A Qualitative Study of Primary Care Physicians’ Approaches to Caring for Adult Adopted Patients

Dear Editor,

We read with great interest the article by Wexler et al, “A Qualitative Study of Primary Care Physicians’ Approaches to Caring for Adult Adopted Patients”, which sheds valuable light on how primary care physicians address the needs of a population that frequently lacks comprehensive family medical histories (1). As a family physician and an independent researcher based in Spain, we recognize many parallels between the authors’ findings and the realities encountered in our clinical and investigative work. In this letter, we aim to extend their discussion by focusing on the Spanish context and exploring how these insights might inform further improvements in health care delivery for adult adoptees, as well as for other patients with limited or uncertain family medical backgrounds in Europe.

Although Spain’s National Health System differs structurally from the system described in the authors’ research, many of the same challenges apply. Most Spanish medical schools do not devote significant time to adoption or to the care of individuals with incomplete family records. Indeed, the curriculum includes only basic instruction on pediatric adoption issues, such as international or domestic adoption processes, leaving the concerns of adoptees in adulthood relatively unexplored. This gap in formal instruction often compels family physicians to rely on personal experiences or general clinical guidelines. Such reliance can be particularly limiting when caring for adults who, like the patients described by Wexler et al, face not only unknown genetic risks but also potential emotional consequences tied to adoption. Research examining international adoption trends in Europe notes the complexity of legal and cultural contexts, underscoring the necessity for health professionals to be better informed (2).

One of the most striking points in Wexler et al’s study is how the participating physicians perceived parallels between adults who were adopted and individuals who are immigrants or refugees. In Spanish primary care, refugees, asylum seekers, and migrants often present with incomplete health records, which makes family history collection challenging (3). Like adoptees, these patients may be unable to trace genetic predispositions or hereditary disorders, requiring physicians to adopt broader strategies for disease prevention and screening. In our experience, this approach typically includes adjusting the threshold for certain diagnostic tests and relying more on population-based risk profiles rather than specific familial patterns. These parallels illustrate the broader applicability of Wexler et al’s analysis, suggesting that improved training on adoption-related issues could concurrently benefit other groups with unknown or unreliable family information.

We also appreciate Wexler et al’s emphasis on mental health. In Spain, most family physicians coordinate closely with psychologists and psychiatrists, but there is a documented shortage of mental health professionals who specialize in adoption-specific issues. Studies have shown that adoptees may be at increased risk of suicidal behavior and other mental health challenges, thus highlighting the importance of specialized care (4). Yet, as the authors note, many physicians are unaware of the potential role of adoption itself as a source of underlying trauma. Several clinicians may assume that early-age adoption removes any meaningful psychological impact. Research on adoption and mental health, however, indicates that subtle yet persistent factors—such as loss of biological ties, identity concerns, or prior adverse experiences—can carry forward into adulthood (5). Our observations in Spain align with these findings, as adult patients sometimes present with unexplained anxiety or depression, only later revealing a complex adoption background that was never addressed in earlier medical encounters.

In clinical settings, addressing these psychosocial considerations can be as critical as managing physical health. For instance, adult adoptees often report frustration when repeatedly questioned about a family history they do not know, a frustration also noted by Wexler et al. Their study suggests the value of clarifying “adoptive” versus “biological” relatives in medical interviews, which can reduce confusion and avoid potential microaggressions. This point resonates with Spanish family medicine, where we strive to incorporate culturally sensitive language and practices, yet still encounter system-level barriers like standardized questionnaires and electronic health record fields that fail to differentiate between adoptive and biological family trees. Adapting these standardized tools can improve patients’ sense of being understood, which may, in turn, encourage more open communication regarding mental health concerns and perceived stigmatization (6).

