The Effect of Infertility on Marriage and Self‐concept
1989; Elsevier BV; Volume: 18; Issue: 1 Linguagem: Inglês
10.1111/j.1552-6909.1989.tb01611.x
ISSN1552-6909
AutoresAnne Hirsch, Stephen M. Hirsch,
Tópico(s)Family Dynamics and Relationships
ResumoTwo groups of subjects (couples seeking medical treatment for infertility and couples not yet attempting to conceive) completed questionnaires assessing the impact of infertility on their marriages and self‐concept. Infertile individuals experienced greater dissatisfaction with themselves and their marriages. Females experienced greater discontent over time and had greater emotional investment than males. Infertile couples, labeled noncommunicators, were found to be affected even more by infertility. Nurses can play vital roles in counseling infertile couples. Two groups of subjects (couples seeking medical treatment for infertility and couples not yet attempting to conceive) completed questionnaires assessing the impact of infertility on their marriages and self‐concept. Infertile individuals experienced greater dissatisfaction with themselves and their marriages. Females experienced greater discontent over time and had greater emotional investment than males. Infertile couples, labeled noncommunicators, were found to be affected even more by infertility. Nurses can play vital roles in counseling infertile couples. Infertility, the inability to achieve pregnancy after a year of regular sexual relations or the inability to carry a pregnancy to a live birth, is estimated to be experienced by 15% of couples of childbearing age in the United States. Nearly 2.5 million American couples are infertile.1Menning B.E. The psychosocial impact of infertility.Nurs Clin North Am. 1982; 17: 155-163PubMed Google ScholarAmong women 20 to 24 years of age the infertility rate has practically tripled since 1965. As a consequence, the need for health-care services related to infertility has increased considerably. In 1982, one in five women who had ever been married and were of reproductive age reported that she had sought professional consultation during her lifetime to increase her chances of having children.2MMWR. 1985; 34: 445-449PubMed Google ScholarPsychosocial problems and infertility have been shown to be closely related. However, the focus of most of the published research has been the attempt to establish a psychogenic cause for the inability to conceive.3Eisner B.G. Some psychological differences between fertile and infertile women.J Clin Psychol. 1963; 19: 391-395Crossref PubMed Scopus (51) Google Scholar, 4Seibel M.M. Taymor M.L. Emotional aspects of infertility.Fertil Steril. 1982; 37: 137-145PubMed Google ScholarThis study attempted to identify some of the psychosocial consequences of infertility.LITERATURE REVIEWSeveral studies have found high incidences of psy-chosexual problems for infertile couples. Berger found infertile men likely to be impotent and their wives likely to be angry.5Berger D.M. Couples' reactions to male infertility and donor insemination.Am J Psychiatry. 1980; 137: 9Google ScholarBattaglia, Graziano, and Scafidi Fonti noted significant changes in sexuality in infertile women; specifically, a decreased frequency of sexual intercourse.6Battaglia A.R. Graziano M.R. Fonti M.G. Scafidi Experimental research into the changes in the way sexuality is experienced by the infertile woman.Acta Eur Fertil. 1983; 14NGoogle ScholarSexual attitudes were more restrictive, and guilt feelings were more prevalent in a study of infertile women, despite a lack of difference in social-role orientations.7Slade P. Sexual attitudes and social role orientations in infertile women.J Psychosom Res. 1981; 25: 183-186Abstract Full Text PDF PubMed Scopus (24) Google ScholarIn addition to reporting sexual dysfunction, infertile couples, in a study by Bell, experienced emotional disturbance, impaired social adjustment, and deterioration in their marital relationships.8Bell S.J. Psychological problems among patients attending an infertility clinic.J Psychosom Res. 1981; 25: 1-3Abstract Full Text PDF PubMed Scopus (47) Google ScholarInterestingly, these problems were reported only by the partner in whom the etiological factor for infertility was found.Other studies that focused on infertile women found lower self-esteem and inhibited sexual attitudes.9Cooper S.L. Female infertility: Its effect on self‐esteem, body image, locus of control, and behavior.Dissertations & Abstracts International. 1980; 40: 4476Google Scholar, 10Freeman E.W. Garcia C. Rickels K. Behavioral and emotional factors: Comparisons of anovulatory infertile women with fertile and other infertile women.Fertil Steril. 1983; 40: 195-201PubMed Google ScholarA recent survey by Tartasky indicated that infertile women are more depressed than infertile men and that both men and women experience self-esteem problems.11Tartasky D.J. Psychological impact of infertility. 