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Communication and counselling are at the heart of the vast web of institutions and practices that comprise sexual and reproductive health. Learning test results, making decisions about treatment and birth control, working through difficult emotions, grappling with personal and cultural expectations—these are experiences that powerfully impact individuals, families, communities and (as some would have it) nations. They are also often mediated through counselling with professionals and peers. Over several decades, sexual and reproductive counselling encounters have been studied and theorised, and their practitioners have developed rich vocabularies of practice.1 Those practices have been shaped by the ‘liberalisation’ of sexuality, psychological and emotional ‘turns’, ethical and legal debates about reproductive autonomy and disability rights, expectations relating to race and gender, a growing requirement for patients to manage risks, and new definitions of responsible citizens. The papers of this special issue analyse the twentieth-century histories of sexual and reproductive health counselling, and differences relating to subject matter and country.2 We draw together three medical specialties in which professional counselling developed—that is, fertility, genetics and sex—and trace these new forms of (often gendered and racialised) communication in different political and religious environments.3
Sexual and reproductive counselling have their origins in the late nineteenth and early twentieth centuries. In many European countries, ‘advice’ on (what we today call) sexual and reproductive health was delivered in birth control clinics, family planning clinics and marriage welfare centres. Such institutions, which have been linked in historical scholarship to histories of eugenics and feminism, were aimed at instructing married couples on various social and health aspects of marital and family life—issues that included sexual difficulties, infertility and the spacing and sometimes prevention of births (Hall 2012; Jarska 2019; Klausen and Bashford 2010; Rusterholz 2019; Varsa 2020). In these contexts individuals learnt to speak about their bodies, sexual desires, intimate relationships and imagined reproductive futures in ways that many had previously considered private (Fisher 2006, 2010 ⇓; Grossmann 1995; Hilevych 2015; Rusterholz 2015; Szreter and Fisher 2010).
It was during the postwar period that counselling and advice practices flourished, amid the foundation and expansion of welfare and socialist states, the growth of activist and social movements, the expansion of ‘popular individualism’, the growing respectability of contraception, changes in sexual mores among younger people, and the legalisation of abortion—all against a backdrop of continued widespread discrimination against people with disabilities (Herzog 2018). Several historians have shown that across Western and Central Europe, the reform of mental health in the interwar and postwar years brought closer the focus on sex and reproduction as part of broader efforts of preventing mental problems (Chettiar 2023; Gijswijt-Hofstra, Oosterhuis, and Vijselaar 2005; Neve 2004; Oosterhuis 2005; Riley 1983; Rose 1990; Bar-Haim 2021). On the one hand, procreation, marriage, childbearing and childrearing became recognised as causes of psychological distress. In the UK, for example, the new instruments of the postwar welfare state helped to create a host of family oriented mental-health initiatives (Chettiar 2023). On the other hand, the liberalisation of sexuality and the psychological turn, in the United States for example, transformed sexuality and reproduction into key public concerns and targets of medicalisation (eg, Clarke 1998; Ginsburg and Rapp 1995; Kline 2010). In Eastern Europe, advice on sexuality and family planning was more prescriptive, targeting specific gender roles and behaviours (Hilevych and Sato 2018; Ignaciuk 2021; Kuźma-Markowska and Ignaciuk 2020; Varsa 2020). Nevertheless, in all these contexts, professionals specialising in sexual and reproductive health developed tailored advice and counselling programmes—including those pertaining to the intimacies of marriage and reproduction. Within a few decades, the provision of guidance on these seemingly private, and emotionally charged, matters had become routine and highly professionalised across Europe. By recovering some of these histories in a selection of diverse political contexts across Europe, we begin to see how debates about reproductive autonomy and risk, and about gender, sexuality, disability, age and race, affected how professionals were expected to counsel and shape responsible citizens and parents.
