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The aim of the essay was to investigate the question: To what extent does infertility affect self-esteem of a woman? The first thought that comes to mind when trying to resolve the question is that its impact is undoubtedly large. To major extent it resulted to be true, however some studies proved that in some cases due to infertility experience women recorded improvement in marital relations. Furthermore, it was shown in another investigations that infertile women do not notice any dramatic change in their lives after the disease had been diagnosed. Nonetheless, firm majority of the researches deliver irrefutable evidences for the process of lowering self-esteem of women facing the problem of infertility.
However, it cannot be concluded that it is bare inability to conceive which leads to substantial decline of self-worth. The cause and effect relationship is not that straightforward in this case as the degeneration of self-confidence experienced by a woman is a result of a series of events occurring in a response to the outbreak of the problem. Most of the contributing factors are reaction of the family, friends and a partner and also the sociocultural attitude to the issue undergoing modifications over time being different in different cultures. A significant material used in my research was the national survey conducted in United States in which social tolerance and acceptation is hugely propagated. Besides, financial possibilities and general access to the public healthcare might have influenced the results. Therefore, more cross-cultural studies should be conducted in order to state the general standpoint towards the problem. Nevertheless, taking into considerations all contributing factors it would be still difficult to create a fixed stance generalised to the whole women population.
Notwithstanding, the holistic analysis summarised in the conclusion of the essay demonstrates that women struggling with infertility problem experience considerable damage to self-esteem.
“You [mothers] are the real builders of the nation wherever you live, for you have created homes of strength and peace and security. These become the very sinew of any nation.” said President Gordon B. Hinckley on motherhood. According to the First Presidency “Motherhood is near to divinity. It is the highest, holiest service to be assumed by mankind”. What happens to a woman whose biology deprives her of the closeness to divinity? Why does nature act against a purpose of woman? “Infertility can cause women to lose their sense of power and control, thus diminishing their self-esteem (Johnson, 1996) and has been described as a developmental crisis that is often experienced as a narcissistic trauma (Kraft et al., 1980 as cited in Downey, 1992). The social impact of involuntary childlessness has been seen as a stigma (Miall, 1986 as cited in Downey, 1992) resulting in a spoiled identity (Matthews & Matthews, 1986 as cited in Downey, 1992). In its severity as a stressor, the inability to achieve the life goal of bearing children has been compared to death and divorce (Mahlstedt, 1985 as cited in Downey, 1992).”
The choice of the topic was obvious for me as I link my future with medicine having particular interest in psychology of a woman. The profession which perfectly connects those two fields is gynaecology. Therefore I am going to become an open-minded doctor specialising in gynaecology, endocrinology and also obstetrics which include not only elements of medicine but also some of psychology which plays a crucial role in this branch. Unfortunately doctors of medicine tend to neglect psychological aspect of human being. Discovery of infinite powers of human brain is still in its infancy, however scientific researches deliver loads of proofs for the link between two spheres: sacrum and profane. In other words, the impact of thoughts, hope and beliefs on the health perceived from the biological perspective is significant though, in the majority of cases is considered negligible.
The focus on infertile women begun when I faced the problem during my stay in a hospital. It was easily noticeable that failure of anatomy in the sphere related to sexuality impairs women’s self-confidence and triggers an image of damaged femininity. This gives the basis of further mental problems resulting in social problems which are unavoidable in both relations with friends and family and also work efficiency. For that reason my essay is supposed to deliver evidences which are to respond to the question to what extent does infertility affect self-esteem of a woman. Exploration of the nature of the most fragile creatures in the world seems to be worth investigating.
INFERTILITY AND SELF-ESTEEM
To begin with, it must be stated what infertility is. The American Society for Reproductive Medicine defines it as a disease of the reproductive system that “impairs the body’s ability to perform the basic function of reproduction. It is often diagnosed after a couple has not conceived after one year of actively trying, while women over the age of 35 are encouraged to seek diagnosis and treatment for infertility after six months.” The statistics delivers outrageous numbers: “More than 7.3 million Americans, or one in eight couples of childbearing age, struggle with fertility problems.” Even though approximately equal percent of fertility problems are due to a female and male factor, it is far more frequent that women tend to blame themselves despite rationality. Infertility can be treated in a variety of ways including hormone treatments, insemination, IVF (in vitro fertilisation) and surgery.
