Life experiences and quality of life of involuntarily

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Life experiences and quality of life of involuntarily childless men in treatment and adoptive fathers a

a

a

Saraswathi Bhaskar , René Hoksbergen , Anneloes van Baar , Arun b

a

Tipandjan & Jan ter Laak a

Utrecht University, The Netherlands

b

ICPCSR, Puducherry, India Published online: 15 Sep 2014.

To cite this article: Saraswathi Bhaskar, René Hoksbergen, Anneloes van Baar, Arun Tipandjan & Jan ter Laak (2014): Life experiences and quality of life of involuntarily childless men in treatment and adoptive fathers, Journal of Reproductive and Infant Psychology, DOI: 10.1080/02646838.2014.956302 To link to this article: http://dx.doi.org/10.1080/02646838.2014.956302

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Journal of Reproductive and Infant Psychology, 2014 http://dx.doi.org/10.1080/02646838.2014.956302

Life experiences and quality of life of involuntarily childless men in treatment and adoptive fathers Saraswathi Bhaskara*, René Hoksbergena, Anneloes van Baara, Arun Tipandjanb and Jan ter Laaka a

Utrecht University, The Netherlands; bICPCSR, Puducherry, India


(Received 5 January 2014; accepted 17 August 2014) Objective: To explore the life experiences and quality of life of involuntarily childless men to determine whether adoption improves their quality of life. Background: The current study focused on specific life experiences – the strength of the desire for a child, problems in marital understanding and the quality of life of involuntarily childless men undergoing fertility treatment and adoptive fathers who had experienced infertility in an Indian context. Methods: A convenience sample of 100 involuntarily childless men undergoing fertility treatment was recruited and 100 adoptive fathers were selected through snowball sampling. Participants provided demographic information and completed seven questions that measured their strength of child wish (four items) and problems in marital understanding regarding childlessness (three items). Quality of life was measured with a German instrument, the Tübingen Quality of Life Questionnaire for Men with Involuntary Childlessness (TLMK; 35 items, English version). Results: Both groups emphasised the importance of being a parent. There was only a slight difference in problems in marriage due to childlessness. However, the results of the TLMK revealed that the adoptive fathers perceived an overall better quality of life than the involuntarily childless men. Conclusion: Adoption can improve the quality of life of involuntarily childless men in this particular ethnic group. Designing culture- and genderspecific counselling could be beneficial to both groups. Keywords: involuntarily childless; adoption; quality of life; infertility; child wish

Introduction Quality of life is used as shorthand for the collective well-being of human groups and also as a summary description of the particulars of individual lives (Rapley, 2007: 63). Researchers have concluded that one’s quality of life is determined by one’s level of functionality across the social, psychological, and health domains (Keyes, 1998; Ryff, 1989). Quality of life depends on an individual’s objective life circumstances and the subjective satisfaction gained from fulfilling familial, cultural, and societal needs. Overall happiness and life satisfaction contribute to the appreciation of those life circumstances (Diener, Suh, Lucas, & Smith, 1999; Watson, 2000). One life circumstance that can affect quality of life is the ability to attain parenthood. Whether compelled by biological drive, social necessity, or psychological *Corresponding author. Email: [email protected] © 2014 Society for Reproductive and Infant Psychology


