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Chapter 1 - Introduction

In connection with the latest amendment of the Danish Adoption Act in 1999, focus was put on, among other things, the requirements concerning the health of adoption applicants.

The report of 20 May 1999 prepared by the Danish Parliament’s Legal Affairs Committee on the Bill included the following comments:
"Regarding the matter of health, the Danish Minister of Justice has stated that the Bill sets the stage for liberalisation of practice in the area, especially as regards the significance of disabilities

Thus, paragraph 8.3. of the Bill’s general notes states that current practice should be modified, making it possible for disabled persons - based on an individual assessment - to be approved as adopters to a greater extent than is possible today. It is furthermore stated that a broader view than the medical one should be taken by involving other expert assistance, including assistance from the Danish Disability Council.

As regards diseases, the possibility of revising practice in the area should be continuously considered in the light of recent developments in the medical field etc. External expertise should be included to the extent it is relevant and expedient, e.g. in the form of discussions with the Medico-Legal Council or the National Board of Health.

Lastly, the guidelines setting out what diseases and disabilities should generally lead to refusal of approval as an adopter should be as clear and predictable as possible, and they should be available to the public".

Against this background, the Department of Private Law set up a working group which had as its object to review the existing guidelines concerning health requirements for adoption applicants and to propose future guidelines.

The working group consisted of the following members:

• Anne Thalbitzer, head of office, Department of Private Law (Chairman)
• Ove Jacobsen, senior hospital physician, member of the Danish National Board of Adoption
• Thure Krarup, MD, senior hospital physician, member of the Danish National Board of Adoption
• Tove Petersen, medical specialist, National Board of Health
• John-Erik Stig Hansen, MD, head of department, Centre for Small Groups of Disabled Persons
• Anne Vikkelsø, attorney-at-law, Equal Opportunities Centre for Disabled Persons
• Lars Klüver, head of secretariat, representing Adoption and Society
• Lars Schriver, general practitioner, representing Adoption and Society.

The working group has held eight meetings.

The members of the working group have contributed discussion papers and proposals which formed part of the group’s discussions. Some members of the working group, including in particular Thure Krarup, MD, senior hospital physician, and Lars Schriver, general practitioner, brought themselves up to date on the latest research results and the latest specialist literature within a number of the disease categories mentioned in this guidance. In addition, the members concerned had a number of informal discussions with several leading specialists.

This guidance presents the working group’s proposal for new guidelines for the assessment of the health of adoption applicants.

Chapter 2 describes partly the legislative framework and partly the general considerations (criteria) that should normally be given weight when assessing the applicants’ health and when evaluat-ing an applicant’s disability.

The primary aim of the assessment of the applicants’ health is to prevent the adoptive child from being placed under additional stress, e.g. as a result of the applicant’s manifest physical or mental disease, early death or functional impairment (disability).

Chapter 3 discusses a number of individual groups of diseases (physical), and Chapter 4 deals with the assessment of the applicant’s mental state of health. Lastly, Chapter 5 discusses the information basis used to assess the applicant’s health.

The new guidelines involve some liberalisation compared with the existing guidelines. This applies in relation to the assessment of young applicants suffering from a disease associated with an increased risk of mortality. The guidelines also include changes in relation to certain groups of diseases, reflecting the development of treatment possibilities and techniques as well as new knowledge of these diseases. In addition, the new guidelines involve significant liberalisation in relation to the assessment of functional impairments. The working group has arrived at the conclusion that the approval of applicants suffering from functional impairment must to a great extent depend on a specific assessment. The working group has therefore found it impossible to establish general guidelines for the individual functional impairments but refers to the fact that in cases of doubt other specialist assistance can be involved through the Danish Disability Council.

Further, it should be noted that the working group has based its work on the overall criteria that may be deduced from the legislative history of the Danish Adoption Act as regards assessment of the health of adoption applicants. The working group has therefore assumed that the health assessment must include an evaluation of the risk of excess mortality. In that connection the working group is aware that there is no real research material showing how and to what extent an adoptive child’s loss of one of its adoptive parents in childhood affects the child compared with other social and family events. The working group finds that there may be a need for collection of more knowledge in this field.

