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Battle of Hampton Roads

The Battle of Hampton Roads, also referred to as the Battle of the Monitor and Merrimack (rebuilt and renamed as the CSS Virginia) or the Battle of Ironclads, was a naval battle during the American Civil War.

The battle was fought over two days, March 8 and 9, 1862, in Hampton Roads, a roadstead in Virginia where the Elizabeth and Nansemond rivers meet the James River just before it enters Chesapeake Bay adjacent to the city of Norfolk. The battle was a part of the effort of the Confederacy to break the Union blockade, which had cut off Virginia's largest cities and major industrial centers, Norfolk and Richmond, from international trade. At least one historian has argued that the Confederacy, rather than trying to break the blockade, was simply trying to take complete control of Hampton Roads in order to protect Norfolk and Richmond.

This battle was significant in that it was the first combat between ironclad warships, the USS Monitor (1862) and CSS Virginia. The Confederate fleet consisted of the ironclad ram Virginia (built from remnants of the burned steam frigate USS Merrimack (1855), newest warship for the United States Navy / Union Navy) and several supporting vessels. On the first day of battle, they were opposed by several conventional, wooden-hulled ships of the Union Navy.

On that day, Virginia was able to destroy two ships of the federal flotilla, USS Congress (1841) and USS Cumberland (1842), and was about to attack a third, USS Minnesota (1855), which had run aground. However, the action was halted by darkness and falling tide, so Virginia retired to take care of her few wounded—which included her captain, Flag Officer Franklin Buchanan—and repair her minimal battle damage.

Determined to complete the destruction of Minnesota, Catesby ap Roger Jones, acting as captain in Buchanan's absence, returned the ship to the fray the next morning, March 9. During the night, however, the ironclad Monitor had arrived and had taken a position to defend Minnesota. When Virginia approached, Monitor intercepted her. The two ironclads fought for about three hours, with neither able to inflict significant damage on the other. The duel ended indecisively, Virginia returning to her home at the Gosport Navy Yard for repairs and strengthening, and Monitor to her station defending Minnesota. The ships did not fight again, and the blockade remained in place.

The battle received worldwide attention, having immediate effects on navies around the world. The preeminent naval powers, Great Britain and France, halted further construction of wooden-hulled ships, and others followed suit. Although Britain and France had been engaged in an iron-clad arms race since the 1830s, the Battle of Hampton Roads signaled a new age of naval warfare had arrived for the whole world. A new type of warship, monitor, was produced on the principle of the original. The use of a small number of very heavy guns, mounted so that they could fire in all directions, was first demonstrated by Monitor but soon became standard in warships of all types. Shipbuilders also incorporated rams into the designs of warship hulls for the rest of the century.

The blockade at Norfolk

On April 19, 1861, shortly after the outbreak of hostilities at Charleston Harbor, US President Abraham Lincoln proclaimed a blockade of ports in the seceded states. On April 27, after Virginia and North Carolina had also passed ordinances of secession, the blockade was extended to include their ports also. Even before the extension, local troops had seized the Norfolk area and threatened the Gosport Navy Yard in Portsmouth. The commandant there, Captain Charles S. McCauley, though loyal to the Union, was immobilized by advice he received from his subordinate officers, most of whom were in favor of secession. Although he had orders from (Union) Secretary of the Navy Gideon Welles to move his ships to Northern ports, he refused to act until April 20, when he gave orders to scuttle the ships in the yard and destroy its facilities.

At least nine ships were burned, among them the screw frigate USS Merrimack (1855). Once the old frigate USS Cumberland (1842) was towed away successfully. Merrimack burned only to the waterline, however, and her engines were more or less intact. The destruction of the navy yard was mostly ineffective; in particular, the large drydock there was relatively undamaged and soon could be restored. Without firing a shot, the advocates of secession had gained for the South its largest navy yard, as well as the hull and engines of what would be in time its most famous warship. They had also seized more than a thousand heavy guns, plus gun carriages and large quantities of gunpowder.

With Norfolk and its navy yard in Portsmouth, the Confederacy controlled the southern side of Hampton Roads. To prevent Union warships from attacking the yard, the Confederates set up batteries at Sewell's Point and Craney Island, at the juncture of the Elizabeth River with the James. (See map.) The Union retained possession of Fort Monroe, at Old Point Comfort on the Virginia Peninsula. They also held a small man-made island known as the Rip Raps, on the far side of the channel opposite Fort Monroe, and on this island they completed another fort, named Fort Wool. With Fort Monroe went control of the lower Peninsula as far as Newport News.

Forts Monroe and Wool gave the Union forces control of the entrance to Hampton Roads. The blockade, initiated on April 30, 1861, cut off Norfolk and Richmond from the sea almost completely. To further the blockade, the Union Navy stationed some of its most powerful warships in the roadstead. There, they were under the shelter of the shore-based guns of Fort Monroe and the batteries at Hampton and Newport News and out of the range of the guns at Sewell's Point and Craney Island. For most of the first year of the war, the Confederacy could do little to oppose or dislodge them.

Birth of the ironclads
When steam propulsion began to be applied to warships, naval constructors renewed their interest in armor for their vessels. Experiments had been tried with armor during the Crimean War (1853–1856), just prior to the American Civil War, and the British and French navies had each built armored ships and were planning to build others. In 1860 the French Navy commissioned FRENCH BATTLESHIP La Gloire, the world's first ocean-going ironclad warship. Great Britain followed a year later with HMS Warrior (1860), the world's first armor-plated iron-hulled warship. The use of armor remained controversial, however, and the United States Navy was generally reluctant to embrace the new technology.

CSS Virginia

When the Civil War broke out in 1861, Confederate Secretary of the Navy Stephen R. Mallory was an early enthusiast for the advantages of armor. As he looked upon it, the Confederacy could not match the industrial North in numbers of ships at sea, so they would have to compete by building vessels that individually outclassed those of the Union. Armor would provide the edge. Mallory gathered about himself a group of men who could put his vision into practice, among them John M. Brooke, John L. Porter, and William P. Williamson.

When Mallory's men searched the South for factories that could build engines to drive the heavy ships that he wanted, they found no place to do it immediately. At the best facility, the Tredegar Iron Works in Richmond, building engines from scratch would take at least a year. Upon learning this, Williamson suggested taking the engines from the hulk of Merrimack, recently raised from the bed of the Elizabeth River. His colleagues promptly accepted his suggestion and expanded it, proposing that the design of their projected ironclad be adapted to the hull. Porter produced the revised plans, which were submitted to Mallory for approval.

On July 11, 1861, the new design was accepted, and work began almost immediately. The burned-out hull was towed into the graving dock that the Union Navy had failed to destroy. During the subsequent conversion process, the plans developed further, incorporating an iron ram fitted to the prow. The re-modeled ship's offense, in addition to the ram, consisted of 10 guns: six 9 in smooth-bore Dahlgrens, two 6.4 in and two 7 in Brooke rifles. Trials showed that these rifles firing solid shot would pierce up to eight inches of armor plating.

The Tredegar Iron works could produce both solid shot and shell, and since it was believed that Virginia would face only wooden ships, she was given only the explosive shell. The armor plating, originally meant to be 1 in thick, was replaced by double plates, each 2 in thick, backed by 24 in of iron and pine. The armor was pierced for 14 gunports: four on each broadside, three forward, and three aft. The revisions, together with the usual problems associated with the transportation system of the South, resulted in delays that pushed out the launch date until February 3, 1862, and she was not commissioned until February 17, bearing the name CSS Virginia.

USS Monitor

Intelligence that the Confederates were working to develop an ironclad caused consternation for the Union, but Secretary of the Navy Gideon Welles waited for Congress to meet to request permission to consider building armored vessels; Congress gave this permission on August 3, 1861. Welles appointed a commission, which became known as the Ironclad Board, of three senior naval officers to choose among the designs that were submitted for consideration. The three men were Captains Joseph Smith, Hiram Paulding, and Commander Charles Henry Davis. The board considered seventeen designs, and chose to support three. The first of the three to be completed, even though she was by far the most radical in design, was Swedish engineer and inventor John Ericsson's USS Monitor (1862).