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longing, the desire for a child is a feature of married life, and the inability to attain parenthood can have an effect on quality of life for many couples (Covington & Burns, 2006). Infertility affects 9–15% of the childbearing population (Boivin, Bunting, Collins, & Nygren, 2007), and 55% of those affected will seek medical advice in the hope of achieving parenthood (Bunting & Boivin, 2007). There are a few studies on childless couples in India (e.g. Mehta & Kapadia, 2008; Riessman, 2000), but we found no studies that addressed the experiences of involuntarily childlessness in men. This could be because infertility is viewed as a female-specific issue and a deviation from the cultural norm (Sayeed, 2000), often focused on women’s experience (Glover, McLellan, & Weaver, 2009). However, men are pressured to prove their virility and are aware that there could be ‘defects’ in themselves, as well (Gujjarappa, Apte, Garda, & Nene, 2002). If involuntary childlessness in men causes a feeling of defectiveness, would adopting a child improve their quality of life? This question will be examined in this study. Involuntary childlessness is caused by problems with conception (failure to conceive; Himmel et al., 1997) or disease (an interruption, cessation, or disorder of body functions, systems, or organs) in the male or female reproductive tract that prevents the birth of a child (Covington & Burns, 2006). Involuntary childlessness is usually diagnosed through medical interviews and physical examinations of both partners (Centers for Disease Control, 2001). Involuntarily childless couples have been found to experience problems that affect their quality of life and social relations (Andrews, Abbey, & Halman, 1991), but also improved communication and enhanced intimacy between couples (Burns & Covington, 1999). Studies also confirm that, like women, men suffer from low self-esteem, feelings of defectiveness, anxiety, isolation, blame, and greater sexual inadequacy. So, it is imperative to study the male experience with involuntary childlessness (Gujjarappa et al., 2002; Lee, 1996; Sandlow, 2000; Webb & Daniluk, 1999). Male perspective on infertility Research has suggested that infertility in men can cause jealousy, social isolation, and feelings of sexual inadequacy and dysfunction (Irvine, 1998). Studies conducted in Europe revealed that it can cause emotional stress and a range of psychological reactions, including depression and anxiety (Fassino, Piero, Boggio, Piccioni, & Garzaro, 2002; Wischmann, Stammer, Scherg, Gerhard, & Verres, 2001). In the United States, men with diagnosed male-specific infertility experienced more stigma and loss of self-esteem than men who were not diagnosed with male infertility (Nachtigall, Becker, & Wozney, 1992). Studies in various parts of the world have pointed out that those men from individualistic cultures experience psychological problems due to childlessness. Less is known about men’s experiences in collectivist societies. Collectivistic cultures emphasise values such as construing the self as related to others and the environment, being embedded in in-groups, and strong emotional dependence on family (Mishra, Srivastava, & Mishra, 2006; Misra, 2001). In Indian culture, for example, there is great importance attached to loyalty to groups, especially to the family, and to compliance with group obligations and duties (Lewis, 1999). These studies confirm the Hindu belief that to produce and raise children is dharma, or sacred duty (Mishra, Mayer, Trommsdorff, Albert, & Schwarz, 2005). Indians are also

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known to place low emphasis on inner dispositions for their self-conceptions as well as on their own well-being (Suh, Diener, Oishi, & Triandis, 1998). Because of these predispositions, it is imperative to know whether involuntarily childless Indian men are likely to achieve well-being even when they do not meet external relational demands.

Involuntary childlessness in Indian men In an exploratory study on childlessness in urban, rural, and tribal settings in India, male respondents found it difficult to talk about their infertility with their wife and family, because of feelings of shame and inadequacy (Baru & Dingra, 2004). When discussing their feelings regarding childlessness, men often reported their wife’s feelings rather than their own (Mehta & Kapadia, 2008). A study by Dhar (2013) revealed that couples are known to consider adoption as an alternate route to parenthood in India.

Adoption in the Indian context According to Bhargava (2005), adoption is ‘a social construction that is shaped by cultural forces’ (p. 24). It is ‘the establishment of a parent–child relationship through a legal and social process other than the birth process. It is a process by which, a child of one set of parents becomes the child of another set of parents or parent’ (Ananthalakshmi, Sampoorna, Mushtaqu, Jayanthi, & Charulatha, 2001, p. 11). Historically in India, Hindu rulers of princely states who did not have male heirs adopted sons to ensure succession to the throne. This practice was not restricted to royalty alone. A male child had a special place and when a couple did not have a son, the couple adopted a male child primarily for performing the last rites and secondarily for the inheritance of property (Ananthalakshmi et al., 2001). Adopting for performing last rites or for the inheritance of the property has changed and to our knowledge, recent trends indicate that adoption is a personal choice that allows involuntarily childless couples to construct a family. However, although there is much literature regarding children who are adopted, very little research has been done on adoptive parents in India. Attitudes toward adoption in India have changed significantly in the last two decades (Bhaskar, Hoksbergen, van Baar, Mothiram, & ter Laak, 2012). Also, it is evident from our clinical practice that most childless Indian couples are now open to adoption. By contacting both involuntarily childless men who were undergoing fertility treatment and adoptive fathers who had experienced infertility (hereafter referred to as adoptive fathers), we sought to gain insight on the overall quality of life of involuntarily childless men in South India and to determine whether adoption improves their quality of life. Main research questions We could not find studies that investigated quality of life and involuntary childlessness specific to Indian men. Thus we sought to explore three related questions: are there differences in the quality of life of involuntarily childless men undergoing fertility treatment and adoptive fathers; do differences exist in child wish and

