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Characteristics of the individual and the transition : mediating factors in the response to infertility Koropatnick, Stephanie J. 1992

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CHARACTERISTICS OF THE INDIVIDUAL AND THE TRANSITION: MEDIATINGFACTORS IN THE RESPONSE TO INFERTILITYbySTEPHANIE J. KOROPATNICKA THESIS SUBMITTED IN PARTIAL FULFILLMENTOF THE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIES(Department of Counselling Psychology)We accept this thesis as conforming to the required standardsTHE UNIVERSITY OF BRITISH COLUMBIADecember 1991© Stephanie J. Koropatnick 1991In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Department of (',ounce dint. l ,,,Ch.o./08/1The University of British ColumbiaVancouver, CanadaDate )er,	/DE-6 (2/88)AbstractUsing Schlossberg's (1981) model of adjustment to transitions in adulthood as a framework, anexploratory study was conducted of the factors mediating responses to involuntary primaryinfertility. Forty-three women and twenty-eight men who were seeking medical attention forinfertility concerns at an Alberta Infertility clinic were recruited to complete five standardized self-report instruments and one researcher-designed survey measuring fourteen predictor variables andten outcome variables. Predictor variables included four Characteristics of the Transition,including: diagnosis, duration, perceived outcome and perceived chances of success, as well asten Characteristics of the Individual, including: age, sex, race, religion, SES, sex-role identity,self-esteem, locus of control, general health and previous experience with a similar transition.Outcome variables included nine symptoms of distress, including somatization, obsessivecompulsiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoidideation and psychoticism. Canonical correlational analyses indicated two significant linksbetween characteristics of the individual and responses to infertility. The first link demonstratedthat men and women with high self-esteem, high SES, higher age and an internal locus of controltended to respond to infertility with fewer symptoms of distress overall, scoring particularly lowon measures of anger and hostility. The second link described a group of individuals who wereamong the oldest members of the sample and who reported low self-esteem and anundifferentiated sex-role identity. These men and women appeared to also report heightenedfeelings of distress overall, with particularly high levels of anxiety and obsessive compulsiveness.From the results, two groups who may be at risk of experiencing difficulties with infertility wereidentified. They include: Men and women who are recently infertile and have yet to receive adefinitive diagnosis and older men and women who demonstrate low self-esteem and a poorlydefined self-image. The counselling needs of each group were briefly discussed andrecommendations made for possible directions of future research.iiTABLE OF CONTENTSContents	 PageAbstractTable of ContentsList of Tables	 viList of Figures	 viiAcknowledgements	 viiiChapter 1: Statement of the Problem	 1Introduction	 1The Model	 4Characteristics of the Transition	 6Characteristics of the Individual	 9Purpose of the Study	 14Assumptions, Limitations and Delimitations 	 15Assumptions	 15Limitations	15Delimitations	 17Chapter 2: Review of the Literature	 19Introduction	 19Historical Approach to Psychology and Infertility	 19Impact of Infertility	 22Factors Mediating the Impact of Infertility 	 35Summary of Findings 	 53Hypotheses	 55Research Hypotheses	 55Null Hypothesis #1	 55Null Hypothesis #2	 55Alternative Hypotheses	 56Alternative Hypothesis #1 	 56Alternative Hypothesis #2	 56iiiChapter 3: Methodology 	 57The Sample	 57Characteristics Relating to Infertility 	 58Comparison of Respondents to Non-Respondents 	 60Instrumentation	61Personal Information Survey 	 61Bern Sex-Role Inventory 	 62Coopersmith Self-Esteem Inventory	 64Rotter Personal Beliefs Questionnaire 	 65Derogatis SCL-90-R	 66Adjustment to Infertility Scale 	 68Procedure	 69Analysis of Data	 71Chapter 4: Results	 72Assumptions and Data Handling	 72Descriptive Data: Independent Variables 	 74Descriptive Data: Dependent Variables	 75Canonical Correlational Analyses 	 76Characteristics of the Transition	 76Hypothesis One	 76Characteristics of the Individual	 78Hypothesis Two	 78Additional Analyses	 83Comparison of Canonical Variates by Gender	 84Comparison of Canoncial Variates by Race 	 84Comparison of Canonical Variates by Sex-Role	 86Summary	 89Chapter 5: Discussion & Conclusions	 90Discussion of the Findings 	 90Characteristics of the Transition	 