Ericsson's Monitor, which was built at Ericsson's yard on the East River in Greenpoint, Brooklyn, incorporated new and striking design features, the most significant of which were her armor and armament. Instead of the large numbers of guns of rather small bore that had characterized warships in the past, Ericsson opted for only two guns of large caliber; he wanted to use 15 in guns, but had to settle for 11 in Dahlgren guns when the larger size were unavailable. These were mounted in a cylindrical turret, 20 ft in diameter, 9 ft high, covered with iron 8 in thick. The whole rotated on a central spindle, and was moved by a steam engine that could be controlled by one man. Ericsson was afraid that using the full 30 pounds of black powder to fire the huge cannon would raise the risk of an explosion in the turret. He demanded that a charge of 15 pounds be used to lessen this possibility.

As with Virginia, trials found that a full charge would pierce armor plate, a finding that would have affected the outcome of the battle. A serious flaw in the design was the pilot house from which the ship would be conned, a small structure forward of the turret on the main deck. Its presence meant that the guns could not fire directly forward, and it was isolated from other activities on the ship. Despite the late start and the novelty of construction, Monitor was actually completed a few days before her counterpart Virginia, but the Confederates activated Virginia first.

Command
The Confederate chain of command was anomalous. Lieutenant Catesby ap Roger Jones had directed much of the conversion of Merrimack to Virginia, and he was disappointed when he was not named her captain. Jones was retained aboard Virginia, but only as her executive officer. Ordinarily, the ship would have been led by a captain of the Confederate States Navy, to be determined by the rigid seniority system that was in place. Secretary Mallory wanted the aggressive Franklin Buchanan, but at least two other captains had greater seniority and had applied for the post. Mallory evaded the issue by appointing Buchanan, head of the Office of Orders and Detail, flag officer in charge of the defenses of Norfolk and the James River. As such, he could control the movements of Virginia. Technically, therefore, the ship went into the battle without a captain.

On the Union side, command of the North Atlantic Blockading Squadron was held by Flag Officer Louis M. Goldsborough. He had devised a plan for his frigates to engage Virginia, hoping to trap her in their crossfire. In the event, his plan broke down completely when four of the ships ran aground (one of them intentionally) in the confined waters of the roadstead. On the day of battle, Goldsborough was absent with the ships cooperating with the Burnside Expedition in North Carolina. In his absence, leadership fell to his second in command, Captain John Marston of USS Roanoke (1855). As Roanoke was one of the ships that ran aground, Marston was unable to materially influence the battle, and his participation is often disregarded. Most accounts emphasize the contribution of the captain of Monitor, John L. Worden, to the neglect of others.

March 8: Virginia wreaks havoc on wooden Union warships
The battle began when the large and unwieldy CSS Virginia steamed into Hampton Roads on the morning of March 8, 1862. Captain Buchanan intended to attack as soon as possible. Virginia was accompanied from her moorings on the Elizabeth River by CSS Raleigh and CSS Beaufort, and was joined at Hampton Roads by the James River Squadron, CSS Patrick Henry, CSS Jamestown, and CSS Teaser. When they were passing the Union batteries at Newport News, Patrick Henry was temporarily disabled by a shot in her boiler that killed four of her crew. After repairs, she returned and rejoined the others.

At this time, the Union Navy had five warships in the roadstead, in addition to several support vessels. The sloop-of-war USS Cumberland (1842) and frigate USS Congress (1841) were anchored in the channel near Newport News. The sail frigate USS St. Lawrence (1848) and the steam frigates USS Roanoke (1855) and USS Minnesota (1855) were near Fort Monroe, along with the storeship USS Brandywine (1825). The latter three got under way as soon as they saw Virginia approaching, but all soon ran aground. St. Lawrence and Roanoke took no further important part in the battle.

Virginia headed directly for the Union squadron. The battle opened when Union tug Zouave fired on the advancing enemy, and Beaufort replied. This preliminary skirmishing had no effect. Virginia did not open fire until she was within easy range of Cumberland. Return fire from Cumberland and Congress bounced off the iron plates without penetrating, although later some of Cumberland's gunfire lightly damaged Virginia.

Virginia rammed Cumberland below the waterline and she sank rapidly, "gallantly fighting her guns as long as they were above water," according to Buchanan. She took 121 seamen down with her; those wounded brought the casualty total to nearly 150.

Ramming Cumberland nearly resulted in the sinking of Virginia as well. Virginia's bow ram got stuck in the enemy ship's hull, and as Cumberland listed and began to go down, she almost pulled Virginia under with her. At the time the vessels were locked, one of Cumberland's anchors was hanging directly above the foredeck of Virginia. Had it come loose, the two ships might have gone down together. Virginia broke free, however, her ram breaking off as she backed away.

Buchanan next turned Virginia on Congress. Seeing what had happened to Cumberland, Lieutenant Joseph B. Smith, captain of Congress, ordered his ship grounded in shallow water. By this time, the James River Squadron, commanded by John Randolph Tucker, had arrived and joined Virginia in the attack on Congress. After an hour of unequal combat, the badly damaged Congress surrendered. While the surviving crewmen of Congress were being ferried off the ship, a Union battery on the north shore opened fire on Virginia. In retaliation, Buchanan ordered Congress fired upon with hot shot, cannonballs heated red-hot. Congress caught fire and burned throughout the rest of the day. Near midnight, the flames reached her magazine and she exploded and sank, stern first. Personnel losses included 110 killed or missing and presumed drowned. Another 26 were wounded, of whom ten died within days.

Although she had not suffered anything like the damage she had inflicted, Virginia was not completely unscathed. Shots from Cumberland, Congress, and Union troops ashore had riddled her smokestack, reducing her already low speed. Two of her guns were disabled and several armor plates had been loosened. Two of her crew were killed, and more were wounded. One of the wounded was Captain Buchanan, who stood out into the open top of the Virginia, thinking it was perfectly safe, which led to him having his left thigh pierced by a rifle shot.

Meanwhile, the James River Squadron had turned its attention to Minnesota, which had left Fort Monroe to join in the battle and had run aground. After Virginia had dealt with the surrender of Congress, she joined the James River Squadron despite her damage. Because of her deep draft and the falling tide, however, Virginia was unable to get close enough to be effective, and darkness prevented the rest of the squadron from aiming their guns to any effect. The attack was therefore suspended. Virginia left with the expectation of returning the next day and completing the task. She retreated into the safety of Confederate-controlled waters off Sewell's Point for the night, but had killed 250 enemy sailors and had lost two. The Union had lost two ships and three were aground.

The United States Navy's greatest defeat (and would remain so until World War II) caused panic in Washington. As Lincoln's Cabinet met to discuss the disaster, the frightened Secretary of War Edwin Stanton told the others that Virginia might attack East coast cities, and even shell the White House before the meeting ended. Welles assured his colleagues that they were safe as the ship could not traverse the Potomac River. He added that the Union also had an ironclad, and that it was heading to meet Virginia.

March 9: Monitor engages Virginia

Both sides used the respite to prepare for the next day. Virginia put her wounded ashore and underwent temporary repairs. Captain Buchanan was among the wounded, so command on the second day fell to his executive officer, Lieutenant Catesby ap Roger Jones. Jones proved to be no less aggressive than the man he replaced. While Virginia was being prepared for renewal of the battle, and while Congress was still ablaze, Monitor, commanded by Lieutenant John L. Worden, arrived in Hampton Roads. The Union ironclad had been rushed to Hampton Roads in hopes of protecting the Union fleet and preventing Virginia from threatening Union cities. Captain Worden was informed that his primary task was to protect Minnesota, so Monitor took up a position near the grounded Minnesota and waited. "All on board felt we had a friend that would stand by us in our hour of trial," wrote Captain Gershom Jacques Van Brunt, Minnesota's commander, in his official report the day after the engagement.

The next morning, at dawn on March 9, 1862, Virginia left her anchorage at Sewell's Point and moved to attack Minnesota, still aground. She was followed by the three ships of the James River Squadron. They found their course blocked, however, by the newly arrived Monitor. At first, Jones believed the strange craft—which one Confederate sailor mocked as "a cheese on a raft"—to be a boiler being towed from the Minnesota, not realizing the nature of his opponent. Soon, however, it was apparent that he had no choice but to fight her. The first shot of the engagement was fired at Monitor by Virginia. The shot flew past Monitor and struck Minnesota, which answered with a broadside; this began what would be a lengthy engagement. "Again, all hands were called to quarters, and when she approached within a mile of us I opened upon her with my stern guns and made a signal to the Monitor to attack the enemy," Van Brunt added.