According to Branden (1992) “self – esteem is a disposition to experience oneself as a competent to cope with the challenges of life and as deserving of happiness.” However, this definition does not specify environmental influences that support healthy self-esteem, nor emotional or behavioural consequences.
Nonetheless, environmental factors play a key role when social expectations are unfulfilled. In all societies women have been associated with caring mothers. Infertile women experience sense of impaired fulfilment of ascribed social role. Branded extended the theory. He stated that “our need of self-esteem is the result of two basic facts – both intrinsic to our species. The first is that we depend on our survivals and our successful mastery of the environment on the appropriate use of our consciousness. The second is that the right use of our consciousness is not automatic, is not ‘wired in’ by nature. In the regulating of its activity, there is a crucial element of choice – therefore, of personal responsibility.” Infertility is an unanticipated developmental crisis (Kodadek, 1988). For most women, the decision to bear a child was seen as a matter of choice. It was a shock to have that choice taken away.
EFFECTS OF LOWERED SELF-ESTEEM
Self-esteem possess a motivating and energizing power. When present in an optimal amount the rate of achieving our goals is significantly enhanced which triggers the sense of pleasure and pride. Due to its presence we are able to experience satisfaction (Branden, 1992). Self-esteem itself does not ensure fulfilment, but its deterioration provides some measure of anxiety, frustration, despair. Self-esteem is highly required regarding the fact that its decline diminish our ability to function due to which it can be considered as possessing a survival value. A number of theories of depression suggest that negative attitudes toward the self increase vulnerability (Beck, 1967; Brown & Harris, 1978 as cited in Andrews & Brown, 1993). The relation between causal attributions and depression has recently received much attention (Brewin, 1985; Peterson & Seligman, 1984 as cited in Brewin & Furnham, 1986). It was revealed that there is a substantial correlation between self-esteem and depression. The investigation also proved that the more frequently that subjects rated themselves as experiencing similar negative outcomes, the lower was their self-esteem. It is generally noticeable that women tend to think towards themselves very critically which is not that abundant in men. As a result, vulnerability to damages to self-esteem in women is bigger. Many women sense the distressing effects of low self-esteem (Sanford & Donovan, 1987). They feel that they are inadequate or worthless, perceive their bodies with some measure of dissatisfaction and experience lack of self-confidence in terms of their physical appearance. Women’s tendency to reject the idea of deserving happiness and success reinforced by disbelief that they can be loved as well as doubt that they are talented, competent and smart. It can be seen in everyday life that any single detail related to the sense of femininity can affect woman’s self-esteem.
If link one of the most severe crisis situation with high vulnerability to depression the outcome will be outrageous. “Women experience depression twice as often as men” (Bhatia & Bhatia, 1999). “The diagnostic criteria for depression are the same for both sexes, but women with depression more frequently experience guilt, anxiety, increased appetite and sleep, weight gain and comorbid eating disorders.” In spite of the lack of sufficient data which would suggest the reason for the difference, depression is more prevalent in women owing to “a combination of gender-related differences in cognitive styles, certain biologic factors and a higher frequency of psychosocial and economic stresses in women. Possible biologic mechanisms may include differences in brain structure and function, genetic factors and the cognitive-behavioural or mood-related effects of female gonadal steroids on neurotransmitters and enzyme functions in vulnerable persons.” These facts oxymoronically illustrate imperfection of nature which in question should not act against itself.
On one hand biology which is a subject responsible for increased fragility in women to suffering from depression, on the other sentences them to suffering due to impairment of the reproductive functions. This dichotomy realises the vicious circle model.
The debate begs the question what are the further effects of lowered self-esteem. Many of us consider lowered self-esteem as a miserable display of a weak personality or even more severe as compulsive moaning. In fact the psychological destruction to a large extent begins with damage to self-valuing, the second step is depression whilst the final stage is frequently suicide. Even though depression is a significant risk factor for suicidal behaviour in both sexes, higher rate of suicidal attempts has been recorded for women particularly those under 30 hence during the period associated with reproduction (Bhatia & Bhatia, 1999). The most frequent method amongst women is self-poisoning which constitutes 70 percent of all suicidal attempts. To conclude, virtually slightly altered self-valuing can turn into lethal process.
