by adoptee advocacy organizations as being retrograde and dangerous.[1] [edit] Open adoption Main article: Open adoption Open, or fully disclosed, adoptions allow adoptive parents, and often the adopted child, to interact directly with birth parents. Communication may include letters, emails, telephone calls, or visits. Direct access to birth parents and history has advantages of answering identity questions ("Who do I look like? Why was I placed?") and lessening fantasies (birth parents are "real"). There are also disadvantages such as no clean break for assimilation into family and the potential for feelings of rejection if contact stops, or for playing families against each other. Arrangements regarding contact are typically informal. Even in an open adoption, the birth parents' legal rights of guardianship are terminated, and the adoptive parents become the legal parents. Another aspect of openness in adoption is an adoptee’s access to the original birth certificate that identifies his birthparents. In some jurisdictions such access is automatic, whereas in most the birthparents identities remain confidential. Semi-open adoption In a semi-open adoption, the birth parents may meet the adoptive parents one or several times and then have no more physical contact. Non-identifying letters and pictures may be exchanged directly or via a third party, such as an adoption agency, throughout the years.[2] The relationship may remain semi-open or may evolve into open or closed. Closed adoption Main article: Closed adoption In some closed adoptions, non-identifying information is shared between the parties involved, such as medical history, up to the point of placement. After the adoption is legalized, no further information is shared between the adoptive and birth parents.[3] In other closed adoptions no information is shared between the parties involved. This may occur because of the law in the jurisdiction concerned, or court order, such as when a child is removed from the home by the state because of abuse or neglect. It may also occur because the parties involved do not want any contact. Types of adoption by location and origin Domestic adoption This section requires expansion. A domestic adoption is the placement of a child for adoption within the country in which he or she was born and normally resides. A special case is an interstate adoption - where an adoption occurs across state lines in the U.S., or within different Canadian provinces. In such cases, additional regulations may apply.[4] Foster care adoption See also: Foster care Foster care adoption is a type of domestic adoption where the child is initially placed into a foster care system and is subsequently placed for adoption. Children may be placed into foster care for a variety of reasons, including removal from the home of the birth family by a governmental agency because of maltreatment of the child by the birth family. Maltreatment can take the form of neglect or abuse. In most adoptions regarding foster children, the foster parents decide to adopt and become the legal parents. In some jurisdictions, adoptive parents are licensed as and technically considered foster parents while the adoption is being finalized. Altogether, of the 127,500 adoptions in the U.S. in 2001,[5] about 51,000 occurred through the foster care system.[6] Children with histories of maltreatment, such as physical and psychological neglect, physical abuse, and sexual abuse, are at risk of developing psychiatric problems.[7][8] Such children are at risk of developing a disorganized attachment.[9][10][11] Studies by Cicchetti et al (1990, 1995) found that 80% of abused and maltreated infants in their sample exhibited disorganized attachment styles.[12][13] Disorganized attachment is associated with a number of developmental problems, including dissociative symptoms,[14] as well as depressive, anxiety, and acting-out symptoms.[15][16] Intra-family adoption Not all adoptions are from outside of the family. An intra-family adoption occurs when a child is adopted by an existing close family member and/or his or her partner. A common example is a "stepparent adoption", where the new partner of a parent may legally adopt a child from the parent's previous relationship. Intra-family adoption can also occur through surrender, as a result of parental death, or when the birthparent cannot care for the child and a family member agrees to take over. International adoption Main article: International adoption International adoption is the placing of a child for adoption outside that child’s country of birth. The laws of different countries vary in their willingness to allow international adoptions. Some countries, such as China and Vietnam, have relatively well-established rules and procedures for foreign adopters to follow, while others, the United Arab Emirates (UAE) for example, expressly forbid it. Some countries, notably many African nations, have extended residency requirements that in effect rule out most international adoptions. And some countries such as Romania are closed to international adoption altogether, with the exception of adoptions by close relatives (such as grandparents). Recognising some of the difficulties and challenges associated with international adoption, and in an effort to protect those involved from the corruption and exploitation which sometimes accompanies it, the Hague Conference on Private International Law developed the Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption, which came into force on 1 May 1995. To date it has been ratified in 70 countries. Reasons for adoption Adoptions occur for many reasons.