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impact on the marriage due to childlessness; and if so, does adoption improve quality of life? Method Participants We compared two groups of involuntarily childless men. The first group was recruited from the Prashanth Fertility Research Centre located in Chetpet, Chennai in Tamil Nadu, India. We secured permission from the Centre’s ethics committee to conduct the study. Participants were involuntarily childless South Indian men who were receiving infertility treatment (n = 100). The second group consisted of 100 South Indian involuntarily childless men who have adopted. The number of participants in the second group was confined to 100 to make the two groups comparable (see Procedure). Instruments The two groups were asked to complete the following questionnaires. A demographic profile sheet was used to obtain data on the men’s age, educational level, socioeconomic status (Kuppuswamy’s Socioeconomic Scale: Kumar, Gupta, & Kishore, 2012), religious affiliation, duration of involuntary childlessness, and number of years in fertility treatment. Strength of child wish and impact on the marriage were evaluated using a seven-item questionnaire to find out the participants’ perceptions due to childlessness (Holter, Anderheim, Bergh, & Moller, 2006). They responded to each item on a visual analogue scale of 1 (not at all) to 5 (very much) (see Appendix 1). The Tübingen Quality of Life Questionnaire for Men with Involuntary Childlessness (TLMK; Schanz et al., 2005) was used to measure the participants’ quality of life. The TLMK is an English version of a German tool developed by Schanz et al. specifically to measure quality of life in men with involuntary childlessness. Four dimensions are measured with 35 items: (1) desire for a child (e.g. ‘I can’t achieve happiness without a child’), (2) sexual relationship (e.g. ‘Sex is a chore’), (3) gender identity (e.g. ‘I feel less masculine than other men I know’), and (4) psychological well-being (e.g. ‘I can enjoy the good things in life’). The responses are marked on a Likert scale, ranging from 1, Not at all; 2, Slightly; 3, Moderately; 4, Mostly; 5, Completely. Low overall score indicate a perception of high quality of life and high over all scores give a perception of low quality of life. Cronbach’s alpha for the four dimensions in this study was .86. Procedure Involuntarily childless men in treatment We randomly approached 157 involuntarily childless men who were receiving treatment (ICM group) with an informed consent form for data collection; of these men, 123 agreed to participate in the study. The following reasons were given by the 34 nonparticipants: (1) no time to fill out the questionnaire; (2) impatience due to long waiting periods to consult with the doctor; and (3) anxiety about the treatment cost and procedures leading to the wrong mindset for taking a


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self-administered test. One hundred involuntarily childless men in treatment fully completed the protocol. We could not include the data of 23 participants in our analyses because they were incomplete.