EMOTIONAL ASPECTS OF INFERTILITY
As summarised on one of the support websites “one of the most challenging aspects of the infertility experience is dealing with the emotional ups and downs relating to medical treatment, the uncertainty about outcomes, and the challenge of having to make important decisions such as when enough is enough” (Resolve, 2010). The feelings associated with infertility are sense of loss, denial, shock, anger, numbness, guilt and shame. “Shame is a searing, painful feeling associated with faltering self-esteem, and a sense of inadequacy, defectiveness and helplessness.” It seems to be horrifying how strongly self-esteem of a woman is altered by the loss of reproductive abilities. Repeated attempts to get pregnant that result unsuccessful gradually realise that the strongly desired goal can never be achieved. Unfortunately, this awareness does not allow for complete preservation of woman’s self-image as failure of the procedure is projected on perceiving herself as failing. All negative feelings converge eventually leading to absolute self-doubt as the dream about creating a family collapses. Not only the woman is affected but also her family and spouse who empathically share the tragedy. The most tragic dimension of chronic infertility is that with time this tiresome sense disperse over all life aspects acting like a snow covering other competencies. This process is usually imperceptible due to unconscious disguising of the shame which must be hidden as it causes the sore sense of self-defect. The statistics implies that there are considerably more women struggling with the problem than it could be expected. The reason for such unconsciousness and underrated numbers is that failure of reproductive functions is not an ordinary disease. The psychological aspects included generate urge to hide the problem.
However, the results obtained in the national survey (Schering-Plough and Merck & Co., Inc., 2009) prove that avoiding talking about the problem cause its deepening. 72 percent admit that having talked to people about the process has made is easier to deal with. For women struggling with the disease, this painful experience includes bereavement of loved people and other hidden losses for the society and individuals as well. The loss may be analysed on certain levels such as “loss of stability in family and personal relationships, loss of work productivity, loss of a sense of spirituality and sense of hope for the future” (Resolve, 2010). All these impairments are further effects of low feelings of self-worth. Application of repressive defense mechanisms such as denial, repression, rejection of diagnosis, projection and isolation is one of the methods of changing the perception of this situation (Griffin & Clapp, 1986; Reading & Kerin, 1989; Bidzan & Józefiak, 2002 as cited in Bidzan, Bidzan, and Smutek, 2006). Some women suffering from infertility modify their opinions about having children. In the study conducted by Bidzan, Bidzan, and Smutek (2006) sense of control over life was investigated in three groups: women suffering from infertility, urinary incontinence and cervical cancer. The lowest ratings were recorded in the group of infertile women. However, it was also proved that despite the progression of the illness, the level of psychological quality of life does not change within the scope of emotional life, depression, fear and positive feelings which may lead to the conclusion that with time patients adapt to the illness. Similar findings are confirmed in another study (Kowalik et al., 2001 as cited in Bidzan, Bidzan, and Smutek, 2006) which proved that level of progression of the illness does not correlate with the level of sense of life satisfaction. Corresponding results were obtained in a study conducted on a group of infertile women (Hearn et al., 1987 as cited in Bidzan, Bidzan, and Smutek, 2006) in which life satisfaction was still derived in spite of the illness. These results broaden the range of arguments soothing my expectations.
Nevertheless, the national survey (Schering-Plough and Merck & Co., Inc., 2009) delivered loads of evidences that struggling to conceive is a severe assault to the self-esteem of women. The survey of 585 women and men was conducted. 71 percent of women admitted that infertility makes them feel flawed, whereas half of men say it makes them feel inadequate. Half of the couples confessed to the attempts to hide the feelings from the partner. Though relatively big amount of men admitted to the sense of condemnation, the problems with getting pregnant still to a larger extent concern women which is proved by the statistics.
Graph 1 – Answers obtained in the National Survey in response to the question directed to both women and men: “Overall, who would you say is more upset about having difficulty getting pregnant?”
Analysing the Graph 1 it is clearly seen that women admit to feel more upset about having difficulty to get pregnant more than twice as men. Analogically, from the point of view of men, women tend to experience distressing feelings almost three times more than themselves. Corresponding results were obtained in response to other questions; 75 percent of surveyed women claim resenting people who take getting pregnant for granted and 72 percent resent people who give advice because of having got pregnant without fertility treatments.
According to the results obtained in the survey presented on the graph below 58 percent of women say “they get tired of people asking them how the process is going”, and 60 percent offering suggestions on how to conceive.