1985Google ScholarInfertility, or the perception of oneself as infertile, has been described by Menning as a life crisis that requires the couple to grieve for the children they will never have before resolution can occur.12Menning B.E. The emotional needs of infertile couples.Fertil Steril. 1980; 34: 313-314PubMed Google ScholarThe psychological reactions to infertility have been described similarly by several authors.12Menning B.E. The emotional needs of infertile couples.Fertil Steril. 1980; 34: 313-314PubMed Google Scholar, 13Kraft A.D. Palombo J. Mitchell D. Meyers C. Meyers S. Schmidt A.W. The psychological dimensions of infertility.Am J Orthopsychiatry. 1980; 50: 618-627Crossref PubMed Scopus (80) Google Scholar, 14Mazor M.C. Barren couples.Psychology Today. 1979; 22: 101Google Scholar, 15Sawatsky M. Tasks of infertile couples.J Obstet Gynecol Neonatal Nurs. 1981; 3–4: 132-133Crossref Scopus (7) Google Scholar, 16Shapiro C.H. The impact of infertility on the marital relationship.Journal of Contemporary Social Work. 1982; 9: 387-393Google ScholarFirst, the couple may react with shock, disbelief, or denial. During the second phase, the couple begins to mourn the loss of a child who was never conceived, and the couple may experience grief reactions, including surprise, denial, anger, guilt, isolation, and depression.The grieving often takes place without the support of family and friends because the couple grieves for intangibles: the loss of their self-ideal and denial of expectations, goals, and experiences. The final phase—resolution—occurs when the couple is forced to consider alternatives to a natural child, such as adoption, in vitro fertilization, surrogate parenting, or child-free living.How does infertility affect sex-role identity, self-esteem, contentment, sexual satisfaction, and marital satisfaction?Olshansky proposed a substantive theory that explains some of the consequences of infertility.17Olshansky E.F. Identity of self as infertile: An example of theory‐generating research.Advances in Nursing Science. 1987; 9: 54-63Crossref PubMed Scopus (59) Google ScholarIn this model, the self is conceptualized as a cluster of constantly shifting identities, some assuming central locations and others assuming more peripheral identities. Olshansky's structured interviews suggested that for individuals to manage their identities as infertile, or to make these identities more peripheral, they must first take on these identities centrally.17Olshansky E.F. Identity of self as infertile: An example of theory‐generating research.Advances in Nursing Science. 1987; 9: 54-63Crossref PubMed Scopus (59) Google ScholarWhen conception does not occur, individuals take on an informal identity as infertile. After attempting informal fertility worksuch as changing sexual practices, couples seek medical assistance. At this point, they assume a formal identity as infertile and become engaged in more formal fertility worksuch as medications and surgeries.17Olshansky E.F. Identity of self as infertile: An example of theory‐generating research.Advances in Nursing Science. 1987; 9: 54-63Crossref PubMed Scopus (59) Google ScholarPURPOSEThis study attempted to identify the psychosocial aspects of the life of an individual who is affected by the assumption of a formal identity as infertile. As infertility takes a central position in a person's life, what are the effects of sex-role identity, self-esteem, contentment, sexual satisfaction, and marital satisfaction; and what roles do pressand investmentplay in the lives of infertile couples?DefinitionsPressEmotional, social, and cultural factors that exert pressure on the individual to achieve a goal.InvestmentThe amount of time and energy expended to achieve a goal.RESEARCH QUESTIONSThe research questions for this study were as follows:•Do individuals seeking treatment for a perceived fertility problem have less self-esteem, marital satisfaction, sexual satisfaction, and general contentment than individuals who have not yet attempted to conceive?•Do infertile males score more feminine and infertile females score more masculine on the Bern sex-role inventory than their respective controls?•As press and investment increase, do self-esteem, marital and sexual satisfaction, and general contentment decrease for infertile individuals?METHODSSampleThe sample consisted of 92 subjects, divided into two groups. The experimental group comprised 58 subjects (28 married couples and 2 married women whose husbands were unable or unwilling to participate). These subjects were all in the process of seeking medical treatment for a perceived fertility problem at an infertility clinic. The control group comprised 34 subjects (17 married couples) who had not yet decided whether or not to have children and, thus, were not concerned with the possibility of infertility.Of the 58 subjects comprising the infertile group, 30 were women and 28 were men. The mean age for this group was 32. The average length of