Adoptive fathers The mailing addresses and phone numbers of adoptive fathers (AF group; n = 100) were obtained through snowball sampling from an adoption support group in Chennai and from two adoption agencies. All men who were contacted agreed to participate in the study. They were contacted over the phone initially to secure permission and to make appointments to visit their homes for data collection. Inclusion criteria All participants met the following criteria: (1) ability to read and understand English, because the questionnaires were self-administered; (2) presence of involuntary childlessness and having had unprotected sexual intercourse for at least one year after marriage; (3) exposure to infertility treatment. In addition for the AF group, they had to have adopted a child. Adoptive fathers with a child age ranging from 3 to 10 years old were selected. Questionnaire administration The researcher and a postgraduate student in psychology visited the ICM at the fertility research centre and AF in their homes and administered the measures. Altogether, data collection took about 7 months. Data analysis The data were analysed using SPSS version 18 software. Descriptive and inferential statistics were used to compare the two groups. Chi-square analysis and multivariate analysis of covariance (MANCOVA) were performed using factors that showed group differences as covariates. Bonferroni correction for multiple comparisons was used with the p < .05 significance level and effect size (ηp²) was calculated to analyse the power. Results Participant characteristics of both groups are presented in Table 1. A multivariate analyses of variance shows that the groups differed in age, years of marriage, years of childlessness, and years of fertility treatment, F(4, 195) = 216.569, p < .000, ηp² = .816. In addition, the groups differed in socioeconomic status (SES) and educational level, but not in religion (see χ² tests in Table 1). All the participants belonged to three major religions: Hindu, Christian, and Muslim. The dominant group was Hindu. Because the groups differed in important characteristics, covariates were used to control for potentially confounding effects. To reduce the number of covariates, correlations were calculated between the characteristics that differed between the groups, to see if these might reflect the same underlying factor. Age correlated

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Table 1. Group characteristics of involuntarily childless men (ICM) and involuntarily childless adoptive fathers (AF).


Characteristic Mean age in years (SD) Mean years of marriage (SD) Mean years of childlessness (SD) Mean years of treatment (SD) Socioeconomic status (%) Low Middle High Educational level (%) Low (high school diploma) Middle (undergraduate) High (postgraduate) Religion (%) Hindu Christian Muslim

χp ²

ICM (n = 100)

AF (n = 100)

F(4, 195)

35.89 (4.87) 7.30 (4.01)

43.75 (4.07) 14.39 (3.97)

155.212 158.116

.001 .001

7.29 (4.01)

9.69 (3.57)

19.932

.001

4.95 (3.66)

6.86 (3.12)

15.743

.001

4 91 5

2 81 17

26

7

38 36

46 47

86 11 3

87 9 4

p

7.794

.02

13.159

.001

0.349 n.s.

Note: n.s., not significant.

strongly with years of marriage (.84) and years of childlessness (.71) and less strongly with years of treatment (.60). Therefore, of these variables, only age was used as a covariate. Because SES and educational level correlated moderately (.34), they were also used as covariates in the analyses of variance comparing the quality of life of the two groups. The results of the MANCOVA concerning strength of child wish and impact on the marriage are presented in Table 2. Overall group differences were found,

Table 2. Results of strength of child wish questionnaire for involuntarily childless men (ICM) and involuntarily childless adoptive fathers (AF). ICM (n = 100)

AF (n = 100)

Item

Mean

SD

Mean

SD

F(8, 188)

p

ηp²

Importance of having a child Emotional impact of childlessness Think about difficulties Effect of childlessness Childlessness causing problem in Marriage Blame Comfort

3.94 2.75 2.77 2.78 1.69

0.343 1.466 1.384 1.554 1.819

3.91 3.66 1.52 1.16 2.76

0.351 0.807 1.761 1.704 1.700

0.611 8.001 21.317 35.952 3.936

.435 .005 .000 .000 .049

.003 .039 .099 .156 .020

.69 3.43

1.323 1.103

.19 1.98

.734 1.923

13.478 10.343

.000 .065 .002 .050

Note: Results based on multivariate analysis of covariance with age, socioeconomic status, and educational level as covariates.


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Table 3. Results of the Tübingen Quality of Life Questionnaire for involuntarily childless men (ICM) and involuntarily childless adoptive fathers (AF). ICM (n = 100)

Desire for child Sexual relationship Gender identity Psychological well-being Overall quality of lifea


a

AF (n = 100)

Mean

SD

Mean

SD

F(5, 191)

p

ηp²

30.69 14.33 14.77 17.10 44.44

11.971 6.652 7.114 6.088 16.263

21.92 9.96 11.19 14.32 33.34

9.952 7.197 4.927 6.580 14.286

37.185 25.692 21.023 13.049 28.598

.000 .000 .000 .000 .000

.160 .116 .097 .063 .128

Higher overall score indicates a lower quality of life.