[17] Adoptive parents may wish to adopt due to infertility, compassion for adoptees and to avoid passing on inheritable diseases. A minority of adoptees are orphans. Another reason could be where a child is found abandoned and the birth parent is never traced. Birth parents may place their child for adoption because they are unable to adequately care for the child, because they have failed to receive the resources they need to parent, or because they are pressured by their own parents or others. Birth family Children fall into three groups according to the reason for their adoption: relinquished infants (15%) (see pregnancy options counseling), those whose parents had requested adoption in complex circumstances (24%), and those children required by social services and the courts to be adopted (62%).[18] Children may be permanently removed from a family due to abuse or unfitness. In some cases, parents' rights have been terminated when their ethnic or cultural group has been deemed unfit by the controlling government. Historically, the Stolen Generation of Aboriginal people in Australia were affected by such policies, as were Native Americans in the United States and First Nations of Canada. Moreover, unwed mothers in many countries still are (and in many more countries used to be) pressured or forced by families, religious bodies or governments to relinquish their children for adoption, due to the social stigma attached to illegitimacy. These practices of the past have become emotionally-charged social and political issues in recent years, and many cases the policies have changed. The United States, for example, now has the 1978 Indian Child Welfare Act, which allows the tribe and family of a Native American child to be involved in adoption decisions, with preference being given to adoption within the child's tribe.[19] Adoptive Parents The reasons why people want to adopt children vary, as well. The inability to biologically reproduce is a common reason, often due to infertility. In many Western countries, step-parent adoption is the most common form of adoption as people choose to cement a new family following divorce or death of one parent. Many prospective parents believe that adoption is an equally valid form of family building, neither better nor worse than the biological child. There are many reasons that fertile couples or individuals adopt children; often people adopt out of compassion, sometimes motivated by religious or philosophical conviction. Others may choose to adopt instead of creating a new life, to avoid contributing to perceived overpopulation, or out of the belief that it is more responsible to care for otherwise parent-less children than to reproduce. Others may do so to avoid passing on inheritable diseases (e.g., Tay-Sachs disease), or out of health concerns relating to pregnancy and childbirth. Some people feel that given the challenges of carrying a baby to term, adoption is the best way to grow a family. After adopting, some parents face judgement over the validity of their parenting and may feel pressure to "prove" themselves causing them to increase their parental involvement. A study, evaluating the importance of biological ties for parental investment indicates strengths in adoptive families. The data was part of a detailed survey called the Early Childhood Longitudinal Study, sponsored by the U.S. Department of Education and other agencies. The study was funded by the National Science Foundation, the Spencer Foundation and the American Educational Research Association. It suggests that parents who have adopted may invest more time in their children than others.[20] Applying to adopt This section needs additional citations for verification. Please help improve this article by adding reliable references. Unsourced material may be challenged and removed. (June 2007) National Adoption Week is used in the United Kingdom to encourage new adopters to come forwardMethods of becoming an adoptive parent also vary from one country to another, and sometimes within a country, depending on region. Many jurisdictions have varying eligibility criteria, and may specify such things as minimum and maximum age limits, whether a single person or only a couple can apply, or whether it is possible or not for a same sex couple to apply. In some countries, applications must be made to a state agency or agencies responsible for adoption. There may also be private, licensed adoption agencies, who may operate either on a commercial or on a non-profit basis. Agencies may operate only domestically, or may offer international adoptions, or may facilitate both. Some jurisdictions allow lawyers to arrange private adoptions, and some allow private facilitators to operate. On applying to adopt, the potential adoptive parent(s) will generally be assessed for suitability. This can take the form of a home study, interviews, and financial, medical and criminal record checks. In some jurisdictions, such studies must be carried out by an independent or state authority, while in others, they can be carried out by the adoption agency itself. A pre-adoption course may also be required. Infants are more commonly sought than toddlers or older children, and many adoptive parents seek to adopt children of the same race. As a result, governments, as well as agencies, actively seek families who are interested in adopting older children and children with "special needs." In this context, "special needs" can mean a variety of things including children with specific chronic medical problems, mental health issues, behavioral problems, and learning disabilities. Often, the adoption fees for adopting a special needs child are either waived or significantly reduced. Adoption by same-sex couples Main article: Adoption by same-sex couples Individuals can adopt in most countries worldwide under