Graph 2 – Answers obtained in the National Survey in response to the question: ‘Couples who have told others about their difficulty getting in pregnant: How much do you agree or disagree with each of the following statements when it comes to difficulty in getting pregnant?’. The results obtained in group of women are shown.
The probable reason for this is that withdrawal mechanisms is ascribed to lowered self-esteem and consequently, lowering urge to meet with people who used to know those women as different people before the tragedy occurred. Women struggling with the sense of being flawed try to hide the feelings from being noticed and as a consequence, avoid situations in which they could be exposed. 56 percent of surveyed women admit feeling uncomfortable around pregnant women or couples who have babies. What is more, 67 percent try to hide how they feel about the difficulty in getting pregnant from family and friends.
What surprised me a lot, more couples agreed that their “difficulty in getting pregnant has brought them closer together (58 percent), as compared with those who say that it has hurt their relationship (36 percent).” These results give rise hope that infertility can unexpectedly deliver positive outcome. This aspect balances rather extreme hypothesis stated in response to the question.
Graph 3 – Answers obtained in the National Survey in response to the question directed to women: “Overall, how supportive has your partner been in the following areas?”
It turns out that large responsibility lies on men sharing the same problem. As can be easily noticed on the Graph 3 majority of women feel supported by their partners not only due to presence of their partners on medical appointments but also receiving empathy towards their emotional instability. Apparently, due to observation of masculine attitude towards the difficulty seen in their partners women can imitate their endurance eventually feeling stronger. Overcoming such painful experience, what was revealed in the survey, can strengthen the relationship between partners. Women despite their inability to fulfil woman’s purpose receive consolation from their partners and as a result an evidence for independence of love. This is somehow connected with the findings from the Islington study (Brown & Harris, 1978 as cited in Andrews & Brown, 1993) which showed that low self-esteem is related to negative elements in current close relationships, such as negative interaction with a spouse and lack of support.
Graph 4 – Answers obtained in the National Survey in response to the question about supposed origin of the difficulty of getting pregnant to the best of knowledge. The results are distinguished for men and women.
As can be seen on the Graph 4, women tend to ascribe the fault to their side. According to my predictions more than half of men admitted that the difficulty of getting pregnant lies on the woman side. Women associated with mothers for centuries inequitably bear responsibility for conception.
Graph 5 – Answers obtained in the National Survey in response to the question asking about negative feeling connected with difficulty of getting pregnant. The results distinguished for men and women.
Graph 6 – Answers obtained in the National Survey in response to the question asking about negative feeling connected with difficulty of getting pregnant. The results distinguished for men and women.
I divided the graphs above in the following manner: The Graph 5 concerns negative feelings more abundant in women whilst the Graph 6 perform negative feelings more abundant in men. Analysing the graphs above it can be noticed that women to a larger extent experience feelings causing unstable self-esteem such as hopelessness, feeling of guilt and devastation, isolation or loss of attractiveness. In the study conducted by Kodadek (1988) the sample as a whole group reported the positive correlation between the lowered level of self-esteem of infertile women and their perception of their body image. The women also reported that there was a relationship between their level of self-esteem and their feelings of alienation. In contrast, men more strongly than women recorded feelings associated with confusion such as lacking answers and frustration. They admitted feeling overwhelmed, drained and more vulnerable. However, what is interesting more men claimed feeling stigmatized which is contradictory to my assumption as I regarded this problem to be far more frequent in women.
Another tragic dimension of the issue is that effort to get pregnant also have a bad effect on intimacy. More than half of all women “report that infertility has made sex a physically and emotionally anxious time.” In addition, half of women say “infertility has taken the fun and spontaneity out of their sex life, and more than 4 in 10 couples report feeling sexually unattractive.” Undoubtedly, women are commonly judged on the basis of their physical attractiveness. Thus, any decrease in feeling sexually attractive results in impaired opportunities not only among the society but also in the labour market which may obviously trigger the feeling of worthlessness.