91Characteristics of the Individual	 93Summary	 98ivChapter 5 continuedImplications for Counsellors	 99Recently Infertile 	 99Older/ Negative Self-Image	 101Implications for Researchers 	 104Review of Methods and Materials	 104Directions for Future Research	 107Conclusion	 109ReferencesAppendix A:Appendix B:Appendix C:Appendix D:Appendix E:Appendix F:Personal Information SurveyResearch Referral FormLetter of ExplanationConsent FormFollow-up LetterSchlossberg's Model of Adaptation to Transition110116119120121122123vList of TablesTABLESPageTable 1: Demographic Characteristics: Responders v. Non-Responders	 59Table 2: Characteristics of the Transition: Responders v. Non-Responders	 60Table 3: Descriptive Data: Independent Variables	 74Table 4: Descriptive Data: Dependent Variables	 75Table 5: Loadings for First Canonical Variable: Characteristics of the Transition	 78Table 6: Results of Canonical Correlations	 79Table 7: Loadings for First & Second Canonical Variables: Characteristics of theIndividual	 81Table 8: Loading of First & Second Canonical Variates: Dependent Variables	 82Table 9: Comparison of Males and Females on First & Second Canonical VariatePairs	 84Table 10: Canonical Correlations: Race Excluded	 85Table 11: Loadings for First & Second Canonical Variates: Race Excluded	 85Table 12: Comparison of Group Means by Race	 86Table 13: Canonical Correlations: Sex-Role Excluded	 87Table 14: Loadings for First & Second Canoncial Variates: Sex-Role Excluded	 87Table 15: Comparison of Groups Means by Sex-Role	 88viList of FiguresFigure	PageFigure 1: Linearity of Correlation Between First Canonical Variates: Characteristicsof the Transition	 77Figure 2: Linearity of Correlation Between First Canonical Variates: Characteristicsof the Individual	 79Figure 3: Linearity of Correlation Between Second Canonical Variates: Characteristicsof the Individual 	 80viiAcknowledgementsIn this space I would like to acknowledge and thank the many people whose support andassistance have been invaluable to my efforts in completing this research project. Despite theseemingly endless lonely hours spent in front of my computer, this thesis has been far from asolitary effort. I wish to thank the following people for their help: Dr. Tony Pattinson and thestaff at the Infertility Clinic in the Dept. of Obstetrics and Gynaecology at Foothills Hospital inCalgary, for providing me with the space and the subjects needed to collect my data, and formaking me feel welcome and comfortable throughout the process; Dr. Walter Bo1dt, for his kindand patient manner as much as for his surefooted guidance through the hazardous world ofmultivariate statistics; the staff at Education Computing Services, for guiding me through theequally hazardous minefield of mainframe computer software; and most importantly, Dr. JudithDaniluk, for the literally countless hours of reading, editing, making suggestions, re-reading and reediting, always with a sure hand, a supportive smile and a sense of humour.I would like also to thank my family and friends, who have been remarkably patient andunderstanding throughout the past three years. I want especially express my heartfelt appreciationto my husband, Bill, for his support and encouragement. Finally, I would like to dedicate thisthesis to the memory of my father, Fred MacDonald, whose unfailing belief in me continues to be asource of inner strength and motivation for me in my work.viiiStatement of the ProblemCHAPTER ONEStatement of the ProblemIntroductionFor an increasing number of North American couples, infertility is an unwelcomedisruption of life goals and plans. It is estimated that between 10 and 17% of couples who planchildren are unable to conceive after at least one year, and often several years of trying (Davis,1986; Kraft, Palombo, Mitchell, Dean, Meyers & Wright Schmidt, 1980; Morse & Dennerstein,1985; Snarey, Son, Kuehne, Hauser & Valliant, 1987). For these couples, the inability toparticipate in the natural transition to parenthood is profoundly distressing, and may be seen as acrisis in adult development. Using Schlossberg's (1981) model of transitions in adulthood, thepresent study views infertility, defined as the inability to conceive a viable pregnancy after one yearof regular, unprotected, sexual intercourse, as a critical non-event transition. The focus of thisstudy is upon identifying factors which may be of relevance in understanding an individual'sresponses to infertility.Within our culture, it is generally assumed that a marriage will produce children; "Theagreement to have children together is an assumption underlying most marriages" (Woollen, 1985,p.473). In marriage ceremonies the expectation that