After fighting for hours, mostly at close range, neither could overcome the other. The armor of both ships proved adequate. In part, this was because each was handicapped in her offensive capabilities. Buchanan, in Virginia, had not expected to fight another armored vessel, so his guns were supplied only with shell rather than armor-piercing shot. Monitor's guns were used with the standard service charge of only 15 lb of powder, which did not give the projectile sufficient momentum to penetrate her opponent's armor. Tests conducted after the battle showed that the Dahlgren guns could be operated safely and efficiently with charges of as much as 30 lb. However, despite this, as the two ironclads circled each other during the fight, Monitor was about to penetrate Virginia’s armor, but a misfiring of its weapons caused it to lose the advantage. At 10 AM that morning, Virginia grounded. Monitor opened fire on its vulnerable adversary, yet Virginia was able to scrape off the shore and rejoin the fight.

Later during the battle, Acting Master Louis N. Stodder and officers Stimers and Truscott were inside the gun turret, discussing the course of action. Stodder was leaning against the turret's inside wall when it took a direct hit. Stodder was knocked unconscious and taken below, where it took him an hour to regain consciousness. Stodder thus became the first man injured during the battle. He was replaced by Stimers.

The battle finally ceased when a shell from Virginia struck the pilot house of Monitor and exploded, driving fragments of paint and iron through the viewing slits into Worden's eyes and temporarily blinding him. As no one else could see to command the ship, Monitor was forced to draw off. The executive officer, Lieutenant Samuel Dana Greene, took over, and Monitor returned to the fight. In the period of command confusion, however, the crew of Virginia believed that their opponent had withdrawn. Although Minnesota was still aground, the falling tide meant that she was out of reach. Furthermore, Virginia had suffered enough damage to require extensive repair. Convinced that his ship had won the day, Jones ordered her back to Norfolk. At about this time, Monitor returned, only to discover her opponent apparently giving up the fight. Convinced that Virginia was quitting, with orders only to protect Minnesota and not to risk his ship unnecessarily, Greene did not pursue. Thus, each side misinterpreted the moves of the other, and as a result each claimed victory.

Confederate Secretary of the Navy Stephen Mallory wrote to Confederate President Davis of the action:

The conduct of the Officers and men of the squadron … reflects unfading honor upon themselves and upon the Navy. The report will be read with deep interest, and its details will not fail to rouse the ardor and nerve the arms of our gallant seamen. It will be remembered that the Virginia was a novelty in naval architecture, wholly unlike any ship that ever floated; that her heaviest guns were equal novelties in ordnance; that her motive power and obedience to her helm were untried, and her officers and crew strangers, comparatively, to the ship and to each other; and yet, under all these disadvantages, the dashing courage and consummate professional ability of Flag Officer Buchanan and his associates achieved the most remarkable victory which naval annals record.

In Washington, belief that Monitor had vanquished Virginia was so strong that Worden and his men were awarded the thanks of Congress:

"Resolved ... That the thanks of Congress and the American people are due and are hereby tendered to Lieutenant J. L. Worden, of the United States Navy, and to the officers and men of the ironclad gunboat Monitor, under his command, for the skill and gallantry exhibited by them in the remarkable battle between the Monitor and the rebel ironclad steamer Merrimack."

During the two-day engagement, USS Minnesota shot off 78 rounds of 10-inch solid shot; 67 rounds of 10-inch shells with 15-second fuse; 169 rounds of 9-inch solid shot; 180 9-inch shells with 15-second fuse; 35 8-inch shells with 15-second fuse and 5,567.5 pounds of service powder. Three crew members, Alexander Winslow, Henry Smith and Dennis Harrington were killed during the battle and 16 were wounded. One of Monitor's crew, Quartermaster Peter Williams, was awarded the Medal of Honor for his actions during the battle.

Spring 1862—a standoff at Hampton Roads
Virginia remained in drydock for almost a month, getting repairs for battle damage as well as minor modifications to improve her performance. On April 4, she was able to leave drydock. Buchanan, still recovering from his wound, had hoped that Catesby Jones would be picked to succeed him, and most observers believed that Jones's performance during the battle was outstanding. The seniority system for promotion in the Navy scuttled his chances, however, and the post went to the 67-year-old Commodore Josiah Tattnall III. Monitor, not severely damaged, remained on duty. Like his antagonist Jones, Greene was deemed too young to remain as captain; the day after the battle, he was replaced with Lieutenant Thomas Oliver Selfridge Jr. Two days later, Selfridge was in turn relieved by Lieutenant William Nicholson Jeffers.

By late March, the Union blockade fleet had been augmented by hastily refitted civilian ships, including the powerful SS Vanderbilt, SS Arago (1855), SS Illinois, and SS Ericsson. These had been outfitted with rams and some iron plating. By late April, the new ironclads USRC E. A. Stevens and USS Galena (1862) had also joined the blockade.

Each side considered how best to eliminate the threat posed by its opponent, and after Virginia returned each side tried to goad the other into attacking under unfavorable circumstances. Both captains declined the opportunity to fight in waters not of their own choosing; Jeffers in particular was under positive orders not to risk his ship. Consequently, each vessel spent the next month in what amounted to posturing.

Destruction of the combatants

The end came first for Virginia. Because the blockade was unbroken, Norfolk was of little strategic use to the Confederacy, and preliminary plans were laid to move the ship up the James River to the vicinity of Richmond. Before adequate preparations could be made, the Confederate Army under Major General Benjamin Huger abandoned the city on May 9, without consulting anyone from the Navy. Virginia's draft was too great to permit her to pass up the river, which had a depth of only 18 ft, and then only under favorable circumstances. She was trapped and could only be captured or sunk by the Union Navy. Rather than allow either, Tatnall decided to destroy his own ship. He had her towed down to Craney Island in Portsmouth, where the gang were taken ashore, and then she was set afire. She burned through the rest of the day and most of the following night; shortly before dawn, the flames reached her magazine, and she blew up.

Monitor likewise did not survive the year. She was ordered to Beaufort, North Carolina, on Christmas Day, to take part in the blockade there. While she was being towed down the coast (under command of her fourth captain, Commander John P. Bankhead), the wind increased and with it the waves; with no high sides, the Monitor took on water. Soon the water in the hold gained on the pumps, and then put out the fires in her engines. The order was given to abandon ship; most men were rescued by USS Rhode Island (1860), but 16 went down with her when she sank in the early hours of December 31, 1862.

The victor
The victory claims that were made by each side in the immediate aftermath of the Battle of Hampton Roads, as both were based on misinterpretations of the opponent's behavior, have been dismissed by present-day historians. They agree that the result of the Monitor–Virginia encounter was not a victory for either side. As the combat between ironclads was the primary significance of the battle, the general verdict is that the overall result was a draw. All would acknowledge that the Southern fleet inflicted far more damage than it received, which would ordinarily imply that they had gained a tactical victory. Compared to other Civil War battles, the loss of men and ships for the Union Navy would be considered a clear defeat. On the other hand, the blockade was not seriously threatened, so the entire battle can be regarded as an assault that ultimately failed.

However, initially after the Battle of Hampton Roads, both the Confederate and Union media claimed victory for their own sides. A headline in a Boston newspaper the day after the battle read "The Merrimac Driven back by the Steamer!", implying a Union victory, while Confederate media focused on their original success against wooden Union ships. Despite the battle ending in a stalemate, it was seen by both sides as an opportunity to raise war-time morale, especially since the ironclad ships were an exciting naval innovation that intrigued citizens.

Evaluation of the strategic results is likewise disputed. The blockade was maintained, even strengthened, and Virginia was bottled up in Hampton Roads. Because a decisive Confederate weapon was negated, some have concluded that the Union could claim a strategic victory. Confederate advocates can counter, however, by arguing that Virginia had a military significance larger than the blockade, which was only a small part of the war in Tidewater Virginia. Her mere presence was sufficient to close the James River to Federal incursions. She also imposed other constraints on the Peninsula Campaign then being mounted by the Union Army under General George B. McClellan, who worried that she could interfere with his positions on the York River. Although his fears were baseless, they continued to affect the movements of his army until Virginia was destroyed.