Chapter 2 – General considerations

When processing an application for approval as an adopter the joint council must decide whether the applicant satisfies the requirements concerning adoption applicants’ physical and mental state of health. These requirements are regulated by section 7 of the approval order, which reads as follows:
"7.-(1) Further, to be approved as an adopter it is a condition that l) the applicant’s physical and mental state of health does not diminish the possibilities of the adoption being in the best interests of the child
2) …."

Vital to the assessment of the applicant’s health is whether the applicant suffers from health problems which significantly diminish the applicant’s possibilities of caring for the child throughout its childhood.

Therefore, the health assessment should first and foremost include the applicant’s current state of health. In addition, attempts should be made to establish a long-term prognosis for a period corresponding approximately to the child’s childhood, i.e. approx. 20 years.

The approval of the applicant will often depend on the prognosis. Even though the applicant’s health problems do not currently affect the applicant’s ability to care for the child, decisive weight will be given to the fact that the applicant is at increased risk either of dying during the child’s childhood or of his or her health problems developing so adversely that they will significantly affect the applicant’s ability to care for the child during its childhood.

The assessment of the applicant’s health will only include identified health problems. The fact that, from a general point of view, the applicant’s lifestyle, working conditions, hobbies, family/genetic predispositions etc. involve a risk of excess mortality or a risk of developing severe diseases – without, however, the disease having manifested itself at the time of application – cannot in itself lead to a health-based refusal.

Physical state of health
As mentioned above, in the assessment of the physical state of health importance must be attached to the risk of the applicant dying during the years of the child’s childhood. In that connec-tion the concept of excess mortality is being used, which means the percentage by which the number of deaths in a population group exceeds the expected number.

If the applicant suffers from a disease, which indicates significant excess mortality within the next 15-20 years, the applicant should not be approved as an adopter.

Excess mortality means substantially increased mortality compared with the healthy population. For healthy persons in the age group of adoption applicants, the rate of mortality for the subsequent 20-year period rises from 2.5% for the 25-year-olds to approx. 10% for the 40-year-olds. The absolute risk of dying within a 20-year period thus rises with age, so that the older the applicant the greater the weight that should be given to the disease risks.

A number of relatively rare diseases are found among adoption applicants, for which it is difficult to find prognosis numbers in the specialist literature. In these cases a professional judgement based on an assessment made by a medical specialist must be formed.

Another matter to focus on in the assessment of the applicant’s health is whether the applicant suffers from a disease involving a substantial risk of a long stressful period of disease, treatment and/or hospitalisation. In such cases the influence of the disease on the family’s everyday life and the applicant’s ability to look after the child’s needs for care, nearness, challenges and experiences must be evaluated.

The fact that one of the spouses is healthy cannot, as a general rule, compensate for the fact that the other spouse suffers from a disease which indicates significant excess mortality and/or a pe-riod of stressful disease. Thus, attempts should be made to ensure that both adopters will be able to care for the child throughout its childhood. If, however, there is any doubt in the case of a single adopter, a precautionary principle should be applied when assessing the applicant’s state of health.

The fact that an applicant has a chronic functional impairment/disability does not in itself prevent the person concerned from being approved as an adopter. This decision must depend on a specific assessment based on a broader view than a purely medical one.

Thus, an overall evaluation must be made, including the following factors:

• The degree of functional impairment, including whether and to what extent and in what way the functional impairment affects the applicant’s ability to parent the child.
• Compensatory factors, including the extent to which the functional impairment is or can be compensated for by the applicant himself or herself, together with his or her spouse or through social and/or medical intervention.
• The applicant’s life situation in general.

In the case of a couple, a general requirement must be that both spouses have the necessary capacity to establish close, continuous contact – physically and mentally – with the child and that the couple together are able to satisfy the child’s needs for nursing, care, challenges and experiences.

Mental state of health
Certain deviations in the personality pattern will greatly affect the applicant’s ability to care for the child.
If – possibly following a psychiatric examination – it is not possible to demonstrate deviations or the like and there is nevertheless doubt about the applicant’s suitability, a psychological examination may be carried out in phase 3, if necessary. Reference is made to the Department of Family Affairs’ Adoption Guide to State Administrations, Guide No. 10282, dated 14 December 2007.
 