F(8, 188) = 12.927, p < .000, ηp² = .355. Both age, F(8,188) = 2.527, p < .011, ηp² = .099, and SES, F(8,188) = 2.202, p < .029, ηp² = .086, had an effect. The experiences regarding strength of the child wish revealed that the importance of having a child was comparable to men in both groups. Emotional impact of childlessness was greater for men who had adopted (AF group) than for those who had not (ICM group). When asked, ‘How much do you think about your difficulty in having a child?’ and ‘To what degree does childlessness affect your life?’ the ICM group had a higher mean than the AF group. Questions related to impact on the marriage due to childlessness revealed an interesting perspective. When asked if they felt childlessness had an impact on their marriage, the two groups had difference in impact on the marriage, p = .049, ηp² = .020. For blame and comfort, the ICM group scored higher than the AF group in partners blaming each other for childlessness, p = .000, ηp² = .065, and in how often they and their partner comforted each other about childlessness, p = .002, ηp² = .050. We found significant differences between the two groups in all four dimensions of quality of life, F(5, 191) = 8.398, p < .000, ηp² = .180 (Table 3), with the largest effect size found for child wish. However, we cannot use individual dimensions to interpret quality of life because they are correlated substantially. We infer from our findings that quality of life was perceived to be higher in the AF group than in the ICM group. Discussion The present study is the first of its kind in an Indian context, specifically, in Chennai, Tamil Nadu, to find out the quality of life, the strength of child wish, and impact on the marriage between involuntarily childless men receiving fertility treatment and adoptive fathers who had experienced infertility. Although we approached 157 involuntarily childless men in treatment, only 123 agreed to participate. Out of those, 100 involuntarily childless men in treatment fully completed the protocol, which we believe has an impact on the generalisability of the findings. All the adoptive fathers who had received infertility treatment we contacted agreed to participate in the study. We found that adoptive fathers were eager to share their life experiences and felt positive about their fatherhood. The two groups differed in age, education and SES. The AF group was better educated than the ICM group and more men in the AF group were in the highest


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SES category. Given the age difference they were at very different phases of individual development and family life cycle. The fertility treatment process takes time, and the adoptive fathers who had gone through treatment were older. It is possible men consider adopting a child after many years of unsuccessful infertility treatment. The experiences of men in both groups regarding the strength of child wish and impact on the marriage due to childlessness showed that the two groups had the same opinion about how important it was to them to have children. This could be attributed to Indians wanting to have a child mostly to continue their generation and to perform the last rites after their death (Das Gupta et al., 2003). However, the ICM group thought more about their difficulties in having a child than the AF group. It was interesting to find that both groups differed significantly in blame and comfort. However, the fact that comfort was higher than blame for ICM can be a new finding attributed to South Indian men. Alternatively, it could be that due to the problem of involuntary childlessness requiring lengthy treatment, couples get closer to each other (Burns & Covington, 1999). The AF group showed a lower level of marital partners blaming each other for their childlessness and a lower level of comforting their partner; the fact that the men in this group had adopted and were no longer childless could have been a factor in these differences. The results of the TLMK revealed that the AF group had a higher overall quality of life. Regarding the four dimensions of quality of life, desire for child was found to be higher for the ICM group. Sexual relationship was marginally lower for the ICM group. This is in line with the findings of Himmel et al. (1997), who found that the sex life of childless couples become more planned intercourse or sex on demand. Differences in gender identity played a part in the overall differences between the two groups. In India, once they are married, men have to become a father to prove their masculinity. This is in keeping with previous findings that involuntary childlessness frequently affects men’s masculinity, self-esteem, and social status, resulting in public humiliation and stigmatisation (Barden-O’Fallen, 2005; Inhorn, 2003; Runganga, Sundby, & Aggleton, 2001). The AF group reported a higher level of perceived psychological well-being. Overall, the results suggest that adoptive fathers perceived a better quality of life than men in treatment. It can be perceived from this study that adoption has been chosen as an alternate route to parenthood after futile fertility treatment. Based on this study finding, we perceive that adoption may improve the quality of life of involuntary childless men in Chennai, Tamil Nadu, India. Limitations It was difficult to find representative samples for our study. There is a paucity of information regarding involuntarily childless men seeking adoption as a consequence of involuntary childlessness. Because of the collectivist nature of the Indian culture, the impact on the marriage due to childlessness items was included to gain better clarity. However, our study could not clearly determine the specific impact that adoptive fathers were experiencing in marriage. Future research should investigate how adoptive fathers experience parenthood following infertility and what their lingering issues are.