Impact upon naval warfare
Both days of the battle attracted attention from almost all the world's navies. USS Monitor became the prototype for the monitor warship type. She thus became the first of two ships whose names were applied to entire classes of their successors, the other being HMS Dreadnought (1906). Many more were built, including river monitors, and they played key roles in Civil War battles on the Mississippi and James rivers.

The US immediately started the construction of ten more monitors based on Ericsson's original larger plan, known as the Passaic-class monitors. More than 20 additional monitors were built by the Union by the end of the war. However, while the design proved exceptionally well-suited for river combat, the low profile and heavy turret caused poor seaworthiness in rough waters. Russia, fearing that the American Civil War would spill into Russian Alaska, launched ten sister ships, as soon as Ericsson's plans reached St. Petersburg. What followed has been described as "Monitor mania". The revolving turret later inspired similar designs for future warships, which eventually became the modern battleship.

The vulnerability of wooden hulls to armored ships was noted particularly in Britain and France, where the wisdom of the planned conversion of the battle fleet to armor was given a powerful demonstration. Another feature that was emulated was not so successful. Impressed by the ease with which Virginia had sunk Cumberland, naval architects began to incorporate rams into their hull designs.

The first purpose-built ram in the modern era was the French armored ram FRENCH IRONCLAD Taureau, whose guns were said to have "the sole function of preparing the way for the ram." The inclusion of rams in warship hull design persisted almost to the outbreak of World War I.

Commemorating the battle: Virginia
The name of the warship that served the Confederacy in the Battle of Hampton Roads has been a continuing source of confusion and some contention. She was originally a screw frigate in the United States Navy carrying the name USS Merrimack (1855). All parties continued to use the name after her capture by secessionists while she was being rebuilt as an ironclad. When her conversion was almost complete, her name was officially changed to CSS Virginia. Despite the official name change, Union accounts persisted in calling Merrimack by her original name, while Confederate sources used either Virginia or Merrimac(k). The alliteration of Monitor and Merrimack has persuaded most popular accounts to adopt the familiar name, even when it is acknowledged to be technically incorrect.

A CSS Merrimac did actually exist. She was a paddle wheel steamer named for the victor (as most Southerners saw it) at Hampton Roads. She was used for running the blockade until she was captured and taken into Federal service, still named Merrimac. Her name was a spelling variant of the river, namesake of USS Merrimack. Both spellings are still in use around the Hampton Roads area.

A small community in Montgomery County, Virginia, near the location where the iron for the Confederate ironclad was forged is now known as Merrimac. Some of the iron mined there and used in the plating on the Confederate ironclad is displayed at the Norfolk Naval Shipyard in Portsmouth. The anchor of Virginia sits on the lawn in front of the American Civil War Museum in Richmond.

Commemorating the battle: Monitor
After resting undetected on the ocean floor for 111 years, the wreck of Monitor was located by a team of scientists in 1973. The remains of the ship were found upside down 16 mi off Cape Hatteras, on a relatively flat, sandy bottom at a depth of about 240 ft. In 1987, the site was declared a National Marine Sanctuary, the first shipwreck to receive this distinction.

Because of Monitor's advanced state of deterioration, timely recovery of remaining significant artifacts and ship components became critical. Numerous fragile artifacts, including the innovative turret and its two Dahlgren guns, an anchor, steam engine, and propeller, have been recovered. They were transported back to Hampton Roads to the Mariners' Museum in Newport News, Virginia, where they were treated in special tanks to stabilize the metal. It is reported that it will take about ten years for the metal to completely stabilize. The new USS Monitor Center at the Mariners' Museum officially opened on March 9, 2007, and a full-scale copy of USS Monitor, the original recovered turret, and artifacts and related items are now on display.

Commemorating the Battle of Hampton Roads
The Battle of Hampton Roads was a significant event in both Naval and Civil War history that has been detailed in many books, televised Civil War documentaries, and in film, to include TNT's 1991 Ironclads. In New York City, where the designer of the Monitor, John Ericsson, died in March 1889, a statue was commissioned by the state to commemorate the battle between the Ironclads. The statue features a stylized male nude allegorical figure on water between two iron cleats. It is located in Msgr McGolrick Park.

In Virginia, the state dedicated the Monitor-Merrimack Overlook at Anderson Park on a jetty that overlooks the site of the battle. The park contains several historical markers commemorating both ships. Also, in 1992, Virginia dedicated the $400 million, 4.6-mile-long Monitor-Merrimac Memorial Bridge-Tunnel, which is located less than 1 mile from the site of the battle.

References in popular culture

 * The film Hearts in Bondage (Republic Pictures, 1936), directed by Lew Ayres, tells the story of the building of USS Monitor and the following Battle of Hampton Roads.
 * A 1991 made-for-television movie called Ironclads, produced by TNT, was made about the battle.
 * The album The Monitor, the second studio album by New Jersey band Titus Andronicus, ends with a fourteen-minute track that references the battle.
 * In Canyonlands National Park, Utah, there are two buttes named after Monitor and Merrimac. There is a viewpoint with a placard describing the significance of their names.
 * Sleater-Kinney recorded an indie rock song referencing the battle, "Ironclad," on the album All Hands on the Bad One in 2000.
 * The book The Virginia by Winston Brady, based on the Battle of Hampton Roads, depicts Captain(s) Franklin Buchanan and John Worden as tragic heroes who are injured during the battle as a punishment for their over-confidence created by the powerful, nigh-indestructible ships they commanded.
 * In the novel The Claw of the Conciliator by Gene Wolfe, set in the Earth's future, the narrator tells a story from a book of myths that conflates the battle with the legend of Theseus and the Minotaur.
 * In the film Sahara, CSS Texas, a later Columbia-class ironclad, is used as a plot device. Two recreations of Texas were constructed for the film: a scale shooting model and full-sized exterior and interior sets. Their outer appearances did not correspond with what is known about the historical ironclad; instead, Texas is represented on screen as an amalgam of the original CSS Virginia and Porter's original casemate ironclad (co-)design, which he based on his two 150 ft. and 180 ft. standard designs. The Columbia class was a variant of the latter and CSS Tennessee. Both were built with larger and differently shaped casemates.
 * The album The Navy Blues (French: Les Bleus de la marine), published in 1975 in French and 2009 in English, of the Belgian series of comic books The Bluecoats (French: Les Tuniques Bleues), depicts the battle.

title: Battle of Hampton Roads


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Talk:Dale

semi-dup with Dale (Middle-earth). Stan 07:49 23 Jun 2003 (UTC)

People Named Dale
Is it necessary to mention who the supposedly 'most popular' Nascar racer named Dale is? Doesn't seem very factual to me, perhaps it should be taken out? Bored461 (talk) 19:32, 24 February 2008 (UTC)

Strange that a lbum of some rapper of 2015 is mentioned, it will be forgotten soon. But for example a character from Chip and Dale Dale is much more renowned, isn't. Seems like strifth for currency.

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title: Talk:Dale


text:
Genetic counseling

Genetic counseling is the process of investigating individuals and families affected by or at risk of genetic disorders to help them understand and adapt to the medical, psychological and familial implications of genetic contributions to disease. This field is considered necessary for the implementation of genomic medicine. The process integrates:

 * Interpretation of family and medical histories to assess the chance of disease occurrence or recurrence
 * Education about inheritance, testing, management, prevention, resources
 * Counseling to promote informed choices, adaptation to the risk or condition and support in reaching out to relatives that are also at risk

History
The practice of advising people about inherited traits began around the turn of the 20th century, shortly after William Bateson suggested that the new medical and biological study of heredity be called "genetics". Heredity became intertwined with social reforms when the field of modern eugenics took form. Although initially well-intentioned, ultimately the movement had disastrous consequences; many states in the United States had laws mandating the sterilization of certain individuals, others were not allowed to immigrate and by the 1930s these ideas were accepted by many other countries including in Germany where euthanasia for the "genetically defective" was legalized in 1939. This part of the history of genetics is at the heart of the now "non directive" approach to genetic counseling.