Chapter 3 – Review of the individual groups of diseases in relation to the state of health of applicants

This chapter discusses some typical groups of diseases and presents a number of recommended guidelines concerning the importance that should be attached to these diseases for adoption purposes.

It is pointed out that the established guidelines are recommended guidelines. Each individual case should therefore always be assessed specifically, including the degree of severity of the relevant health problems compared with the applicant’s general state of health.

Further, it should be noted that, in specific cases, life style factors etc. may be included in the overall assessment provided that these factors are relevant from a health point of view, e.g. smoking, exercise habits and alcohol consumption. Normally, however, these factors cannot in themselves lead to a health-based refusal.

Under the individual groups of diseases it is stated that, in certain cases, examination by a medical specialist should be carried out before the final decision is made. This means that the joint council should normally make this decision in accordance with section 15(3) of the approval order. However, an examination need not be carried out by a medical specialist if a statement has been obtained from an attending medical specialist and such statement contains adequate information about diagnosis, treatment and possibly prognosis. Reference is made to chapter 5 concerning the information basis.

Heart and circulatory diseases
A congenital heart disease is usually a kind of malformation: a hole in the cardiac wall, defective heart valves, no closing of connecting artery between lung artery and body artery, narrowing of the body artery or a combination of these.

In most cases these malformations have been corrected surgically and usually with a good result and a favourable prognosis. In these cases a congenital heart disease will not normally prevent approval. If, however, the condition has not been corrected and the heart function is reduced, approval should normally be refused because of the increased risk of morbidity and early death.

Acquired heart diseases are in most cases secondary to "arteriosclerosis" involving the coronary arteries. If this is found in an adoption applicant, approval should be refused because of the increased risk of early death associated with a proven artery disease. This applies even though the heart function is normal at the time of approval. If the applicant has previously had a blood clot in the heart, approval must be refused because of the high risk of a new blood clot in the heart.

Other acquired heart diseases are caused by infection which in most cases is localised to the heart valves. If after such an infection the heart function is still reduced, the application should, as a principal rule, be refused. If new heart valves have been implanted surgically, whether it is the so-called biological valves or mechanical valves, the application can normally be approved if the heart function is normal and the applicant is undergoing correct treatment with blood-diluting medication. However, examination by a medical specialist should normally be carried out. Applicants suffering from heart rhythm disorders can usually be approved if their heart function is not reduced. This also applies if the applicant is to be treated with blood-diluting medication. Certain heart rhythm disorders are serious and may lead to refusal of approval. Examination by a medical specialist should normally be carried out.

Other circulatory disorders (for example in the legs): Early onset of arteriosclerosis is often seen as a consequence of tobacco smoking and increased fat content in the blood. This condition, which increases the risk of early death and morbidity, should be assessed by a medical specialist.

Venous diseases
Both varices and venous blood clot development are frequently occurring disorders which are seldom so serious that they will lead to refusal of approval. However, this does not apply if the venous blood clot has spread into the lung arteries (pulmonary emboli), blocking large parts of these permanently. This is a condition with a poor prognosis and early death.

High blood pressure
If the elevated blood pressure is well treated and uncomplicated, no approval should be refused. If the blood pressure remains high under treatment or if there are complications from kidneys, brain or severe changes in the eye’s retina, the application will normally be refused because of the increased risk of sequelae, particularly blood clots in the brain, cerebral haemorrhage and reduced renal function.

Lung diseases
In terms of number, these diseases are dominated completely by asthma and chronic bronchitis (so-called chronic obstructive lung disorder, usually caused by smoking). They exist in all degrees of severity, ranging from very light to fatally severe. Applicants suffering from these diseases must be assessed by a medical specialist and have their lung function measured. If the function is clearly reduced, approval should be refused because of the increased risk of morbidity and early death if the lung disorder has led to heart strain (cor pulmonale). Factors of importance in the assessment are the amount of medication required for the disease and whether the applicant is still smoking.

Kidney diseases
Applicants suffering from a chronic kidney disease should be examined by a medical specialist. Chronic renal insufficiency clearly involves increased morbidity and mortality. If the renal function is reduced or there is a risk of continued reduction of the renal function, approval should be refused. Importance should be attached to high blood pressure as well as brain or eye complications.