Europe offers a defined focus for this special issue, and by covering histories in countries from East to West, also allows us to show how counselling provisions were shaped by the new and varied social, political and religious conditions of the postwar period.4 Half of the contributions take the UK as their case study—this focus is, in part, due to the Wellcome Trust’s support of research in this field, but it also enables us to uniquely trace the evolution of all three areas of counselling (sexuality, fertility and genetics), with examples of top-down and bottom-up provision, in one national context. This is not to imply that the UK is a more important example than any other country, but it does provide a detailed, and politically and culturally specific, example against which to compare the counselling encounters that developed in other welfare states (eg, Eastern and Western Germany, in socialist Poland and Czechoslovakia) and religious environments (eg, the majority-Catholic contexts of Ireland, Belgium and Poland).5
Critical to understanding these transformations are the historically diverse modes of (and mediums for) counselling. For this special issue we extend our definition of ‘counselling’ practices to include interactions beyond in-person encounters in clinical spaces, to those enacted through magazine advice columns, telephone services, paper leaflets, and self-help resources and activist support groups. One consequence of this approach is to draw attention to the material dimensions of such encounters, and how these have the potential to affect who does (or does not) engage (Bonah and Laukötter 2020; Greene 2022; Sellen and Harper 2001). In the essays presented in this collection, we see cheap self-help manuals and newsletters that could be made with little publishing expertise and equipment and made to circulate within grassroots organisations. We learn about mass-produced paper leaflets that were light and mobile and could travel from pharmacies and surgeries into peoples’ homes. Widely distributed telephone networks and letter correspondence offered clients crucial levels of anonymity as they sought counsel, sometimes from hard-to-reach settings, like prisons and schools. Advice columns in women’s and teenage magazines reached broad audiences and constituted sources of sexual health information in contexts where such a topic was taboo. These forms of letter-writing and magazine advice were forms of encounter in and of themselves, but they also helped to create the conditions and demand for medical counselling. Thus, our expansive framing of ‘counselling’ helps us to pay attention to the relationships between mediating technologies and access—and in some instances how these intersected with gender, sexuality, disability, age and race.
The papers collected here recover a wide variety of exchanges, and show how social shifts and political restructurings shape intimate encounters. These historical analyses also offer insights into the forms of counselling we live with now. What emotions could, and should, be discussed during counselling encounters? How are gender roles and identities challenged and renegotiated in intimate counselling spaces? Who is reached by today’s counsellors, and why? How were race and class made into reference points for counselling provision? And, looking transnationally, how have the services in different nations and states actively shaped one another? The analyses in this collection offer tools for understanding how and why we talk about sex and reproduction today.
Forms of sexual and reproductive health counselling
This special issue traces the emergence and establishment of three distinct types of counselling in postwar Europe. One of those, sexual counselling, was (and is) the guidance and education of individuals on matters relating to sex, sexual relationships, birth control and sexually transmitted diseases. Sexual counselling had its roots in the interwar years, but underwent significant growth in the postwar era, owing to an increasingly liberalised attitude towards sexuality that often clashed with the traditional and religious views that confined sex to heterosexual marriage (Cook 2004; Eder 2014; Fishman 2017; Jarska and Ignaciuk 2022). These tensions created anxieties that prompted individuals to seek new forms of help with their emotional and sexual problems. In various national contexts, counselling consisted of person-to-person consultations in formal settings like advice centres, but also took place via telephone conversations and the exchange of letters, in the public spaces of schools, and in the semi-private domain of advice columns in women’s and teenage magazines.
The chronology and content of sexual counselling were influenced by the political and religious environments in which it was provided. Two essays in this issue describe how in Britain, sexual counselling was offered by voluntary organisations, among them the Albany Trust for queer people (Chettiar 2022) and the Brook Advisory Centre for young people (Rusterholz 2021). Both were established in the 1960s and built on a longer tradition of sex counselling for married couples. These organisations retained and adapted the idea of ‘good’ sexual behaviour that had been propagated in the interwar years through family planning and marriage guidance centres—namely that sexual relations should occur within loving and committed relationships (see also Chettiar 2023). Rusterholz argues that this notion of ‘good’ sexual behaviour was racialised through the resort to a white middle-class notion of sexual responsibility. In another essay we see that sexual counselling in state socialist Poland was influenced by Western counselling practices and built on a longer tradition of sexology (Kościańska 2022). However, it emerged there a decade later than in Britain and was supported by state-funded services. Despite the growing influence of the Catholic Church, sexual counselling in Poland was progressive and patient-centred.
In the UK and Ireland, sexual counselling was also provided through advice columns in teenage and women’s magazines. The essays by Loughran and Kelly both show how magazine columns were an important source of information on sexual health, and how they sought to help readers navigate their emotions (Loughran 2022; Kelly 2022). Loughran (like Rusterholz and Chettiar) identifies a trend in British advice columns towards greater openness about sex, although they clearly propagated a model of intimate relationships in which love and commitment were paramount. Writing about Ireland, Kelly analyses the impact of the repressive social, cultural and religious context on young people’s sexual knowledge. Letters sent to magazines testify to the ignorance of young people and their emotional struggles. Kelly also touches on how the AIDS crisis generated fears among young people and and how advice columns provided information about the disease.