marriage was 6.7 years. Twenty-nine of the subjects were professionals, but occupations ranged from clerk and salesperson to pilot and engineer.An attempt was made to obtain a control group as close in age and socioeconomic background to the experimental group as possible. The volunteer participants tended to be younger (mean age was 26 years) and married for a shorter length of time. Among the controls, 24 subjects were college students. The others were professionals or white collar workers.InstrumentsSubject Data FormTo discriminate those subjects who had spent considerable time and energy in formal fertility work from those who had invested relatively little, a brief, nine-item questionnaire was developed with the help of several professionals, including a medical doctor, two nurse clinicians, and a social worker actively involved in counseling infertile clients.Infertility investment was operationally defined by the responses (on a scale of one to five) to questions regarding the length of time the subjects had been involved in fertility work and the extent of medical intervention. The questionnaire also allowed the division of infertile subjects into two groups, reflecting the extent of press (emotional, social, and cultural pressures) they perceived. Questions relating to sense of time urgency, extent of support networks, availability of parenting options, and desire for children were included.For both variables, investment and press, median splits were used to place subjects in one of four possible groups: low press/low investment, low press/high investment, high press/high investment, and high press/low investment.The investment/press questionnaire, an instrument designed by the experimenters, was not assessed in terms of reliability and validity. Construct validity for both investment and press was obtained by interviewing health professionals working with infertile couples. The distinction between high and low investment and/or press was arbitrary, based on median splits. The questions asked (e.g., "Which of the following procedures have you undergone?") were of a factual nature and, therefore, did not necessitate reliability or validity assessment.Press is a term rooted in the psychoanalytic literature, and represents perceived pressure from both the environment and from within the person.18Murray H.A. Explorations in personality. Oxford Press, 1938Google ScholarPress is a fluctuating state, and a questionnaire designed to measure this state would not be amenable to reliability studies. The questions focused on perceived urgency and desire for children. That the median splits led to significant differences and interaction effects helped to validate the questionnaire.Bern Sex-Role InventoryOperating under the premise that men and women show both masculine and feminine traits to some extent, the Bern sex-role inventory asks subjects to evaluate how much they are like or unlike each of 60 adjectives. Of the 60 adjectives, 20 represent soci-etally acknowledged feminine personality traits, 20 represent masculine personality traits, and 20 represent neutral personality characteristics. Thus, three scores were obtained for each subject: femininity, masculinity, and femininity/masculinity difference scores, which could then be transformed into standardized scores. Scores in this study were not categorized but were dealt with directly as interval data.The Bern sex-role inventory has been normed for at least nine different populations covering several ethnic and age groups. Estimates of internal consistency range from alpha coefficients of 0.75 to 0.87. Test/retest reliability coefficients ranged from 0.76 to 0.94. Criterion-related validity has been demonstrated in that sex-typed subjects were significantly more likely than androgynous or cross-sex-typed subjects to prefer sex-appropriate activity and to resist sex-inappropriate activity.19Bem S.L. Bern Sex‐Role Inventory: Professional manual. Psychologists' Press, Inc., 1981Google ScholarHudson Clinical Measurement ScalesThe Hudson clinical measurement scales were designed for repeated use with a client to monitor and evaluate progress in therapy.20Hudson W.W. The clinical measurement package. The Dorsey Press, 1982Google ScholarThe four scales used in this study were designed to measure the severity or magnitude of problems that clients had with 1) depression, 2) self-esteem, 3) marital discord, and 4) sexual dissatisfaction. Each scale asked subjects how often each of 25 feelings was experienced.Alpha coefficients, as a measure of split-half reliability, ranged from 0.92 to 0.96. Concurrent instrument validity was estimated for the general contentment scale by correlating it with both the Beck and Zung depression scales. The coefficients were 0.80 and 0.85, respectively.Discriminant validity also was established using the known-groups method. Across scales, discriminant validity coefficients ranged from 0.52 to 0.92, with an average