Sheldon Clark Reed coined the term genetic counseling in 1947 and published the book Counseling in Medical Genetics in 1955. Most of the early genetic counseling clinics were run by non-medical scientists or by those who were not experienced clinicians. With the growth in knowledge of genetic disorders and the appearance of medical genetics as a distinct specialty in the 1960s, genetic counseling progressively became medicalized, representing one of the key components of clinical genetics. It was not, though, until later that the importance of a firm psychological basis was recognized and became an essential part of genetic counseling, the writings of Seymour Kessler making a particular contribution to this. The first master's degree genetic counseling program in the United States was founded in 1969 at Sarah Lawrence College in Bronxville, New York. In 1979, the National Society of Genetic Counselors (NSGC) was founded and led by the first president, Audrey Heimler.

Detection and early processes
Diagnostic testing occurs when an individual is showing signs or symptoms associated with a specific condition. Genetic testing can be used to arrive at a definitive diagnosis in order to provide better prognosis as well as medical management or treatment options. Testing can reveal conditions can be mild or asymptomatic with early treatment, as opposed to debilitating without treatment (such as phenylketonuria). Genetic tests are available for a number of genetic conditions, including but not limited to: Down syndrome, sickle cell disease, Tay–Sachs disease, muscular dystrophy. Establishing a genetic diagnosis can provide information to other at-risk individuals in the family.

Any reproductive risks (e.g. a chance to have a child with the same diagnosis) can also be explored after a diagnosis. Many disorders cannot occur unless both the mother and father pass on their genes, such as cystic fibrosis; this is known as autosomal recessive inheritance. Other autosomal dominant diseases can be inherited from one parent, such as Huntington disease and DiGeorge syndrome. Yet other genetic disorders are caused by an error or mutation occurring during the cell division process (e.g. aneuploidy) and are not hereditary.

Screening tests are often used prior to diagnostic testing, designed to separate people according to a fixed characteristic or property, with the intention of detecting early evidence of disease. For example, if a screening test during a pregnancy (such as maternal blood screening or ultrasound) reveals a risk of a health issue or genetic condition, patients are encouraged to receive genetic counseling to learn additional information regarding the suspected condition. A discussion of the management, therapy and treatments available for the conditions may take place; the next step may differ depending on the severity of the condition and range from during pregnancy to after delivery. Patients may decline additional screening and testing, elect to proceed to diagnostic testing, or pursue further screening tests to refine the risk during the pregnancy.

Presymptomatic or predictive testing occurs when an individual knows of a specific diagnosis (typically adult onset) in their family and has other affected relatives, but they themselves do not manifest any clinical findings at the time when they seek testing. The decision about whether or not to proceed with presymptomatic testing should entail a thoughtful approach and consideration of various medical, reproductive, social, insurance, and financial factors, with no "right" or "wrong" answer. Availability of treatment and medical management options for each specific diagnosis, as well as the genetics and inheritance pattern of the particular condition should be reviewed as inherited conditions can have reduced penetrance.

Insurance and legal issues should also be discussed during genetic counseling. There are laws in the United States such as GINA (Genetic Information Non-discrimination Act) and ACA that provide certain protections against discrimination for individuals with genetic diagnoses.

Approach
There are different approaches to genetic counseling. The reciprocal-engagement model of genetic counseling practice includes tenets, goals, strategies, and behaviors for addressing patients' genetic concerns. Some counselors favor a psycho-educational approach while others incorporate more psycho-therapeutic techniques. Genetic counseling is psycho-educational as patients "learn how genetics contributes to their health risks and then process what this means and how it feels."

Whether the process of genetic counseling is a form of psychotherapy is up for debate. The relationship between the client and counselor is similar as are the goals of the sessions. As a psychotherapist aims to help his client improve his wellbeing, a genetic counselor also helps his client to address a "situational health threat that similarly threatens client wellbeing". Due to the lack of studies which compare genetic counseling to the practice of psychotherapy, it is hard to say with certainty whether genetic counseling can be "conceptualized as a short-term, applied, specific type of psychotherapy". However, there few existing studies suggest that genetic counseling falls "significantly short of psychotherapeutic counseling" because genetic counseling sessions primarily consist of the distribution of information without much emphasis placed on explaining any long-term impacts to the client.

Structure
The goals of genetic counseling are to increase understanding of genetic diseases, discuss disease management options and explain the risks and benefits of testing. Counseling sessions focus on giving vital, unbiased information and non-directive assistance in the patient's decision-making process. Seymour Kessler, in 1979, first categorized sessions in five phases: an intake phase, an initial contact phase, the encounter phase, the summary phase, and a follow-up phase. The intake and follow-up phases occur outside of the actual counseling session. The initial contact phase is when the counselor and families meet and build rapport. The encounter phase includes dialogue between the counselor and the client about the nature of screening and diagnostic tests. The summary phase provides all the options and decisions available for the next step. If patients wish to go ahead with testing, an appointment is organized and the genetic counselor acts as the person to communicate the results. Result delivery can happen both in person or via phone. Often counselors will call out results to avoid patients having to come back in as results can take weeks to be processed. If further counseling is needed in a more personal setting, or it is determined that additional family members should be tested, a secondary appointment can be made.

Support
Genetic counselors provide supportive counseling to families, serve as patient advocates and refer individuals and families to community or state support services. They serve as educators and resource people for other health care professionals and for the general public. Many engage in research activities related to the field of medical genetics and genetic counseling. When communicating increased risk, counselors anticipate the likely distress and prepare patients for the results. Counselors help clients cope with and adapt to the emotional, psychological, medical, social, and economic consequences of the test results.

Each individual considers their family needs, social setting, cultural background, and religious beliefs when interpreting their risk. Clients must evaluate their reasoning to continue with testing at all. Counselors are present to put all the possibilities in perspective and encourage clients to take time to think about their decision. When a risk is found, counselors frequently reassure parents that they were not responsible for the result. An informed choice without pressure or coercion is made when all relevant information has been given and understood.

After counseling for other hereditary conditions, the patient may be presented with the option of having genetic testing. In some circumstances no genetic testing is indicated, other times it may be useful to begin the testing process with an affected family member. The genetic counselor also reviews the advantages and disadvantages of genetic testing with the patient.

Outcomes
The most commonly measured genetic counseling outcomes included knowledge, anxiety or distress, satisfaction, perceived risk, genetic testing (intentions or receipt), health behaviors, and decisional conflict. Results suggest that genetic counseling can lead to increased knowledge, perceived personal control, positive health behaviors, and improved risk perception accuracy as well as decreases in anxiety, cancer-related worry, and decisional conflict.

Adult genetics
Adult or general genetics clinics serve patients who are diagnosed with genetic conditions that begin to show signs or symptoms in adulthood. Many genetic conditions have varying ages of onset, ranging from an infantile form to an adult form. Genetic counseling can facilitate the decision-making process by providing the patient/family with education about the genetic condition as well as the medical management options available to individuals at risk of developing the condition. Having the genetic information of other members of the family opens the door to asking important questions about the pattern of inheritance of specific disease‐causing mutations. Whilst there is a wealth of literature that describes how families communicate information surrounding single genes, there is very little which explores the experience of communication about family genomes. Adult-onset disorders may overlap multiple specialties.

ART/Infertility genetics
Genetic counseling is an integral part of the process for patients utilizing preimplantation genetic testing (PGT), formerly called preimplantation genetic diagnosis. There are three types of PGT and all require in vitro fertilization (IVF) using assisted reproductive technology (ART). PGT-M, for monogenic disorders, involves testing embryos for a specific condition before it is implanted into the mother. This technique is currently being done for disorders with childhood onset, such as Cystic Fibrosis, Tay-Sachs and Muscular Dystrophy, as well as adult-onset conditions, including Huntington's Disease, Hereditary Breast and Ovarian Cancer Syndrome, and Lynch Syndrome. PGT-SR, for structural rearrangements, involves testing embryos to establish a pregnancy unaffected by a structural chromosomal abnormality (translocation). PGT-A, for aneuploidy, was formerly called preimplantation genetic screening, and involved testing embryos to identify any de novo aneuploidy. The indications to carry out PGT-A are: previous aneuploidy in the couple, implantation failure, recurrent miscarriage, severe male factor or advanced maternal age. Finally, PGT seems to be: safe for the embryo, trustable in the diagnosis, more efficient from the reproductive point of view and cost-effective.