Gastrointestinal disorders
With the use of modern treatment, gastric ulcer diseases will only in very rare cases give rise to doubt about approval.

Inflammatory bowel diseases: There are two main forms, ulcerative colitis ("inflammation of the colon with bleeding") and Crohn's disease.

If ulcerative colitis is treated surgically with removal of the sick colon or is well treated with medication, the disease will not in itself give rise to refusal of approval.

As regards the form of inflammatory bowel disease that is called Crohn's disease, the disease can be localised in all parts of the gastrointestinal system, from the tongue to the rectum, and the disease has an unpredictable, often more serious and variable course with good and bad periods. With modern treatment there is no significantly increased mortality (during a disease course of 20 years), but approx. 2/3 of the patients with Crohn's disease will periodically experience high disease activity which may have a significant effect on their everyday life. Within a period of 15 years the patient will typically have undergone one or more operations. Crohn's disease should therefore generally lead to refusal of approval.

Some patients with Crohn's disease experience a more favourable course, particularly where the disease is localised to the colon only. In such cases approval may possibly be given if the disease has been inactive for many years. Examination by a medical specialist should be carried out.

Diseases of the nervous system
The most frequently occurring disease among adoption applicants is epilepsy in different forms as well as the so-called demyelination diseases, especially sclerosis. If the epilepsy is well treated so that the applicant is attack-free and well functioning in his or her everyday life, approval may be given following examination by a medical specialist.

As regards the demyelination diseases (multiple sclerosis), the disease should generally lead to refusal of approval because the disease often leads to severe disability. In cases of doubt, examination by a medical specialist should be carried out.

Both tension headache and migraine are very frequently occurring conditions. Normally they only cause slight or moderate discomfort, which should not lead to refusal of approval.

However, in severe cases with frequent migraine attacks, chronic tension headache or a large medicine consumption, the disease may be such a substantial burden for the family that approval must be refused. In that case examination by a medical specialist should be carried out.

Autoimmune diseases
These are diseases caused by increased quantities of autoantibodies, i.e. antibodies against the organism’s own cells or cell parts. Today a large number of very different diseases are classified as autoimmune. Among the commonest of these diseases can be mentioned the skin disease psoriasis as well as chronic articular rheumatism. Most of the applicants suffering from these diseases may be approved. The development of some of these diseases may be so serious that approval should be refused. Applicants suffering from these diseases should be assessed by a medical specialist.

Diabetes
Adoption applicants suffering from this disease usually have it in the form requiring insulin treatment. If the applicant has had the disease for more than ten years, the applicant should be assessed by a medical specialist. If the disease is well regulated and uncomplicated, approval will not be refused. The occurrence of microalbuminuria, retina change or kidney effect are complications which will usually lead to refusal of approval. Non-insulin-requiring diabetes (diet and/or tablet treated) will not normally give rise to refusal unless the disease has caused complications. Updated information on whether there are complications should be available, possibly in the form of a statement from a medical specialist.

Metabolic diseases
Metabolic diseases (thyrotoxicosis and myxoedema) will generally be easy to treat, and applicants suffering from these diseases can be approved if the metabolism has become normal after treatment. The metabolism is evaluated against the background of the metabolism hormones T4 and T3. If these hormones are at the normal level or close to it, the applicant can be approved. In a number of cases the hormones T4 and T3 are normal, but the superordinate regulating hypophysis hormone TSH (thyroidea-stimulating-hormone) is outside the normal range. In such instances the metabolism is normal and the applicant can be approved, even if months (in some instances years) can elapse before TSH normalises. It is only in unusual cases, with a metabolism which is hard to regulate, or with complications in the disease in the form of serious eye disease, that a refusal must be considered, based upon the assessment of a medical specialist.

Overweight
A person’s weight must be evaluated in relation to his or her height.

Overweight can be calculated on the basis of the so-called body mass index, abbreviated as BMI.

The BMI is calculated as the person’s weight in kilograms divided by the height in metres squared. For example, a person who weighs 70 kilograms and is 1.76 metres tall will have a BMI of 22.6 kg/m2. According to WHO, the BMI is normally between 18.5 and 24.9 kg/m2.