Infertility counselling seeks to guide couples in how to manage their emotional responses to infertility and involuntary childlessness. In the postwar decades, infertility counselling was neither readily available, nor recognised as a distinct form of counselling, and in the 1970s and 1980s, grassroots organisations in some countries stepped into that gap. Hilevych and Claes show that in both Britain and Belgium, infertility counselling originated from self-help groups, prior to the institutionalised services of the late 1980s and early 1990s. Indeed, because provision was lacking, childless couples felt the need to create spaces where they could provide and access non-directive peer-to-peer support. Unlike other types of self-help, this provision aimed to be systematic and was rooted in popular psychology of the time.6 By contrast, Dudová and Hašková (2023) show that in Czechoslovakia, infertility advice was integrated in the broader system of reproductive and maternal health counselling from the 1950s . However, there, infertility advice was not an independent field but closely connected to abortion. As was the case in other socialist contexts, infertility in Czechoslovakia was presented as a potential side effect of pregnancy termination (Hilevych and Sato 2018; Randall 2011). Writing about Czechoslovakia, Dudová and Hašková show that forms of counselling could be profoundly racialised. For example, white Czech women were advised that abortion could lead to infertility, while women from minority groups, such as Roma, were not discouraged from having abortions. Rather, unlike the majority, Roma women were directed to limit their fertility. Although the papers on Britain and Belgium find no such direct racialisation of advice, infertility counselling there nevertheless targeted primarily white middle-class women and couples.
Genetic counselling is a distinct form of reproductive counselling that, postwar, tended to be delivered by professional geneticists who would inform prospective parents about their ‘risks’ for particular inherited conditions. In the German Democratic Republic (GDR), that advice-giving continued to be openly directive in the 1970s and 1980s—in the sense that it was focused on the ‘prevention’ of inherited conditions. Doetz (2023) shows that on that basis, counsellors sought to divert clients’ emotional responses and instead encouraged individuals to make ‘rational’ decisions. Nemec’s essay shows that the prevention of disability was also an underlying rationale in the Federal Republic of Germany, where the thalidomide tragedy became the impetus for the redevelopment of genetic counselling. This ‘rebirth’ of genetic counselling took place in the context of new medical and moral support groups for children and families affected by thalidomide, and now promoted individual decision-making as the cornerstone of prosperity and emotional well-being.
The UK took a different trajectory. There, as elsewhere, the postwar expansion of clinical genetics was initially driven in part by a logic of preventing inherited conditions, and clinical geneticists encouraged prospective parents to make ‘rational’ decisions based on ‘risk’. In striking contrast to Germany, though, Bangham (2023) shows that in the 1970s and 1980s, some aspects of genetic counselling were increasingly taken on by genetic nurses and social workers, who carved out distinctive roles relating to the care and emotional management of clients and families within the National Health Service genetic services. Meanwhile, a pathbreaking group of black nurses and health visitors established specialist counselling provision for families affected by the inherited conditions sickle cell and thalassaemia, and as they did so drew attention to the ways in which differences of language, ethnicity and culture might affect encounters and racialise access to care. These shifts contributed to growing interest by researchers and practitioners in the social and psychological experiences of those receiving genetic information, which might also be understood as a response to the growing significance of the Human Genome Project, and a conscious distancing of clinical genetics from eugenics. By the 1990s, ‘psychosocial’ counselling—that is, non-directive, emotion-focused, culturally aware, and psychologically sensitive—had taken a central place in the UK’s first formal training course for professional genetic counsellors.
In another state-run healthcare system, Czechoslovakia was the first socialist country to use prenatal diagnosis. There, genetic counselling was integrated into a broader state policy of antenatal and postnatal care, which closely monitored couples. Dudová and Hašková (2023) emphasise that Czechoslovakia’s pronatalist policy was unevenly applied, and that marginalised groups—including Roma women, women with disabilities, non-heterosexual women and poor women—were targets of far greater surveillance and reproductive oppression. The ableist and racist aim of that policy was to discourage young, healthy, white women from seeking abortions, but, conversely, to grant easier access to abortions for those who did not meet these criteria. The analyses here underline how powerfully ‘race’, disability, sexuality and class have been used to define the counselling a person receives, and how these identities have been affected by the character, media and form of encounters.