Genetic counseling can also involve medical evaluation and clinical work-up for couples with infertility or recurrent pregnancy loss, as these histories can be associated with parental chromosome aberrations (such as inversions or translocations) and other genetic conditions.

Cardiovascular genetics
A rapidly expanding field in genetic counseling is cardiovascular genetics. More than 1 in 200 people have an inherited cardiovascular disease. Hereditary cardiac conditions range from common diseases, such as high cholesterol and coronary artery disease, to rare diseases like Long QT Syndrome, hypertrophic cardiomyopathy, and vascular diseases. Genetic counselors who specialize in cardiovascular disease have developed skills specific to the management of and counseling for genetic cardiovascular disorders and practice in both the pediatric and adult setting. Cardiovascular genetic counselors are also integral in local and national efforts to prevent sudden cardiac death, which is the leading cause of sudden death in young people. This is done by identifying patients with known or suspected heritable cardiovascular diseases and promoting cascade family screening or testing of at-risk relatives.

Common referral reasons include:
 * Cardiomyopathy, including, hypertrophic cardiomyopathy and familial idiopathic dilated cardiomyopathy
 * Arrhythmia, including Long QT syndrome and Brugada syndrome
 * Vascular disease, including Marfan syndrome and aortic aneurysm and/or dissection (<50 years old)
 * Congenital heart defects (e.g. conotruncal defects, left ventricular outflow tract defects)
 * Familial hypercholesterolemia
 * Family history of unexplained sudden death

Guidelines on cardiovascular genetics are published by multiple professional societies.

Hereditary cancer genetics
Cancer genetic counselors see individuals with a personal diagnosis or family history of cancer or symptoms of an inherited cancer syndrome. Genetic counselors take a family history and assess for hereditary risk, or risk that can be passed down from generation to generation. If indicated, they can coordinate genetic testing, typically via blood or saliva sample, to evaluate for hereditary cancer risk. Personalized medical management and cancer screening recommendations can be provided based on results of genetic testing or the family history of cancer. While most cancers are sporadic (not inherited), some are more likely to have a hereditary factor, particularly when occurring at young ages or when clustering in families. These include common cancers such as breast, ovarian, colon and uterine cancers, as well as rare tumor types. General referral indications can include, but are not limited to:
 * Personal or family history of cancer with unusually young age of onset (e.g. breast cancer under age 45, colon cancer under age 50)
 * Diagnosis of a tumor or cancer with a high likelihood to be hereditary (e.g. male breast cancer, triple negative breast cancer, ovarian cancer, metastatic or high-grade prostate cancer, pancreatic cancer, retinoblastoma, adrenocortical carcinoma, pleuropulmonary blastoma, neuroendocrine tumor, medullary thyroid cancer, pheochromocytoma or paraganglioma )
 * Personal or family history of bilateral cancers (e.g., both breasts or both kidneys) or multiple primary tumors in one person
 * Features associated with an inherited cancer syndrome (e.g. more than 10 adenomatous polyps, rare types of gastrointestinal polyps, such as hamartomatous polyps), or specific skin findings like café au lait macules or freckling on the lips
 * Family history of related cancers clustered on the same side of the family (e.g. breast/ovarian, colon/uterine, sarcoma/leukemia/brain)
 * Family history of a known inherited cancer syndrome (e.g. hereditary breast and ovarian cancer syndrome, hereditary non-polyposis colorectal cancer, Li-Fraumeni syndrome)
 * Individuals of Ashkenazi Jewish ancestry with a personal or family history of breast, ovarian, or pancreatic cancer
 * Possible germline (inherited) genetic mutation suggested by tumor profile testing

Neurogenetics
Genetic counselors specializing in neurogenetics are involved in the care of individuals who have or are at risk to develop conditions affecting the central nervous system (brain and spinal cord) or peripheral nervous system (the nerves that leave the spinal cord and go to other places in the body, such as the feet and hands, skeletal muscles, and internal organs). Effects of these conditions can lead to various impairments some examples of which include cognitive decline, intellectual disability, seizures, uncontrolled movements (e.g. ataxia, chorea), muscle weakness, paralysis, or atrophy. Examples of neurogenetic disorders include:
 * Brain malformation syndromes, including lissencephaly and polymicrogyria
 * Brain tumor predisposition syndromes, including Neurofibromatosis 1 and 2
 * Epilepsy (seizures)
 * Hereditary motor neuron diseases, including amyotrophic lateral sclerosis (ALS/Lou Gehrig's disease) and spinal muscular atrophy
 * Hereditary neuropathies, including Charcot-Marie-Tooth disease
 * Intellectual disabilities, developmental delays, and autism spectrum disorder
 * Leukodystrophy (hereditary white matter diseases)
 * Memory and other cognitive disorders, including Alzheimer disease and frontotemporal dementia
 * Movement disorders, including hereditary ataxia, spastic paraplegia, Huntington disease, and Parkinson disease
 * Neuromuscular disorders, including muscular dystrophies, congenital myopathies, and congenital myasthenic syndromes

Pediatric genetics
Pediatric genetic counseling can be indicated for newborns, infants, children and their families. General referral indications can include:
 * Birth defect(s) or multiple congenital anomalies (cleft lip/palate, heart defects, spina bifida)
 * Intellectual disability of unknown cause, learning disabilities, or autism
 * Sensory impairments (vision, hearing)
 * Metabolic disorders (PKU, galactosemia, inborn errors of metabolism)
 * Known/Suspected genetic disorders (e.g., Down syndrome, Cystic Fibrosis, Muscular Dystrophy)
 * Primary immunodeficiency

Prenatal genetics
Prenatal genetics involves services for women either during or prior to a pregnancy.

General indications for referral to genetic counseling in the preconception or prenatal setting may include, but are not limited to:
 * Advanced maternal age (35 years old or older at time of delivery)
 * Advanced paternal age
 * Current pregnancy with anomalies identified by ultrasound (e.g. increased nuchal translucency measurements)
 * Current pregnancy with an abnormal genetic screening test or test result
 * Current pregnancy with risk of or concern for maternal exposures, such as medications, radiation, drugs/alcohol, or infections
 * Consanguineous union (cousins or otherwise blood related)
 * Family history of an inherited genetic condition or chromosome abnormality
 * Genetic carrier screening for recessive and/or X-linked diseases
 * History of a previous child with a birth defect, developmental delay, or other genetic condition
 * History of infertility, multiple unexplained miscarriages or cases of unexplained infant deaths
 * Molecular test for single gene disorder

Prenatal genetic counseling may help with the decision-making process by walking patients through examples of what some people might do in similar situations, and their rationale for choosing that option. Decisions made by patients are affected by factors including timing, accuracy of information provided by tests, and risk and benefits of the tests. This discussion enables patients to place the information and circumstances into the context of their own lives, and in the context of their own values. They may choose to undergo noninvasive screening (e.g. ultrasound, triple screen, cell-free fetal DNA screening) or invasive diagnostic testing (amniocentesis or chorionic villus sampling). Invasive diagnostic tests possess a small risk of miscarriage (1–2%) but provide more definitive results. Testing is offered to provide a definitive answer regarding the presence of a certain genetic condition or chromosomal abnormality. Prenatal genetic counseling also comes with ethical concerns both as the parents and as the counselor. It is important to consider all factors that go into the counseling, race, ethnic background, family history, and other significant issues that may arise.

Psychiatric genetics
Psychiatric genetic counseling is a sub-specialty within genetic counseling focused on helping people living with a psychiatric disorder and/or their family members understand both the genetic and environmental factors that contributed to their illness and address associated emotions such as guilt or self-blame. Genetic counselors also discuss strategies to promote recovery and protect mental health and address any questions on chances for recurrence in other family members. While currently there is no single gene solely responsible for causing a psychiatric disorder, there is strong evidence from family, twin studies, and genome-wide-association studies that both multiple genes and environment interact together. Like other areas of genetic counseling, patients at all different stages of life (pediatric, adult, prenatal) can have psychiatric genetic counseling. Since the etiology of psychiatric disorders is complex and not fully understood, the utility of genetic testing is not as clear as it is in Mendelian or single gene disorders. Research has shown that individuals who receive psychiatric genetic counseling have significant increases in feelings of empowerment and self-efficacy after genetic counseling.