Provided that the applicant is otherwise healthy, the health risk from light degrees of overweight is moderate (BMI under 33 kg/m2), and light overweight will therefore not give rise to refusal of approval.

The significance of a given degree of heavy overweight varies a little for men and women. In the case of heavy overweight (for men BMI between 33 and 38 kg/m2 and for women BMI between 33 and 40 kg/m2), it is normally a requirement that there has been an examination carried out by a medical specialist. However it is not necessary to set up an examination by a medical specialist if it already emerges from the information available from the general practitioner that the applicant’s blood pressure, cholesterol and glucose are normal (plasma glucose fast < 6.1 or 2-hour peroral glucose load < 11.1 mmol/l). If there are significant complications - a particularly high blood-pressure level, diabetes, high cholesterol or if the applicant is a smoker - approval should be refused.

In the case of very heavy overweight (BMI over 38 kg/m2 for men and 40 kg/m2 for women), the risk of morbidity and mortality is so much higher even without proven complications that approval will be refused unless the applicant is young and a non-smoker.

Organ transplant patients
Applicants, who have received a kidney, liver, lung and/or heart transplant, should be refused approval. This is due to the fact that there is clear excess mortality in these groups, both because of the primary organ disease and because of side effects from the necessary immunosuppressive therapy.

Applicants having previously received a bone marrow transplant can be approved based on a specific assessment if they are medicine-free and cured for the primary disease. The observation period after completed treatment ought to be eight years.

Transplantation of bone pieces, cornea or skin does not in itself give rise to doubt as to approval.

Cancer diseases
Adoption applicants being treated for cancer or leukaemia must be refused approval. Applicants who have previously been treated for cancer or leukaemia and who have been cured for the dis-ease may be approved following examination by a medical specialist if the risk of relapse is minimal. The observation period after completed treatment ought to be eight years for both leukaemia and other cancer diseases. In the case of breast cancer and mole cancer (apart from the superficial forms, see below), the risk of late relapses is greater than for other forms of cancer, for which reason approval should be refused. For certain forms of cancer of the testicles, the observation period can be much shorter than eight years.
However, certain forms of diseases of the neck of the uterus (slight cell changes, so-called dysplasia and the early stages of cancer of the neck of the uterus, carcinoma in situ) may be approved after completed treatment. Well treated cancer of the neck of the uterus of the type planocellular carcinoma stages I and II without metastases can be approved after completed treatment and five years of observation as relapses after five years occur very rarely. After the conclusion of treatment and a 5-year observation period, the risk of relapse is below 5%. Insofar as the applicant has had metastases, the risk is slightly higher, circa 5-7%.
It is very rare to see a relapse after 3 years observation if there have not been any metastases; for this reason young applicants, in particular, whose illness has taken this course of development, and who do not smoke, will be able to be considered for approval after 3 years observation. Insofar as there have been metastases, the observation period must be 5 years. Applicants with a well-treated cancer of the neck of the uterus, stage 1a, will be able to be approved after 3 years observation. 

Skin cancer: So-called basocellular carcinoma and very superficial mole cancer (malignant melanoma, not deeper than 0.6 mm) do not give rise to refusal of approval, but an assessment should be made by a medical specialist.

Side effects of medication
After longstanding use some drugs have so pronounced side effects that they cause increased morbidity and mortality. This applies first and foremost to medical treatment of cancer, the so-called chemotherapy or cytostatic treatment. After completed treatment with cytostatic agents leukaemia may later develop. This increased risk of leukaemia is limited to the first eight years after completed treatment with cytostatic agents. A specific evaluation of the nature of the disease and the medication must be made.

Immunosuppressive treatment
In very severe cases of autoimmune diseases and in the case of organ transplants the formation of antibodies is reduced by combining prednisol with one or possibly two cytostatically acting drugs. Ongoing immunosuppressive treatment should lead to refusal of approval. After completed treatment, a specific evaluation of duration, types of medication and nature of disease should be carried out.

HIV/AIDS
For HIV positive persons and AIDS patients the prognosis is so serious that the application for approval will be refused.
 