certain circumstances. The discussion question is in many countries, if same-sex couples can adopt. Legal status of adoption by same-sex couples in Europe Gay adoption legal Step-child adoption legal Gay adoption illegal Unknown/AmbiguousCertain jurisdictions prohibit homosexual couples from adopting children,[21] or have a policy of considering applications made by heterosexual couples before those of homosexual couples. The issue of adoption by nonheterosexual couples is tied in with the debate on homosexuality. Preference to heterosexual couples may be given in the belief that heterosexuals who adopt often have fertility problems and therefore must be given preference on medical grounds. Opponents[who?] say this system is untenable in a free society and can leave needy children with limited access to a family structure. Adoption by same-sex civil unions or marriages are allowed in Australia (regions: Western Australia, Tasmania, ACT), the United Kingdom, Canada, the Netherlands, Belgium, Iceland, Sweden, Spain and in some of the USA (see Adoption by same-sex couples). As adoptions are mostly handled by local courts in the United States, some judges and clerks accept or deny petitions to adopt on criteria that vary from other judges and clerks in the same state.[22] Only stepchild adoptions within same-sex couples, i.e. where one of the partners in the relationship has children of his or her own, are allowed in Denmark, Norway, France and Germany. Ireland (which does not recognize same-sex unions) does not allow joint applications to adopt from same-sex couples, but does permit applications from one of the partners. According to the adoption laws in India, same-sex couples are not allowed to adopt. In January 2008, the European Court of Human Rights ruled that homosexual persons have the right to adopt a child.[23] Cost of adoption For the adoptive parents, adoption costs and assistance vary between countries. In many countries, it is illegal to charge for an adoption, while in others, adoptions must be facilitated on a non-profit basis. On the other hand many adoption programs will give financial assistance to adoptive parents, especially with their expenses. Some jurisdictions offer tax credits to offset the cost of adoption. In the United States there is a $10,390 tax credit for adoption. Adoptions through the child welfare system typically do not cost the adopting family anything beyond minor legal or other types of documented fees. In some states, families adopting from foster care may also receive yearly reimbursements for educational or therapeutic expenses up to a preset limit as well as have the adopted children retain Medicaid coverage even if they are covered by other insurance. The same is true in Canada. Regulations specify to whom payments may or may not be made, e.g., in some jurisdictions, no money may be paid to a birth mother above her medical expenses. There may also be significant expenses, such as legal fees and fees associated with searching for possible adoptees. International adoptions tend to be more expensive and often incur additional costs, as the adoptive parents may be required to travel to the source country. Translation fees may also apply to legal documents. Adoption numbers The number of children available for adoption inside Western nations has dropped considerably in recent years, in part because of lower fertility rates, legalization of abortions, and the increased acceptance of single parenthood. In the USA, the number of children awaiting adoption has dropped from 132,000 to 118,000 during the period 2000 to 2004[24] This is a list of adoptions recorded (alphabetical, by country) in recent years. Country Adoptions Notes Australia 443 (2003-2004)[25] Includes known relative adoptions England 3,800 (2005)[26] Children adopted from care only Iceland between 20-35 year[27] Ireland 263 (2003)[28] 92 non-family adoptions; 171 family adoptions (e.g. stepparent). 459 international adoptions were also recorded. Italy 3,158 (2006)[29] Norway 791 (2004)[30] 124 of these were national adoptions, including stepchild adoptions. The rest were international adoptions, mainly from China (269), South Korea (93) and Colombia (86). Sweden approx 1,000[31] 10-20 of these were national adoptions of infants. The rest were international adoptions. United States approx 127,000 (2001)[32] This list is incomplete; you can help by expanding it. Issues surrounding adoption Reunion Some adopted people and birth parents who were separated by adoption have a desire to reunite. Brodzinsky & Brodzinsky reported in 1990 that only about twenty percent of adoptees engage in an "active search" to find their birth parents.[33] In countries which practice confidential adoption, this desire has led to efforts to open sealed records. In the United States, for example, there are organizations such as the International Soundex Reunion Registry,[34] an Adoption reunion registry that allows people who register to be matched with their missing parent or child, and Bastard Nation, which seeks to change state laws in order to establish the right of adoptees to access their sealed birth records. For German-Born Adoptees,[35] German Birth Register, the central birth register for Germany is the most efficient means of locating their German Birthfamilies. In the United Kingdom, adoption law has been amended to allow for open adoptions, the right to access one's records, and a state-run adoption reunion registry has been established, while in Ireland, a National Adoption Contact Preference Register was launched by the state Adoption Board in 2005.