Several authors examine the training required for counsellors, which was diverse and inconsistent across fields. In sexual and infertility counselling, the postwar decades saw increasing focus on therapeutic talking as integral in this area of health. In the UK, medical students were first trained in how to address patients’ ‘psychosexual’ problems after World War II; Irwin (2022) shows how such training was formalised in the 1970s in some medical schools, using so-called ‘Sexual Reassessment Seminars’.7 Remarkably, these seminars involved the screening of sexually explicit films (imported from the USA) to prompt small groups of trainees to discuss their own sexual attitudes and beliefs and provide them with the skills they would need to discuss patients’ sexual confirms without awkwardness or prejudice.
Training for some other forms of counselling was relatively informal. In Ireland, agony aunts writing in teenage magazines were trained counsellors (Kelly 2022), while in the UK, some simply drew on their own experience (Loughran 2022). In the case of infertility counselling, Hilevych and Claes show that personal experience was often deemed necessary for counselling others, and in both Belgium and Britain, childless couples who had experienced infertility themselves were often taught counselling skills. Here, strikingly, the experience and positionality of the counsellor was clearly understood as crucially relevant to their ability to counsel others. And in all these cases, the influence of popular psychology on both the vocabulary and ethos of infertility counselling was crucial in re-establishing what counted as counselling and what expertise it required, which in several respects blurred the boundaries between professionally trained and self-trained experts.
Both counsellors and counselees learnt to position emotions front and centre. Several papers analyse how charities and grassroots organisations created communities organised specifically around emotional expression and management. Chettiar (2022) shows that, in the 1960s, counselling services established by the UK-based Albany Trust sought to build communities and create social integration specifically through the articulation and sharing of non-heteronormative ‘queer’ emotional experiences. Similarly, Hilevych and Claes show that in 1970s Belgium and Britain, grassroots counselling initiatives that brought together couples experiencing infertility were designed to forge relationships that would facilitate the communication of emotions. Indeed, those groups published several handbooks that sought to deflect the ‘hope’ invested in reproductive technologies, and instead define other emotions that needed to be shared and narrated through non-directive counselling. This emphasis on community building and the sharing of emotions brings to mind the phrase ‘emotional communities’, coined by historian Barbara Rosenwein to refer to groups that share the same norms and values with respect to the expression of feelings (Plamper 2012; Rosenwein 2006). Indeed, in some of the cases described here, the expression and narration of emotions were understood to both define these communities and give them purpose.
Other papers in this issue examine how professional counsellors learnt to discipline the emotions of both counselees and themselves. For example, in the GDR, clinical geneticists explicitly sought to defuse and discipline clients’ feelings of fear and guilt in order to project genetics as a rational, objective science and protect it from ‘eugenic’ associations (Doetz 2023). This stood in contrast to the growing visibility of ‘emotional labour’ among UK genetic nurses—that is, the management of clients’ emotions as well as the professionals’ own (Bangham 2023). Indeed, in the UK, the increasing visibility of emotional management in genetic counselling seems to have occurred hand in hand with the gendered professionalisation of counselling roles.8 Over a period of 30 years, genetic counselling underwent a dramatic transformation from a set of practices delivered by (male) geneticists to a field led by a female workforce of genetic nurses, social workers and (later) specially trained genetic counsellors. This gendered trend also occurred in sexual counselling, with the shift from (male) psychiatrists to (predominantly female) family planning doctors, nurses and relationship counsellors (Irwin 2006; Irwin 2009; Rusterholz 2020). Strikingly, though, Brook Advisory Centre doctors and counsellors learnt to use ‘non-emotive’ language when talking to clients about pregnancy and termination—this, they believed, was appropriately non-directive and would help clients reach their own decisions, without outside influence (Rusterholz 2021).
Indeed, the strategies of emotional management were used for directive counselling approaches too, as methods for managing and disciplining certain health behaviours. We see clear examples of directive counselling around genetic ‘risk’ that, on the one hand, operated by reinforcing fear and guilt, and on the other, by fostering senses of responsibility and hope. In case of Czechoslovakia, Dudová and Hašková argue that such emotional strategies around notions of ‘risk’ were forms of biopower. Indeed, they show that the ways that women were counselled for abortion, infertility, congenital abnormalities and infant health more generally, and their framing of ‘risk’, varied depending on whether women were of white or of Roma background. In the very different political context of West Germany, Nemec shows how visually emotive representations of healthy, white, middle-class, prosperous, families functioned to persuade couples to take appropriate reproductive decisions to ‘prevent’ genetic disease. In both cases, counselling could become a means of evoking or alleviating emotions to direct clients towards particular kinds of decision.