Another area that merits deeper exploration is genetic testing. Direct-to-consumer testing has recently gained popularity in Spain, but many patients and physicians remain unclear about its limitations. Wexler et al discuss how primary care physicians in their study felt uncertain about the clinical utility, accuracy, and potential insurance implications of such tests. Our observations are comparable: without formal guidelines, family physicians in Spain find themselves discussing risks and benefits on a case-by-case basis, often without support from genetic counselors. This situation is further complicated by legal frameworks that vary among different Autonomous Communities, especially with respect to data privacy and the possibility of contacting biological relatives. Professional recommendations on when and how to employ genetic testing for adult adoptees could bring more clarity, especially in the context of diseases with significant hereditary components (3).

Practical screening protocols also warrant attention. The ambiguity surrounding family history leaves clinicians uncertain whether to recommend early imaging or more intensive follow-up. Some colleagues propose earlier screenings for conditions such as breast or colon cancer in adoptees, whereas others rely on the general population-based schedules. Although little evidence directly addresses whether these adjusted screening regimens reduce morbidity or mortality in adoptees, the question warrants further study. With more robust data, it might become possible to create standardized approaches that allow clinicians to balance the risk of overtesting with the potential cost of delayed diagnoses.

Furthermore, ethical and legal considerations play a significant role when attempts to access an individual’s biological family history conflict with privacy regulations. In Spain, adoption records are generally sealed, yet a complex mosaic of regional laws can dictate how and under what circumstances these records might be unsealed. Similar to the issues raised by Wexler et al, Spanish physicians often find themselves in a position of wanting more biological data to inform screening or treatment plans, but are constrained by privacy rules designed to protect all parties involved. While respect for legal boundaries is paramount, collaboration with social service agencies and, when appropriate, legal advisors can sometimes open narrow paths for obtaining partial information. Such collaboration could be beneficial not only for adoptees but also for health professionals striving to provide optimal care (6).

Finally, we believe that the core message of the article—that training for physicians regarding adult adoptees is minimal—applies broadly across our health system. Here in Spain, some efforts focus on foster children, but there is limited attention to those who enter adulthood and remain vulnerable due to unknown hereditary factors. It seems prudent for our academic institutions and professional societies to incorporate adoption-specific modules into training, similar to calls for enhanced instruction in other underrepresented areas of medicine (2). This could involve teaching family physicians the language and sensitivity required to take a nuanced patient history, ways of addressing mental health needs that may arise from ambiguous losses, and strategies for responsibly discussing genetic testing when family history is missing.

In conclusion, the work of Wexler et al provides an insightful, methodologically sound view into a topic that extends beyond the United States. We share their stance that adult adoptees have distinct needs in primary care, and we agree that current medical education leaves many clinicians uncertain how best to meet these needs. Our experiences in Spain corroborate their findings, highlighting parallel issues with refugees, migrants, limited mental health resources, and the challenges of incomplete family records. We commend the authors for drawing attention to a population that has not been sufficiently represented in the medical literature, and we hope that further studies will build on this foundation by examining how evidence-based guidelines, training programs, and policy reforms can ultimately lead to more consistent and compassionate care for adult adoptees around the world.

1. Wexler JH, Toll E, Goldman RE. A Qualitative Study of Primary Care Physicians’ Approaches to Caring for Adult Adopted Patients. Ann Fam Med. 2025 Jan 1;23(1):24–34.
2. Selman P. The rise and fall of intercountry adoption in the 21st century. Int Soc Work. 2009 Sep 1;52(5):575–94.
3. Qureshi N, Santaguida P, Carroll J. Collection and use of cancer family history in primary care. Agency for Healthcare Research and Quality (AHRQ); 2007. (Evidence Report / Technology Assessment).
4. Keyes MA, Malone SM, Sharma A, Iacono WG, McGue M. Risk of Suicide Attempt in Adopted and Nonadopted Offspring. Pediatrics. 2013 Oct 1;132(4):639–46.
5. Farr RH, Grotevant HD. Adoption. In: APA handbook of contemporary family psychology: Foundations, methods, and contemporary issues across the lifespan, Vol 1. Washington, DC, US: American Psychological Association; 2019. p. 725–41. (APA handbooks in psychology®).
6. Borders LD, Penny JM, Portnoy F. Adult Adoptees and Their Friends: Current Functioning and Psychosocial Well-Being. Fam Relat. 2000;49(4):407–18.