[36] This Register, set up in consultation with organizations representing adopted people, natural parents and adoptive parents, is unusual in that it was widely advertised on both radio and print media, and an explanatory leaflet, with contact details for the Adoption Board and the voluntary support organizations, was delivered to every household in the country. This register allows adopted people over the age of 18 and natural parents to state their preference for contact, what form that contact may take (e.g., post, e-mail, telephone or meeting), and/or their willingness to share medical or background information even if they do not wish actual contact. Reunions can bring a variety of issues for the adoptees, adoptive parents, and birth parents. The degree of wanting to reunite and the reasons why a reunion is desired depends on the individuals involved. This can often lead to disappointment for all three parties. Since adoption isn't part of regular society's function on views of family[citation needed] anxieties about identity can surface at this point for all three parties that were not an issue before.[citation needed] The most common reasons an adoptee wants to meet their birth parents are cited as wanting to find out more about themselves and to recover medical records. However, despite these two being cited there are often other reasons that they do not cite. This can be for emotional or personal reasons. There are also reasons that an adoptee may reject the idea of finding their birth parents or even reject birth parent or birth family's advances to reunite. Many of these stem from emotional reasons or fears of recategorization of personal identity. Many adoptees have a hard time dealing with the issues of identity and loss and would rather not deal with it.[citation needed] Not all reunions go well. There are some cases where the adoptee has a hard time reconciling their three identities and reject one side for another. This can be for a variety of reasons, such as emotional load, disillusionment towards one culture or the other, or discovery of political reasons. There are some organizations that often try to help adjust to this and go beyond the reunion. Such organizations as GOA'L for Korean adoptees often act to try to minimize the shock. Adoptive parents may go through the fear that their child will abandon the family once they find their birth parents or even may become distant. This can even manifest by not telling the child that they are adopted, refusing to help with the search, hindering the search, and even may extend to after the search where they refuse to acknowledge the birth parents. Not all adoptive parents are like this. Some have mixed feelings or even think its their duty to help their child with the search. Some adoptive parents also want to meet the birth parents to personally thank them. Birth parents often also go through the same kind of fear of rejection. Often seeing their child is a reliving of the events that lead up to the adoption, regret, and even fear that the child that they were forced or had to give up will reject them. There are often fears that the adoptee will be angry, will not forgive them. Some birth parents do not want to deal with the emotional burden and reliving of events and will reject the adoptee on these bases. Some birth parents also face cultural taboos in reuniting. For example in Korea a birth mother may face the stigma of having a "foreign" child. The degree of contact that a birth parent may want with their child can vary from situation to situation, which can be influenced by the manner in which the child was surrendered. Because there is often a lack of communication between these three groups and the combination of these needs can vary, reunion can cause strain in relations between the three groups. This is not always the case. But because reunion brings a variety of issues to the table, and the three groups have a tendency not to communicate, or be able to this can often cause rifts that become more apparent at this time.[citation needed] In other ways it can also unite the identity of the adoptee as well. Family heritage Preserving the adopted child's biological heritage has become an issue in adoption. Recent work on openness in adoption has attempted to address this issue. These efforts are relatively recent, and full openness, while on the upswing, is still not the norm in adoption. International adoptees face additional challenges. Some adoptive families in international adoptions commit to integrating the child's birth nation cultures, traditions, stories, languages and relationships. Some countries require that adoptive parents keep the birth names of their adoptive children. German-born children are allowed full access to their birth and adoption records.[37] In many cases, biological family genealogical research is possible. For adopted people in adoptions where information about the family of origin is withheld, secrecy may disrupt the process of forming an identity.[38][39] Family concerns regarding genealogy can be a source of confusion.[40] Another common concern is the lack of a medical history, which can affect the adopted person and also his/her subsequent children. In most U.S. domestic adoptions, medical information is not withheld from the child. However, if the adoption is closed, such information becomes out of date unless a trace is undertaken in adulthood. Adoption may also pose questions for adoptive parents. There are various schools of thought about openness, maintaining connections to the child's birth family, answering a child's questions and helping a child deal with biological parents who may not maintain regular contact. A study, published in the American Sociological Review, found that couples who adopt invest more time in their children than do biological parents. The researchers said that their findings call into question the long-standing argument that children are best off with their biological parents.