The international landscape of sexual and reproductive health in the twenty-first century remains highly dynamic. As the proliferation of genomic data undergoes rapid expansion in healthcare systems around the world, questions are being asked about how it will be interpreted, and who will counsel and advocate for patients and families (Navon 2019; Middleton et al. 2022). Elsewhere, the promises that accompany the expansion and availability of fertility treatments are changing individuals’ expectations of how they will have babies and when, while the high cost of those technologies means that access remains highly stratified (Smietana, Thompson, and Twine 2018; van de Wiel 2020). Meanwhile, rising nationalism and pronatalism around the world means that many people are grappling with new abortion restrictions, with dramatically unequal consequences for people of different economic resources and racial, class and disability identities.
As the pandemic disrupted face-to-face encounters, many of us have witnessed for ourselves how much the medium matters to the content of and access to information. Online televisual technologies dramatically altered the character of those encounters, changing the power dynamics of counsellor and counselled, the emotions that could be shared, and the people who could access care (for a longer, historical view: Greene 2022). All these shifts are rapidly changing what can be talked about, expected and hoped for, and who people can expect to seek information and advice from. Looking back offers some tools analysing present-day practice and linking these to broader currents of political and social change.
Patient consent for publication
We’re grateful to all of those who contributed to the workshop, ‘Let’s Talk about Sex (and Reproduction): Counselling for Reproductive Health in Postwar Europe’. They included Elizabeth Anionwu, Angus Clarke, Lucy Delap, Lesley Hall, Nick Hopwood, Jennifer Hunt, Ester Mcgeeney, Jim Monach, Naomi Pfeffer, Rachel Thomson, and many of the authors in this special issue. Thanks to Teri Chettiar, Susanne Doetz, Hana Hašková, Robert Irwin, and Tracey Loughran, for their comments on this introduction.
1. We have used the phrase counselling 'encounters’ here and elsewhere to emphasise our interest in the moment of exchange, and the space of interaction, between counsellor and counselee. Although ‘medical encounters’ have been analysed most thoroughly by historians of early modern medicine (see: Leah Astbury and Carolin Schmitz, eds., Medical Encounters in the Early Modern World, in preparation), our focus on professional notions of what encounters looked like, what they should accomplish, and how they were experienced, chimes with recent scholarship on clinical encounters in the twentieth century, such as Boddice and Hitzer (2022); Brown (2023), Chettiar (2023), Greene (2022), Hayward (2014) and Hitzer (2022).
2. The anglophone term ‘counselling’ in this special issue refers to a wide range of encounters between experts and clients in clinical settings, as well as between peers in self-help groups, and has variously been used to refer to the provision of guidance, advice, and emotional and psychological support. We also want to acknowledge that translations are not always precise, and that the vocabularies pertaining to ‘guidance’, ‘advice’ and ‘support’ have changed with period and context.
3. Counselling involves more than ‘communication’; but in our attention to materiality and form we are building on recent scholarship that positions communication as central in the history of reproduction—see Hopwood et al. (2015) and the other papers in that special issue of the Bulletin for the History of Medicine.
4. For sexual and reproductive health advice and counselling beyond Europe, the US is a well-researched reference point, and valuable scholarship on other contexts includes Ashford (2022), Doyle (2013), Hunt (1999), López (2014) and Mooney (2009).
5. While some papers directly touch on the HIV/AIDS pandemic, its impact on sexual and reproductive health counselling practices was broad (eg, Elizabeth 2021) and goes beyond the scope of this special issue (see: Nikolaos Papadogiannis and Somak Biswas, eds., ‘Transnational Histories of Collective Action on AIDS in Europe, 1980s-1990s’ special issue of Journal of Sexuality, in preparation).
6. On the history of ‘popular psychology’ in Britain and its remarkable range and depth of influence, see Thomson (2006).
7. Psychosexual problems were sexual problems thought to be linked to emotional or psychological issues resolving around one’s sexual life and sexuality in general.
8. Bangham (2023); for nursing and emotional labour, see Smith (1992); for gender and genetic counselling in the USA, Stern (2012), and for broader historical reflections on gender and professionalisation in the twentieth century, Egginton and Thomas (2021).
Twitter @YHilevych, @carorusterholz
Funding The workshop was funded and hosted by the Centre for Research in the Arts, Social Sciences and Humanities (CRASSH), and received additional funding from the George Macaulay Trevelyan Fund of the University of Cambridge Faculty of History, the Cambridge Reproduction Strategic Research Initiative, the British Academy (through a grant to Yuliya Hilevych, NF170487) and the Wellcome Trust (through a grant to Caroline Rusterholz, 209726/Z/17/Z). JB is funded by a Wellcome University Award (grant number: 212648/Z/18/Z).
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.