Chapter 4 - Mental state of health

The assessment of the mental state of health is closely connected with the evaluation of the applicant’s suitability to adopt – both from a personal and a family point of view. This is very significant to the adoption. On the one hand, the applicants’ mental state of health and personality are no doubt the most important criterion for their suitability as adoptive parents, and positive qualifications in this area may to a great extent offset defects of a social or other nature. On the other hand, however, it is often very difficult to obtain detailed and adequate information. The extent and nature of information available in the ordinary processing of the case will vary greatly, and it is therefore not possible to give precise guidelines.

The evaluation of the available personal information raises additional difficulties. Cases where the deviations are more pronounced will lead to refusal of approval, but even in such cases the knowledge you have of qualifications that are the best to create a good adoptive home is limited, and the evaluation is often based on judgement. The more expertise and the more knowledge of human nature the case officer has and the more adequate the available information is, for example from the doctor, the greater is the possibility of serious deviations being discovered.

To be able to assess the applicant’s mental state of health for adoption purposes, special attention should be paid to the applicants’ maturity, ability to make contact and empathy as well as mental balance, intellectual capacity and level-headedness, such as can be evaluated in connection with the treatment of the case, as well as on the basis of the applicant’s life history and relationships.

For the child it is important that the parents are mentally healthy during its childhood, not only because they must be able to support and look after the child but also because diseases create insecurity in the environment and affects the whole family situation in an unfortunate way. Applicants suffering from recurring depression or more permanent conditions like anxiety, compulsive symptoms or psychosomatic symptoms (body symptoms associated with or reflecting mental difficulties) should not be approved because their resources will to a great extent be used to tackle their own problems, and the ability to lead a normal life and establish a stable emotional contact with the child will be hampered.

In the case of permanent mental disorders like schizophrenia and related conditions as well as recurring mental disorders, including periodically occurring mood disorders, or if one of the applicants suffers from a mental disorder, an adoption application must be refused. In cases where an applicant has earlier in life suffered from a transitory mental disorder, it may be a matter of doubt whether this will justify refusal of approval. An examination of the medical information from the period of disease may possibly show whether the disease was provoked by special circumstances or whether it reflected reduced resistance as a result of personality or neurotic character weaknesses. If the disease was provoked by special external circumstances, approval may be considered if the necessary conditions are present. A psychiatric and/or a psychological examination should normally be carried out in order to evaluate the cause of the disease and thus the guarantee that it will not return.

Developmentally retarded applicants (intelligence defect) cannot be approved as adopters. A family environment where a child will receive less intellectual stimulation than in a normal environment should not be approved as this will inhibit the child in its development or affect its development adversely.

Likewise, personality disturbances will make an applicant unsuitable to raise a child and justify refusal of approval. In this case, importance should be attached not only to the applicant’s social adaptability and working capacity but also to how the conditions affect his or her relationship with other people or hamper his or her emotional life, responsibility and ability to make contact.

Persons who have previously had substantial adaptability problems, exhibited antisocial behaviour or had medicine, drug or alcohol abuse problems will usually suffer from personality disturbances, and great care should be exercised in the approval of the applicants. This applies not least to applicants who to have previously had abuse problems and are at great risk of relapse.

In the assessment of applicants whose mental suitability gives rise to doubt, a conventional psychiatric examination is often not sufficient. It will often be necessary to carry out a psychological examination, possibly based on test material, with a view to obtaining a more detailed picture of the applicant’s personality and background with regard to relationships.
 

Chapter 5 – Information basis

According to section 4 of the approval order, the applicant is required to forward a health statement completed by the applicant and a health certificate from the applicant’s own doctor together with the application. The health certificate must not be more than three months old at the time of application.

In cases where the statement or certificate gives information about health problems, the county authority should normally obtain a statement from the attending doctor, including information about diagnosis, treatment and possibly a prognosis. The applicant’s consent must have been obtained.

If the joint council finds that examination by a medical specialist is needed before a decision is made, the council may decide that such an examination of the applicant must be carried out. It will be appropriate to send a copy of this guidance to the medical specialist together with the request for examination.

In the assessment of a chronic functional impairment (a physical disability) a broader view than a purely medical one must be taken. The possibility of obtaining a statement from another specialist through the Danish Disability Council should therefore be considered unless it is obvious that the functional impairment is insignificant to the approval as an adopter.

Revised by The Department of Family Affairs, 2002