coefficient of 0.8.20Hudson W.W. The clinical measurement package. The Dorsey Press, 1982Google ScholarProcedureCouples seeking medical treatment for a perceived fertility problem were approached by nurses at the infertility clinic and asked if they would be willing to participate in a research study. If the patients agreed, their names and addresses were forwarded to the researchers. An informed consent form was included with the questionnaires mailed to the potential subjects with a stamped return envelope. All questionnaires were number-coded to provide anonymity. A total of 92 questionnaires were sent to infertile individuals; 58 were returned. Of the 81 questionnaires sent to the control group, 34 were returned.RESULTSUnless noteworthy, only significant results (p < 0.05) will be discussed. A multifactor analysis of variance (MANOVA) was performed, comparing infertile to childless individuals across all six dependent measures: femininity, masculinity, general contentment, self-esteem, marital satisfaction, and sexual satisfaction. Among both infertile and childless couples, sex was factored out and considered an independent variable.Infertile couples perceived themselves as more masculine than the childless couples in the control group (F = 3.56; df = 1,88; p< 0.06). On the Bern sex-role inventory, for which high scores are at the masculine end of the continuum, the mean for infertile males was 54.25 (SD = 10.42), while the mean for the control males was 50.23 (SD = 12.17). Infertile females also viewed themselves as more masculine, with a mean of 49.83 (SD = 10.77) than control females, whose mean was 44.18 (SD = 14.83).Infertile couples also experienced significantly less sexual satisfaction than the couples in the control group (F = 4.88; df = 1,88; p< 0.03). On the Hudson clinical scales, high scores indicate dissatisfaction. The mean for infertile females was 22.67 (SD = 14.45), whereas the control females' mean was 15.06 (SD = 13.20). The mean for infertile males was 18.68 (SD = 13.77), whereas the mean for control males was 13.00 (SD = 13.82).A second MANOVA examined the influences of press, investment, and gender on the six dependent variables within the group of infertile individuals. In this group, females (mean = 27.95; SD = 13.12) exhibited a greater degree of discontent than the males (mean = 22.15; SD = 9.6). Again, as these scores were based on the Hudson scales, higher scores represent greater discontent. This difference between genders approached statistical significance (F = 3.20; df = 1,50; p< 0.08).As investment in infertility increased, general discontent increased (F = 3.52; df = 1,50; p< 0.06; Figure 1). An interaction between gender and investment, with respect to contentment, also was found (F = 3.17; df = 1,50; p< 0.08; Figure 2). Whereas time in infertility work did not lead to greater discontent in males, females exhibited a significant decrease in contentment.Figure 2Mean general contentment scores on Hudson Clinical Measurement Scales as a function of degree of investment and gender among infertiles.View Large Image Figure ViewerDownload (PPT)Investment also had an impact on sexual satisfaction (F= 3.49; df = 1,50; p< 0.02; Figure 3). However, sexual dissatisfaction decreased with increased investment. (High scores indicate dissatisfaction.) Whereas, infertility led to decreased sexual satisfaction, over time this initial dissatisfaction waned significantly.Figure 3Mean sexual satisfaction scores on Hudson Clinical Measurement Scales as a function of degree of investment among interfiles.View Large Image Figure ViewerDownload (PPT)As with general contentment and sexual satisfaction, self-esteem was affected by investment but did so differentially for men and women (F = 3.51; df = 1,50; p< 0.06; Figure 4). Whereas, the women's self-esteem decreased, the men's self-esteem increased with greater investment. (Self-esteem resulted in high scores on the Hudson scales.)Figure 4Mean degree of self-esteem on Hudson Clinical Measurement Scales as a function of degree of investment and gender among infertiles.View Large Image Figure ViewerDownload (PPT)A three-way interaction of gender, press, and investment across a composite of all six dependent measures was used to assess the overall impact of infertility as a function of investment and press (F= 2.11; df = 1,50; p< 0.07; Figure 5). Investment differentially affected men and women, depending on the subject's perceived press. When this infertility work began, the individuals under the greatest stress were those with the least amount of press. As investment increased, however, the individuals making the greatest adaptation were the men with low press, whereas the women—especially those under high press—were most affected.Figure 5Interaction of gender, investment, and press on a mean of Hudson Clinical Measurement Scale scores.View Large Image Figure ViewerDownload (PPT)A select subgroup of five couples from the