[41] Adoption in schools Adoption rights organizations often focus on the adoptees rights in school and advocate for change in the system to accommodate the adoptee in the classroom.[42] Familiar lessons like "draw your family tree" or "trace your eye color back through your parents and grandparents to see where your genes come from" are viewed as hurtful to children who were adopted and do not know this biological information. New lesson plans can be substituted easily, that focus on "family orchards" or steer away from personal medical histories. Discussions about these sensitive topics, advocates argue, are the same as those that were conducted around issues of disability, race, and gender, and foster respect for differences in the same way as these earlier national conversations. Adoption in the media Adoption experts complain that too much of the media coverage of adoption goes to one extreme or the other. There is favoritism in portraying the reunion rather than looking at the adoptee's life. In movies and TV the representation of adoption is often[citation needed] viewed as unfair by adoption advocates. Adoption blogs, for example, criticized Meet the Robinsons for using outdated orphanage imagery [43][44] as did advocacy non-profit The Evan B. Donaldson Adoption Institute.[45]: "On the reverse many countries that are the source of adoptions internationally put emphasis on the biological parents where the adoptee is spending their entire life (or the length of the movie / TV show) searching for their biological parents. In both cases the feelings and thoughts of the adoptee are downgraded and one participant group is favored, ignoring the two other participants in the adoption process." This also is in news reports covering adoption as either stories of failed adoptions, troubled children, adoption scandals, and even "baby buying" or saccharine stories of “perfect” children and families. Only a very few news programs have treated the subject in a serious way and in its full breadth. Ignorance about adoption leads to representation of children in foster care as being so troubled that it would be impossible to adopt them and create “normal” families.[46] The result is that many children who would thrive in a loving family instead wait years in foster care, and even “age out” of the system at 18 without a family. A 2004 report from the Pew Commission on Children in Foster Care has shown that the number of children waiting in foster care doubled since the 1980s and now remains steady at about a half-million a year."[47] Adoption in the wake of disasters After disasters such as hurricanes, tsunamis, and wars there is often an outpouring of offers from adults who want to give homes to the children left in need. While adoption is often the best way to provide stable, loving families for children in need, it is also suggested[48] that adoption in the immediate aftermath of trauma or upheaval may not be the best option. Moving children too quickly into new adoptive homes among strangers may be a mistake because with time, it may turn out that the parents have survived but were unable to find the children, or there may be a relative or neighbor who can offer shelter and homes. Providing safety and emotional support may be better in those situations than immediate relocation to a new adoptive family.[49] There is also an increased risk, immediately following a disaster, that displaced and/or orphaned children may be more vulnerable to exploitation and child trafficking.[50] Adoption reform Two important influences on the reform of voluntary infant adoption have been Nancy Verrier and Florence Fisher.[51] Verrier describes the "primal wound" as the "devastation which the infant feels because of separation from its birth mother. It is the deep and consequential feeling of abandonment which the baby adoptee feels after the adoption and which may continue for the rest of his life."[52] However, this theory has been criticized by other supporters of adoption reform for being extremely sexist, somewhat naïve, as well as cruel towards those women who would make an adoption plan for her child.[53] Proponents of adoption reform argue for increased open adoption rather than closed adoption, with the latter only being used where absolutely necessary. They also argue for open records, the provision of supports for adopted people and natural parents, and facilitation for search and reunion. Adoptism This article needs additional citations for verification. Please help improve this article by adding reliable references. Unsourced material may be challenged and removed. (June 2007) Adoptism is a prejudice against adoption. This can be the belief that adoption is not a way to build a family (which is different from the preference for any other way or the personal free choice of not to do so spending time and resources without a self-preservation purpose). This may not be in blatant forms, but by assuming that the individual's abilities come from their family's abilities and all abilities, like other physical and psychological traits (and also because of those), are "inherited" rather than learned, which actually has scientifical basis to be the rule though learning has equally proven influence over some hereditary abilities. This can also be the belief that birthing children is preferable to adopting (which is different from preferring to birth and raise children for the sake of self-preservation and sense of belonging). This can extend to the idea that one should not adopt anyone that does not "look" like the parents and can hide forms of racism and sometimes sexism. Also