Psychiatric genetic counselors can help "dispel mistaken notions about psychiatric disorders, calm needless anxiety, and help those at risk to draw up a rational plan of action based on the best available information".

Global Genetic Counseling Community
In 2018, there are nearly 7000 genetic counselors practicing worldwide, across at least 28 countries.

China
Genetic counseling in China (mainland) has been primarily provided by pediatricians or obstetricians for prenatal or birth defect diagnoses. Most genetic tests can only be performed in academic institutions as research tests or in commercial direct-to-consumer companies for non-clinical use.

In China, genetic counseling is steered by the Chinese Board of Genetic Counseling (CBGC), a not-for-profit organization. CBGC is composed of senior experts engaged in genetic education and research. CBGC is committed to establishing standardized procedures of genetic counseling, training qualified genetic counselors, improving health for all, and reducing the incidence of birth defects. CBGC was established in 2015 and is the major professional organization for genetic counselors in mainland China, providing training through short term online and in-person lectures, educational conferences, and certification for trainees.

Genetics education in China began in the 1980s when selected medical schools began offering genetics courses that focused predominantly on molecular genetics and had limited clinical content. At present, there are no official master's level graduate programs in genetic counseling or clinical genetics in China, and there is great variability in the duration and content of genetics curricula among medical schools and professional organizations.

The Chinese Ministry of Health has not yet recognized genetic counselors as an independent health care occupation. There are no official statistics for the number of health care professionals (e.g., physicians, nurses, and lab technicians) who are providing genetic counseling services in China.

South Africa
Genetic Counselling is a developing field in South Africa. Currently, there are about 20 registered genetic counsellors practicing in the country. In South Africa, genetic counsellors work within academic institutions, in the private health sector and more recently, private genetic laboratories. A few qualified genetic counsellors have been employed outside of the country or in other professions, owing to funding limitations that have impacted employment opportunities, particularly in the academic/public health sector.

The first Genetic Counselling Programme in South Africa started in 1989 at the University of the Witwatersrand in Johannesburg, in the Gauteng province. A second programme started in 2004 at the University of Cape Town in the Western Cape province. These are the only two programmes offering Masters level genetic counselling training in South Africa. Currently these courses are running at full capacity. This is a two-year degree and includes a research component. The majority of students enter the Masters programme with a science background but those with a psychology background are also considered.

The Health Professions Council of South Africa (HPCSA) requires two years of internship. Often the first year forms part of the master's degree in Genetic Counselling and a further 12-month internship thereafter. Genetic Counsellors are required by law to register with the HPCSA in order to practice as genetic counsellors. At the end of the training period, registrants submit a portfolio to HPCSA for assessment. If successful, the intern will be registered with the HPCSA and will be able to practice as a Genetic Counsellor in South Africa.

There is a professional organisation for Genetic Counsellors in South Africa, Genetic Counselling South Africa (GC-SA), which provides information and guidance to the HPCSA and others regarding professional issues. The GCSA is a focus group of the South African Society of Human Genetics (SASHG).

Europe
The profession of genetic counseling is established or developing in more than 11 European countries including Austria, Denmark, France, Ireland, the Netherlands, Norway, Portugal, Romania, Spain, Sweden, Switzerland, and the UK. Genetic counselors (GC) trained in other countries are beginning to establish genetic counseling-related roles in at least 7 more. As of 2018, there were about 900 genetic counselors practicing in Europe. There are at least eight genetic counseling training programs. Formal GC registration occurs through two different programs: in the United Kingdom (UK, via the GCRB as described below) and the European Union via the European Board of Medical Genetics (EBMG). Genetic counselors are not currently recognized as a profession in several European countries including Austria, Belgium, Germany, and Portugal. This is likely due to legal restrictions in these countries, stating genetic counseling is a medical act, and therefore must be conducted by physicians.

Training
Training programs currently exist in Austria, Italy, France, the Netherlands, Norway, Portugal (currently inactive), Romania (currently inactive), Spain, and the UK. While genetic counselors practice in the following countries, currently no formal genetic counseling programs exist in Belgium, Denmark, Finland, Germany, Greece, Ireland, Sweden, and Switzerland.

Reciprocity (Internationally and Locally)
Due to the limited Master's level Genetic Counseling programs located in Europe, the EBMG organization recognizes practicing genetic counselors that trained in the US, Canada, South Africa, and Australia. These counselors must possess current registration or certification from their home country as well as be working full time in Europe for 1 year to apply for Registration with EBMG.

Professional organizations

 * The Association of Genetic Nurses and Counsellors (AGNC) is the UK's professional organization representing genetic counsellors, genetic nurses and non-medical, patient-facing staff working within the discipline of Clinical Genetics. There are currently (March 2018) 330 AGNC members within the UK. The AGNC is one of the constituent groups of the British Society for Genetic Medicine (BSGM).
 * European Board of Medical Genetics (EBMG) developed competencies and standards of practice for GC registration within the European Union (EU).
 * The Association of Genetic Counselors (APPAcGen), is working to achieve recognition of the profession of GCs in Portugal.
 * The Romanian Association of Genetic Counseling (RAGC) was founded to set national practice standards and lobby for recognition as a distinct health profession. In the meantime, genetic counseling tends to adhere to international organizations' guidelines (e.g., EBMG)
 * In Norway there is an "Interest Organization for Genetic Counselors in Norway", which meets yearly.

United Kingdom
The majority of Genetic Counsellors in the UK work in the National Health Service (NHS) in one of the 33 Regional Clinical Genetics Services (some renamed Genomic Medicine Centres in England), Scotland, Wales or Northern Ireland. Others work in specialist roles in the NHS, education, policy or research. A minority work in the private sector.

Training The first two-year MSc in Genetic Counselling program established in the UK was from the University of Manchester in 1992, followed by Cardiff University in Wales in 2000. 2016 saw major changes in the way genetic counsellors are trained in England. A 3-year training programme funded by Health Education England, the Scientist Training Programme (STP) uses a combination of work-based training in Genomic Medicine Centres and a part-time MSc in genetics (Genomic Counselling) from the University of Manchester. Recruitment is performed nationally through the National School of Healthcare Science (NSHCS). A 3-year part-time MSc in Genetic and Genomic Counselling is also now delivered by Cardiff University, through blended learning, with most of the teaching delivered online, alongside some short face-to-face teaching blocks in Wales. A 2-year MSc Genetic and Genomic Counselling program began at the University of Glasgow in Scotland in 2016. Prerequisites for acceptance on all the programmes include a degree in a relevant science or a nursing or midwifery qualification, and experience in a caring role.

Credentialing/certification/licensure Genetic counselling training programmes are accredited by the UK Genetic Counsellor Registration Board (GCRB) and the European Board of Medical Genetics (EBMG). Genetic counsellors in the UK are regulated through the GCRB, although currently GCRB registration is voluntary. The GCRB registry was accredited in 2016 by the Professional Standards Authority under its Accredited Registers programme. Over 200 genetic counsellors are currently registered through the GCRB. Genetic Counsellors trained through the STP programme are expected to be eligible to apply for statutory regulation through the Health Care Professions Council and it is planned that soon there will be equivalence arrangements with the GCRB to ensure statutory regulation for GCRB registered genetic counsellors. In order to be eligible for GCRB credentialing, one of two sets of requirements must be met: completion of a 2-year Master's of Science degree and 2 years of experience as a genetic counselor, or completion of a 3-year combined Master's program and work-based training. In addition, a portfolio including a 50 case logbook, evidence of supervision, case studies, essays, and recorded counseling sessions is required.

In order to be eligible for EBMG credentialing, a Master's of Science in genetic counseling is required, along with a portfolio including a logbook of 50 cases, case studies, references, and reflective essays. Both the EBMG and the GCRB also offer an alternative route to credentialing in which the applicant completes a nursing degree.