the couple will have children is nearly alwaysimplicit and is often explicitly prescribed as a requisite of a 'proper' or fulfilled marriage. Family,friends and even strangers often express their eagerness for the newlywed couple to 'sanctify' orcomplete the marital union with a child, with frequent questions and encouragement about thetiming of childbirth (Sandelowski & Jones, 1986). Most couples, moreover, tend to be inagreement with this cultural imperative and plan to have at least one child. In fact, only 5% ofcouples choose voluntarily to remain childless (Veevers, 1980).Of the 95% majority of married couples who plan for and expect to become parents, it isestimated that at any given time, between one-in-five and one-in-twelve couples (Matthews &Matthews, 1986; Morse & Dennerstein, 1985) are experiencing difficulty conceiving and1Statement of the Problemmaintaining a pregnancy. These estimates refer predominantly to married couples who arecurrently seeking medical assistance for fertility issues and include couples with primary infertility,who have never carried a pregnancy to full term as well as those with secondary infertility, whohave previously given birth to one or more children. They do not include married couples or singleindividuals who have yet to discover their infertile status and may in fact currently be using birthcontrol. Nor do these estimates include couples who have previously had problems with fertilityand are no longer seeking medical assistance for it (Halpern, 1989; Matthews & Matthews). It ispossible, therefore, that as many as 15 to 20% of adult North Americans have problems withfertility in terms of conceiving and carrying a viable pregnancy (Morse & Dennerstein).Furthermore, it is suggested that these numbers may be on the increase (Bryant, 1990).Becoming a parent is generally assumed to be one of the fundamental transitions in adultlife. Throughout childhood and adolescence, the female socialization process is strongly gearedtoward potential motherhood (Maccoby & Jacklin, 1974; Russo, 1979). From the onset of themenstrual cycle, girls become aware of their body's readiness for pregnancy, and the fear ofbecoming pregnant prematurely is promoted as the primary prohibition to teenage sexuality(Hendricks, 1985). Many religious and sociocultural influences also effectively prescribemotherhood as the primary purpose of women (Deutsch, 1947; Russo, 1979). Girls and womensubsequently come to assume fertility and eventual parenthood as inevitable.Boys and men are also socialized to anticipate fatherhood as a valued role, although in lessdirect ways. While there are no childhood rituals specifically concerned with the role offatherhood, in many families a great deal of emphasis is placed upon the young man'sresponsibility, even obligation, to 'carry on the family name'. Erikson (1963) identifiedgenerativity, or the ability to pass on knowledge (and implicitly genetic material) as one of thefundamental and essential requisites for normal adult development. Further, a man's fertility isstrongly linked with his virility and masculinity (Pohlman, 1970). In many cultures, the morechildren produced in a marriage, particularly male children, the greater respect accorded to the man.In view of the high degree of importance placed upon child-bearing and rearing in North2Statement of the ProblemAmerican society and the inevitability with which these events are anticipated by both men andwomen, the discovery of infertility is frequently experienced as a "developmental crisis" (Kraft, etal., 1980, p.620). Indeed, the pattern of responses observed in infertile subjects over a variety ofstudies is similar in many ways to a 'crisis reaction', and numerous writers have adopted a crisismodel in examining the experience (Lalos, Lalos, Jacobsson & Von Schoultz, 1986; Menning,1980; Valentine, 1986). These researchers and clinicians have observed behavioral indicators ofshock, denial, anger, depression and loss of control in individuals and couples experiencinginfertility.Unlike a crisis, which is typically a sudden event or series of events, with a definitebeginning and end and a relatively brief duration, infertility may be an active issue for a couple foranywhere from eighteen months to several years. While viable pregnancies are achieved forbetween 50 and 60% of couples who seek medical assistance for infertility (Daniluk, 1988), forother infertile couples it may be difficult to identify a point at which the crisis is over. Coupleswho choose adoption or a child-free lifestyle may need to arbitrarily close the issue of infertilityand make a choice to move onward. Other couples may never make that choice and