DESTRUCTIVE DIMENSION OF THE TREATMENT
There is another problem related to the topic which is worth mentioning. The infertility treatment have been proved to induce both anxiety and depression. It was indicated (Parikh et al., 1991) that “women presenting for IVF were more depressed, had lower self-esteem and were less confident than a control group of fertile women. Depression, anxiety and hostility scores tended to be higher in women at the time of embryo transfer (before the pregnancy test) than at the first or second (before transfer) visits. After a failed IVF cycle, women experienced a further lowering of self-esteem and an increase in depression relative to pre-treatment levels. Comparisons between women undergoing repeated IVF cycles and first-time participants suggest that ongoing treatment may lead to an increase in depressive symptoms.” In another study (Brand, 1989; Connolly, Edelmann, & Cooke, 1987; Daniluk, 1988; Lalos, Lalos, Jacobsson, von Schoultz, 1985; Stewart & Robinson, 1989 as cited in Downey, 1992) while undergoing evaluation and treatment for infertility, women have been reported to experience grief, denial, anger, high levels of anxiety and depression, lowered self-esteem, poor body image, marital difficulties, and problems with sexual identity and functioning. In another study (Verhaak, Smeenk, Evers, Kremer, Kraaimaat, Braat, 2006) investigation was focused on the question how women adapt emotionally to the various stages of IVF treatment concerning anxiety, depression or general distress before, during and after different treatment cycles. “The findings indicated that women starting IVF were only slightly different emotionally from the norm groups. Unsuccessful treatment raised the women’s levels of negative emotions, which continued after consecutive unsuccessful cycles.” The researches deliver a variety of evidences that impairment of self-esteem of infertile women is a complex process having ground not only in the fact of having the disorder and experiencing distressing consequences. Unfortunately, also attempts to overcome the problem become a vast contributing factor.
I find it terrifying how far does the concern progresses. It turns out that “psychiatric illness in populations undergoing infertility treatment using standardized diagnostic instruments” is prevalent. In a study from Taipei Veterans General Hospital (Chen et al., 2004), “women attending an assisted reproduction clinic were assessed using the Mini-International Neuropsychiatric Interview. Of the 112 participants, 40.2 percent met criteria for a psychiatric disorder. The most common diagnosis was generalized anxiety disorder (23.2 percent), followed by major depressive disorder (17.0 percent) and dysthymic disorder (9.8 percent).” “Infertility has been estimated to lead to psychiatric symptoms of clinical severity in more than a third of the women who undergo treatment” (McEwan, Costello, & Taylor, 1987 as cited in Downey, 1992). Of the infertile women (Keye, Deneris, Wilson, and Sullivan, 1981 as cited in Downey, 1992) 57 percent said that “infertility was the hardest thing they had had to face in life.”
Taking all into consideration, it should not be questionable whether the experience of infertility lowers self-esteem of a woman. A number of studies quoted in the essay deliver clear evidences supporting my expectations and the general opinion. Distressing failures of the treatment cycles to a large extent deepen the degeneration of self-confidence. Furthermore, the prevalence of meeting criteria for psychiatric disorder quite firmly summarise the topic. However, it cannot be assumed that the illness cause damages to self-respect to the absolute dimension. The national survey proved that in the majority of couples the problem paradoxically has strengthened their relationship which contributes to the feeling of being appreciated to a huge degree. Also multiplicity of organisations and websites oriented to grant support to infertile women substantiate the scale of the problem. Nevertheless, it must be taken into account that participants of the national survey which constitute a significant material of my research were Americans. Hence, the answers collected are limited to the population of United States which considering sociocultural aspects is a specific nation. With regard to the high standard of life, financial abilities and relatively wide opportunities the positive results obtained might be concerned as overrated. Not to mention the average level of life satisfaction which is rather high owing to which the reinforcing effect on a relationship may be considered as unrepresentative for the generalized world population. Another scope of the cross-cultural research are the sociocultural differences due to which the attitude towards procreation and family should not be compared as they are not the same in different areas.
In order to increase global validity of the enquiry more studies concerning the topic should be conducted in various countries.
Notwithstanding, the ratio of studies delivering evidence for destructive impact of fertility problems on the self-assurance of affected women is still far bigger. In my opinion, women with the infertility experience should be given notice about coping techniques by their leading medical doctors whose words usually possess influential power. Apart from being constantly informed, attention should be paid to encourage to overcome isolation and not to avoid contact with family. Affected women should be persistently confirmed in the conviction that it is possible to convert the sense of failure into an empathy with oneself and others who also experience overwhelming moments in life. , an affirmation of the power, an acceptance of limits, a pride in endurance, It is vital that women felt supported and permitted to show their emotions either crying or being angry being confirmed the belief that they possess infinite power to face the problem and accept the limits. In accordance with the Zen proverb which says, “The way to control a bull is to give it a big pasture.”
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