infertile sample did not agree with their mates on their answers to the question: "Our problem, in having children, is due primarily to …." These couples fell into the category of noncommunicators, based on the assumption that their lack of agreement on this crucial question was symptomatic of a greater problem: lack of communication. Two additional subjects were included in this group: two women whose husbands declined to fill out the questionnaire, even after their initial consent to participate had been obtained.The means for this subgroup, the means for the infertile group, and the results of the t-test comparing these two sets of means were examined (Table 1). Noncommunicating couples showed significantly higher levels of general discontent and of marital dissatisfaction.Table 1Comparison of Noncommunicating Infertile Couples to Population of Infertiles with Respect to Scores of Hudson Clinical Measurement ScalesNoncommunicating Couples versus Population (Infertiles)Clinical ScalePopulation MeanSample MeanStandard Error of Sample Meant-ratiopGeneral Contentment2530.172.392.16≈06Self-esteem2423.752.950.08NSMarital Satisfaction1218.673.142.13≈06Sexual Satisfaction2122.924.290.45NS Open table in a new tab DISCUSSIONThat both infertile men and women perceived themselves as more masculine than the controls was an interesting finding of this study. For women, infertility may have been dealt with by emphasizing non-traditional motherhood activities, such as a career or self-development and may have led to a more masculine self-perception. Among men, the heightened masculine self-perception might have represented an overcompensation for the couple's inability to conceive. The masculinity may have been a virility message to the world.Both the men and women in infertile couples perceive themselves as more masculine than do the members of noninfertile couples.The finding that the infertile individuals in this study were less sexually satisfied is consistent with the literature.5Berger D.M. Couples' reactions to male infertility and donor insemination.Am J Psychiatry. 1980; 137: 9Google Scholar, 6Battaglia A.R. Graziano M.R. Fonti M.G. Scafidi Experimental research into the changes in the way sexuality is experienced by the infertile woman.Acta Eur Fertil. 1983; 14NGoogle Scholar, 13Kraft A.D. Palombo J. Mitchell D. Meyers C. Meyers S. Schmidt A.W. The psychological dimensions of infertility.Am J Orthopsychiatry. 1980; 50: 618-627Crossref PubMed Scopus (80) Google Scholar, 21Keye W.R. Psychosexual responses to infertility.Clin Obstet Gynecol. 1984; 27: 760-766Crossref PubMed Scopus (65) Google ScholarThe infertile individual may feel damaged or defective, and this feeling often affects his/her sense of self-esteem. This, in turn, can lead to a decreased desire or decreased ability to respond sexually or a decreased ability to enjoy sex and sexuality.Some individuals attach failure to conceive to their entire sexual identity; women especially may feel incomplete and unfeminine. Sexual problems may develop because of the focus on sex for procreation. The need to have sex on schedule may result in the view that sex is a purely mechanical act, done in a specific way, at a specific time, with a predetermined frequency. Sex, then, was no longer performed for the sake of pleasure.Slade found that infertile women had a tendency toward high levels of guilt.7Slade P. Sexual attitudes and social role orientations in infertile women.J Psychosom Res. 1981; 25: 183-186Abstract Full Text PDF PubMed Scopus (24) Google ScholarSlade suggested that sexual activity became associated with failure and pressure rather than pleasure, particularly when timing is dictated by the day of the cycle rather than mutual interest. Despite the lack of empirical data, most reviews on this subject are remarkably similar in their descriptions of sexual problems.22Bernstein J. Mattox J.H. An overview of infertility.J Obstet Gynecol Neonatal Nurs. 1982; 9–10: 309-314Crossref Scopus (6) Google Scholar, 23Mahlstedt P.P. The psychological component of infertility.Fertil Steril. 1985; 43: 335-346PubMed Google Scholar, 24Mai F.M. Munday R.N. Rump E.E. Psychiatric interview comparisons between infertile and fertile couples.Psychosom Med. 1972; 34: 431-439Crossref PubMed Scopus (61) Google Scholar.That infertile women reported greater discontent than infertile men also is consistent with the findings of other studies. Hubert, Hellhammer, and Freischem failed to find any evidence of depression in men, whereas both Cooper and Tartasky found high levels of depression in women.9Cooper S.L. Female infertility: Its effect on self‐esteem, body image, locus of control, and behavior.Dissertations & Abstracts International. 1980; 40: 4476Google Scholar, 11Tartasky D.J. Psychological impact of infertility. 