it can be that making an adoption plan is never a preferable option for biological parents who are unable or choose not to raise their children. This also extends to the idea that it's alright to tell the adoptee should only love either their biological family or their adoptive family and they cannot love both, inclusively denying or limiting any contact with or denigrating his birth family or heritage or the one of his adoption. Usually this form is a hidden form of prejudice on the environment or biology makes the child. Sometimes adoptism is not conscious. For example, with international adoption, there is often the idea that it's not right to adopt internationally when there are kids domestically that need to be adopted. This idea isn't blatantly adoptism but rather a matter of priority for children of one's own country are closer or simply for a nativist sense of belonging. This can also be subtle as telling an adoptee that they don't have an accent. With domestic adoptions it's often extended through language choice that the adoptee, adoptive parents or the biological parents can find offensive, such as "real" parents or when an adoptee plans on finding their biological parents or the idea that they can now ask many personal questions that the adoptee may not be equipped or ready to respond to. These can sometimes be prejudices against actual adopted people. Sometimes this only is limited to certain kinds of adoption. Adoption is often used to cover other social issues in the society. For example, with adoption to gay and lesbian couples, many who are against it are also against gays and lesbians - the idea that a child needs a father and mother to function properly is an issue. This also can extend to race where the idea that whites should not adopt children of color because it's "unnatural". [edit] Disruption Main article: Disruption (adoption) Disruption is the term most commonly used for ending an adoption. While technically an adoption is disrupted only when it is abandoned by the adopting parent or parents before it is legally completed (an adoption that is reversed after that point is instead referred to in the law as having been dissolved), in practice the term is used for all adoptions that are ended (more recently, among families disrupting, the euphemism "re-homing" has become current). It is usually initiated by the parents via a court petition, much like a divorce, to which it is analogous. While rarely discussed in public, even within the adoption community, the practice has become far more widespread in recent years, especially among those parents who have adopted from Eastern European countries, particularly Russia and Romania, where some children have suffered far more from their institutionalization than their parents were led to believe. [edit] The language of adoption The language used in adoption is changing and evolving, and it has become a controversial issue. The controversy arises over the use of terms which, while designed to be more appealing or less offensive to some persons affected by adoption, may simultaneously cause offense or insult to others. This controversy illustrates the problematic nature of adoption, as well as the fact that coining new words and phrases to describe ancient social practices does not alter the feelings and experiences of those affected by them. The two contrasting sets of terms are commonly referred to as "Positive (or Respectful) Adoption Language" and "Honest Adoption Language." Positive Adoptive Language (PAL) It is believed that social workers in the field of adoption, most notably Marietta Spencer, created and began the promotion of what they termed "Positive Adoption Language" around the mid 1970s.[54]. The terms contained in ""Positive Adoption Language" include the terms "birthmother" (to replace the terms "natural mother" and "first mother"), "placing" (to replace the terms "relinquishment" or "surrender"), and restricting the terms "mother" and "father" to refer solely to the parents who had adopted. It reflects the point of view that (1) all relationships and connections between the adopted child and his/her previous family have been permanently and completely severed once the legal adoption has taken place, and that (2) "placing" a child for adoption is invariably a non-coerced "decision" the mother makes, free of coercion or pressure from external circumstances or agents. The reasons for its use: In many cultures, adoptive families face adoptism. Adoptism is made evident in English speaking cultures by the prominent use of negative or inaccurate language describing adoption. To combat adoptism, many adoptive families encourage positive adoption language. The reasons against its use: Many natural parents see "positive adoption language" as terminology which glosses over painful facts they face as they go into the indefinite post-adoption period of their lives. They feel PAL has become a way to present adoption in the friendliest light possible, in order to obtain even more infants for adoption; ie, a marketing tool. These people refer to PAL as "Adoption Friendly Language" or AFL. Honest Adoption Language (HAL) "Honest Adoption Language", on the other hand, refers to a set of terms that reflect the point of view that: (1) family relationships (social, emotional, psychological or physical) that existed prior to the legal adoption often continue past this point or endure in some form despite long periods of separation, and that (2) mothers who have "voluntarily surrendered" children to adoption (as opposed to involuntary terminations through court-authorized child-welfare proceedings) seldom view it as a choice that was freely made, but instead describe scenarios of powerlessness, lack of resources, and overall lack of choice.