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Conclusion In our study 34 participants from ICM declined to participate, citing long waits to consult with the doctor and anxiety about the treatment procedures and cost of fertility treatment. It appeared that these men in treatment saw study participation as an additional stressor which they were unwilling to take on. In contrast, 100% of the adoptive fathers who were approached agreed to participate. Their willingness to share their life experiences was a major strength of our study. We gather from this study that while both groups felt the importance of having a child in their life, the ICM group perceived lower quality of life and the adoptive fathers experienced an emotional impact. With this knowledge, mental health professionals could establish culture- and gender-specific counselling programmes to lower distress during fertility treatment and to make an informed decision when choosing adoption as an alternative route. Counselling in its broadest connotation has existed in one form or another from time immemorial. In India, elders – especially parents and teachers – have believed that counselling in the form of advice and guidance is one of their fundamental duties. Ancient epics of India are replete with depictions of counselling. Indian youngsters often hear ‘Mata, Pita, Guru, Deivam’ (Mother, Father, Teacher, God), reminding them that they are the receivers of counselling at various stages of life (Sreedhar, 2012). Counselling to promote psychological well-being has gained momentum in the last three decades. The clinical guidelines of the Indian Society of Assisted Reproduction identify mental health of couples undergoing fertility treatment as a priority and recommend provision of counselling (Ministry of Health and Family Welfare, Government of India and Indian Council of Medical Research, 2005). Gerrity (2001) suggested that infertility counselling could be given according to the stages of their infertility treatment. However, if and when the involuntarily childless men choose adoption as the only remaining method to attain parenthood, they may proceed without exploring their psychological preparedness. Hence, pre-adoption counselling for these men could help them to take an informed, reflective and united decision that will allow them to enjoy the fulfilment of societal valued function of parenting. References Andrews, F., Abbey, A., & Halman, J. L. (1991). Stress from infertility, marriage factors, and subjective well-being of wives and husbands. Journal of Health and Social Behavior, 32, 238–253. Ananthalakshmi, S., Sampoorna, G. L., Mushtaq, A., Jayanthi, S., & Charulatha. (2001). Child adoption and thereafter – A psycho-analytical study. Chennai: Indian Council for Child Welfare. Barden-O’Fallen, J. (2005). Unmet fertility expectations and the perception of fertility problems in a Malawian village. African Journal of Reproduction Health, 9, 14–25. Baru, A., & Dhingra, R. (2004). Personal and interpersonal dimensions of childlessness in three different ecological systems. Journal of Human Ecology, 15, 289–294. Bhargava, V. (2005). Adoption in India – Policies and experiences. New Delhi: Sage. Bhaskar, S., Hoksbergen, R., Baar, A. van, Mothiram, S., & ter Laak, J. (2012). Adoption in India – The past, present and the future trends. Journal of Psychosocial Research, 2, 321–327. Boivin, J., Bunting, L., Collins, J. A., & Nygren, K. (2007). An international estimate of infertility prevalence and treatment-seeking: Potential need and demand for infertility medical care. Human Reproduction, 22, 1506–1512.


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Appendix 1. Strength of child wish and impact on the marriage questions (1) (2) (3) (4) (5) (6) (7)

How important is it to you to have children? To what degree does your childlessness affect you emotionally? How much do you think about your difficulty in having children? To what degree does your childlessness affect your life Do you feel that childlessness has caused problems in the marriage? Do you blame each other for your childlessness How often do you comfort each other about your childlessness?