1985Google Scholar, 25Hubert W. Hellhammer D.H. Freischem C.W. Psychobiological profiles in infertile men.J Psychosom Res. 1985; 29: 161-165Abstract Full Text PDF PubMed Scopus (24) Google ScholarPerhaps women feel more of the burden. Eighteen of the 28 couples in the experimental group of this study attributed their fertility problems to the women. In these couples, no differences were noted between the subjects taking hormonal medications and those not receiving medications.The impact of investment on general discontent is not surprising considering that, with time passage and additional medical intervention, a greater sense of despair and urgency may arise. Hopelessness becomes more prevalent, and because a child is still seen as the ultimate goal in marriage, an increased sense of frustration results.The interaction between gender and investment, with respect to contentment, also is interesting. While discontent in women increased dramatically as investment increased, among men there was little change from the initial levels of discontent. If time and emotional investment took their toll, it was primarily on the woman. As the fertility work continued, men appeared to manage their infertile identities more successfully, perhaps relishing their role as support person.A possible explanation for the impact of investment on sexual satisfaction came from the infertility nurse clinicians associated with this study. These nurses reported that, after a period of time in the formal fertility work, the couples learned to budget their time and took time off from the medical interventions. Their initial attitudes are exemplified in the statement, "Let's not skip a single month, because it could be the one"—an attitude that does not permit any respite from the stress of infertility treatment. With the passage of time, couples tended to be realistic about their chances of fertility. Pregnancy, which may still have been perceived as a high priority, was no longer an all-encompassing goal. For example, it was not unusual for a couple to tell the clinic to "hold off this month because we are going on vacation."Noncommunicating infertile couples were less content and had higher levels of marital dissatisfaction than controls.The effect of investment on self-esteem for men and women supports the interaction noted for contentment. The men appeared to be adapting as the fertility work continued, while the women found that the fertility work took an increasing toll on their lives. The findings regarding the interaction of gender, press, and investment are consistent with those of Tartasky, who found that infertile couples experience self-esteem problems, and that press and investment play a role in the impact of infertility.11Tartasky D.J. Psychological impact of infertility. 1985Google ScholarIndividuals under considerable pressure, with respect to their infertility, anticipated the low feelings associated with the infertility work. This anticipation protected them from the resultant impact of infertility. As investment increased, however, the individuals making the greatest adaptation were the men with low press scores, while the women—especially those under high press—were most affected. One possible explanation is that as investment in infertility work increased, women felt a greater sense of urgency and desperation. The men, on the other hand, either resigned themselves to the process or reacted to their spouses' discontent and depression by playing more stoic roles. This would be the empirical analogy to Olshansky's notion of formal identity of self as infertile. Perhaps, in this case, women take on the role of self as infertile and make a commitment to the fertility work.The results of the comparison of the subgroup of noncommunicators to the infertile sample have important implications. Kraft et al. found that couples with "ongoing mutuality" viewed infertility as a common problem, regardless of who had the physical impairment.13Kraft A.D. Palombo J. Mitchell D. Meyers C. Meyers S. Schmidt A.W. The psychological dimensions of infertility.Am J Orthopsychiatry. 1980; 50: 618-627Crossref PubMed Scopus (80) Google ScholarThus, empathy and tender sharing of feelings occurred in healthier couples, actually strengthening their marital bond. Other couples may not fare as well, however. If unable to share their feelings, couples may feel isolated from each other and drift apart.LimitationsThe major limitation of this study was the inclusion of primarily married, professional, upper/middle-class subjects in the sample. As all subjects were attending the same private fertility clinic, results cannot be generalized to the infertile population as a whole. Infertility may have an even greater impact on single, low-income, ethnic individuals who cannot afford expensive medical intervention. Additional limitations include the reliance on self-report questionnaires and the lack of established reliability and validity for the questionnaire designed to measure press and investment.Recommendations for Fut
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