[55][56] It also reflects the point of view that the term "birthmother" is derogatory in implying that the woman has ceased being a mother after the physical act of giving birth. Proponents of HAL liken this to the mother being treated as a "breeder" or incubator".[57]. Terms included in HAL include the original terms that were used before PAL, including "natural mother," "first mother," and "surrendered for adoption." The reasons for its use: In most cultures, the adoption of a child does not change the identities of its mother and father: they continue to be referred to as such. Those who adopted a child were thereafter termed its "guardians," "foster," or "adoptive" parents. Most people use "Honest Adoption Language" (HAL) because it is the original and most widely-used terminology. Many of those directly affected by adoption loss believe these terms more accurately reflect important but hidden and/or ignored realities of adoption. It also has the advantage of not excluding further contacts, sometimes even allowed since the beginning and never totally severed by adoptive parents between birth parents and their children, as well as after they reach majority. The reasons against its use: The term "Honest" implies that all other language used in adoption is dishonest. Terms used in Positive Adoption Language: Non-preferred: PAL term: Reasons stated for preference: your own child birth child; biological child Saying a birth child is your own child or one of your own children implies that an adopted child is not. child is adopted child was adopted Some adoptees believe that their adoption is not their identity, but is an event that happened to them. ("Adopted" becomes a participle rather than an adjective.) Others contend that "is adopted" makes adoption sound like an ongoing disability, rather than a past event. give up for adoption place for adoption or make an adoption plan "Give up" implies a lack of value. The preferred terms are more emotionally neutral. real mother/father/parent birth, biological or genetic mother/father/parent The use of the term "real" implies that the adoptive family is artificial, and is not as descriptive. natural parent birth parent or first parent The use of the term "natural" implies that the adoptive family is unnatural, and so is not a descriptive or accurate term. Although it can be seen as unnatural to conceive and relinquish children, the purpose is to present the adoption of those children in need as natural. The term "natural" in its origin means a family by the natural means of conception and birth and its primal bound which exists by itself since the beginning unless it's severed. your adopted child your child The use of the adjective 'adopted' signals that the relationship is qualitatively different from that of parents to birth children. surrender for adoption placed or placed for adoption The use of the adjective 'surrendered' implies "giving up." For many parents placing a child for adoption is an informed completely voluntary choice. For others, there is no choice as the parent's rights were terminated because the parent was deemed to be unfit. Terms used in Honest Adoption Language: Non-preferred: HAL Term: Reasons stated for preference: birth mother/father/parent mother, natural mother, first mother (or father/parent) HAL views term "birth mother" as being derogatory, limiting a woman's purpose in her child's life to the physical act of reproduction and thus implying that she is a "former mother" or "breeder." HAL terms reflect the point of view that there is usually a continuing mother-child relationship and/or bond that endures despite separation birth child natural child, child of one's own HAL views the term "birth child" as being derogatory, implying that the adoptee was a "birth product" produced for the adoption market, and having no relationship or connection with his or her natural mother past the event of having been born. It also implies that the mother is a "birth mother" with no connection to her child or interest in her child past this point place for adoption give up for adoption surrender for adoption (have) lost to adoption (are) separated by adoption, HAL acknowledges that past adoption practice facilitated the taking of children for adoption, often against their mother's expressed wishes. Many women who have gone through the process and who lost children to adoption believe that social work techniques used to prepare single mothers to sign Termination Of Parental Rights papers closely resembles a psychological war against natural motherhood; hence the term "surrender."[58] "Surrender" is also the legal term for the mother's signing a Termination of Parental Rights. "Make a plan" and "place for adoption" are viewed by HAL proponents as being dishonest terms which marginalize or deny the wrenching emotional effect of separation on the mother/child dyad.[59] and imply the mother has made a fully-informed decision. mother/father/parent (when referring solely to the parents who had adopted) adoptive mother/father/parent Referring to the people who have adopted the child as the mother or father (singular), ignores the emotional and psychological (and often physical) presence of a second set of parents in the child's life. In contrast to RAL, HAL reflects the opinion that there are two sets of parents in the adopted person's life: adoptive parents and natural parents. adopted child adopted person or person who was adopted The use of the adjective 'adopted' signals that the relationship is qualitatively different from that of parents to other children. The use of the word "child" is accurate up until the end of childhood. After that the continued use of "child" is infantilizing.