Reciprocity (internationally and locally) The GCRB offers credentialing for internationally trained genetic counselors.

Australia/New Zealand
As of early 2022, there were almost 400 active Genetic Counsellors in Australia and New Zealand, according to the database maintained by the Australasian Society of Genetic Counsellors. In order to practice as a GC, individuals must first attain a recognized Master's degree, after which time they can practice as an Associate. Then, following at least two years of supervised practice and successful passing of assessment as set by the Australasian Society of Genetic Counsellors' Board of Censors, an individual can then be accredited by the Human Genetics Society of Australasia and registered through the National Alliance of Self Regulating Health Professions as an independent GC. Most GCs practice in public or private hospital settings, but roles in private ambulatory care, genomic diagnostic laboratories, industry, and in academia (teaching and research) are becoming increasingly common. Both public and private healthcare services are available in Australia and New Zealand. Genetic services are offered through the public health system in all states and territories. In the public system, genetic testing is paid for by the State Governments when the test is deemed clinically appropriate by the GC and clinical geneticist. GCs in private practice may also offer 'self-funded' genetic testing, which is largely paid for out-of-pocket by the client/patient.

Training
A one-year graduate diploma program was established in 1995, and a two-year Master's level training program was established in 2008. As of 2024, two Master's training programs in Australia accredited by the Human Genetics Society of Australasia (HGSA), one at the University of Melbourne and one at the University of Technology, Sydney.

Credentialing/certification/licensure
New graduates practice as an Associate Genetic Counselor under the supervision of a certified genetic counselor and a clinical geneticist. They can submit to the HGSA certification process via a portfolio application after one year of practice. Recertification is currently voluntary and available by completing continuing education units (CEUs).

Reciprocity (internationally and locally)
Genetic counselors with training from the UK, Europe and Australia are eligible for registration and GCs from other countries are considered on a case-by-case basis.

More information can be found through the Australasian Society of Genetic Counsellors, a special interest group of the Human Genetics Society of Australasia.

Education
A genetic counselor is an expert with a Master of Science degree in genetic counseling. Programs in North America are accredited by the Accreditation Council for Genetic Counseling (ACGC). There are currently 52 accredited programs in the United States, four accredited programs in Canada, and four programs with the intent to become accredited. Students enter the field from a variety of disciplines, including biology/biological sciences and social sciences such as psychology. Graduate school coursework includes topics such as human genetics, embryology, ethics, research, and counseling theory and techniques. Clinical training including supervised rotations in prenatal, pediatric, adult, cancer, and other subspecialty clinics, as well as non-patient facing rotations in laboratories. Research training typically culminates in a capstone or thesis project.

State licensure
As of May 2019, 29 states have passed genetic counselor licensure bills that require genetic counselors to meet a certain set of standards to practice. These states are Alabama, Arkansas, California, Connecticut, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Nebraska, New Hampshire, New Jersey, New Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Tennessee, Utah, Virginia, and Washington. Almost every other state in the United States is in the process of obtaining genetic counseling licensure.

Although genetic counseling has been established over four decades, the first licenses for genetic counselors were not issued until 2002. Utah was the first state to do so. The American Society of Human Genetics (ASHG) has since encouraged more states to license genetic counselors before they are allowed to practice. ASHG argues that requiring practitioners to go through the necessary training and testing to obtain a license will ensure quality genetic services as well as allow for reimbursement for counselors' services. Laws requiring licensure ensure that "professionals who call themselves genetic counselors are able to properly explain complicated test results that could confuse patients and families making important health decisions".

Reimbursement and recognition
Insurance companies usually do not reimburse for unlicensed genetic counselors' services. Patients who may benefit from genetic counseling may not be able to afford the service due to the expensive out-of-pocket cost. In addition, licensure allows genetic counselors to be searchable in most insurance companies' databases which gives genetic counselors increased opportunities for earning revenue and clients the opportunity to see "the level of coverage insurers provide for their services".

The Center for Medicare and Medicaid Services (CMS) does not currently recognize genetic counselors as healthcare providers and therefore does not reimburse for genetic counseling services unless they are provided by a physician or nurse practitioner. On June 12, 2019, H.R. 3235 "Access to Genetic Counselor Services Act of 2019," was introduced to the U.S. House of Representatives by U.S. Rep. Dave Loebsack (D-Iowa) and U.S. Rep. Mike Kelly (R-Pennsylvania). H.R. 3235 would authorize CMS to recognize certified genetic counselors as healthcare providers and to cover services furnished by genetic counselors under part B of the Medicare program. Genetic counselors are those licensed by states as such, or, for those in states without licensure, the Secretary of Health and Human Services will set criteria through regulation (likely ABGC certification). Genetic counselors would be paid at 85% of the physician fee schedule. Other providers currently providing genetic counseling services will not be affected by the bill.

Job outlook
As genetic counseling continues to grow as a branch in the medical field, employment rates of genetic counselors are expected to grow by 21% over the next decade; this statistic suggests that approximately 600 new jobs will become available in the US over this time period. Graduating from an accredited program with a passing score on the board certification exam increases the job prospect. As of May 2019 the median annual wage for genetic counselors was $81,880; the lowest 10% earning less than $61,310 and the highest 10% earning more than $114,750. This includes the varying industries in this field, such as medial and diagnostic laboratories, offices of physicians, hospitals, and colleges/universities.

Middle East
Out of the approximate 100 genetic counselors practicing in the Middle East, most are located in Israel and Saudi Arabia, with a few located in Lebanon, Oman, and Turkey. In Israel, licensed genetic counselors must work under the supervision of a medical geneticist. Most practice in genetics departments in hospital settings, with a few working in industry or research.

Training
The first training program in Israel started in 1997. There are currently three programs that offer a master's degree in genetic counseling, training 20 students per year. The first training program in Saudi Arabia was a graduate diploma in 2005 with a master's degree being available as of 2015. There are two training programs available in Saudi Arabia with approximately 10 trained genetic counselors graduating per year.

Credentialing/certification/licensure
The Israeli Ministry of Health offers licensure to genetic counselors in Israel following an exam written one year after their post-graduate work and 85-case logbook. Recertification is not required as licensure is permanent after the exam. Licensure is also offered through the Saudi Commission for Health Specialties (SCFHS) following a panel interview, testing, or oral exam by a medical board; recertification in this country is under review at this time, but all counselors practicing in Saudi Arabia are expected to obtain a license from the SCHS.

Media
The National Society of Genetic Counselors (NSGC) blog provides information about current topics in genetic testing and genetic counseling.

Public attitude
Many studies have examined the attitudes of the lay public toward genetic counseling and genetic testing. Barriers to obtaining genetic counseling include lack of understanding of genetics by both patients and healthcare providers, concerns about cost and insurance, and fears of stigma or discrimination.

The reach of genetic testing and health equity is expanding due to telephone counseling. Telephone delivery has proven "less expensive, yielded non-inferior cognitive, minimized psychological distress, facilitated informed decision making, and achieved positive counselor-patient interactions." As a result, telephone-based genetic counseling and testing are now commonly offered and reimbursed by many insurance companies.

No simple correlation has been found between the change in technology to the changes in values and beliefs towards genetic testing.

Health disparities
An increase in genetic counseling outreach efforts are needed to intentionally extend opportunities to populations that have been historically underrepresented in the profession to create a more diverse and inclusive workforce and access to services. Given the history of low engagement of under-represented minority populations in both clinical genetic services and genetic research, both of these aspects will be challenged and must be addressed before the benefits of precision medicine will be fully realized.

Future Directions
In Europe and Australia, the current model of care in genetic counselling involves clients being referred by a general practitioner or other medical professional to a publicly funded hospital-based genetics service. Due to the rapid increase in demand for genetic counselling services, new ways to integrate genetic counselling into the healthcare system are being actively investigated. Future potential models of care currently being trialled include the genetic counsellor-embedded model, where genetic counsellors are integrated into hospital departments from which patients are referred, such as cancer and immunology. Another model of care that has been investigated is the provision of specially-trained nurses or other non-genetics healthcare personnel to identify persons eligible for genetic testing, and to provide pre-test counselling. Taken together, these alternative models of care are called genetic counselling mainstreaming.

title: Genetic counseling