may continuepursuing pregnancy long after reasonable hope is exhausted.The term 'crisis' usually connotes some sort of a dramatic event, which occurs suddenlyand with no forewarning (Hopson, 1981). While infertility may in fact have a dramatic impact onthe lives of those affected, it is difficult to construe it as an 'event'. Rather, infertility can be morethoroughly understood when seen as a series of 'non-events', as each menstrual cycle passes,failing to culminate in the much-anticipated and hoped-for pregnancy. Except in rare cases, suchas when an emergency hysterectomy must be performed, the recognition that a problem exists islikely to be less a dramatic revelation, than a gradual dawning.Despite the high incidence of infertility and the importance of parenthood in the lives ofmen and women, infertiltiy continues to be viewed as a rare condition, both in popular thought andwithin the academic world. A review of more nearly two dozen texts concerning adultdevelopment revealed only a handful which even make a cursory mention of childlessness as an3Statement of the Problemalternative and none which refer to infertility. Individuals and couples enduring the experiencetend to feel marginalized and victimized by their condition. While medical advances have identifiedorganic correlates in as many as 90% of the cases of infertility, a large proportion of the academicresearch produced in the field to date has continued to focus on identifying the psychologicaletiology of infertility. Although numerous psychological symptoms have been found to correlatewith infertility, no progress has been made in discovering which factor or factors may play acausative role (Pantesco, 1986). The present study adopts an alternative view that infertility playsa causative role in a number of psychological symptoms. Infertility has been reported to have anegative intrapersonal and interpersonal impact. The factors which mediate this impact are ofparticular interest in this study.Schlossberg (1981) has developed a model of adult transition which may provide a morecomprehensive framework for understanding of the impact of infertility on the life of an individualadult. The model is based within a theoretical framework which views adult development as anongoing process of adapting, or not adapting, to psychosocial transitions. Transitions may be theresult of normative events such as first job, marriage or retirement, or non-normative events likesudden wealth or job loss, or may be triggered by crisis events such as family deaths or naturaldisasters.Schlossberg (1981) has identified a range of factors which may interact to influence orshape the short-term and long-term effects of the transition. These include characteristics of theevent, characteristics of the environment and characteristics of the individual. The present studyuses Schlossberg's model of psychosocial transitions as a framework for attempting to understandthe factors that serve to mediate the impact of infertility on men and women currently livingthrough the experience.The ModelSchlossberg (1981) has defined psychosocial transition as "an event or non-event (which)results in a change in assumptions about oneself and the world and thus requires a correspondingchange in one's behavior and relationships (and which) may provide both an opportunity for4Statement of the Problempsychological growth and a danger of psychological deterioration" (p. 5-6). The inclusion of 'non-events' or the "non-occurrence of anticipated events" (p.5) in this definition, makes Schlossberg'smodel particularly useful for understanding the impact of infertility. In this context, infertility isthe non -occurrence of the anticipated event of parenthood.Schlossberg (1981) suggests that adaptation to a psychosocial transition may be positive ornegative, with the potential for growth or deterioration. The flexibility of this definition affords anopportunity to utilize the model in examining the complexity of responses reported by couplesexperiencing infertility. Through popular usage, 'adaptation' implies a positive set of responseswhich function to integrate a change or development into one's life. Hopson (1981) suggests thatthis popular connotation of adaptation interferes with its usefulness in describing transitionoutcomes. He suggests that more clarity in the understanding of transitions outcomes may byachieved by replacing 'adaptation' with 'responses to transition' (p.37). This more generaldescriptor accomodates the diversity of possible responses to any change, which range on acontinuum from 'non-adaptive', through 'mere survival' and 'managing', to 'growth' (Hopson;Schlossberg). In the present study, 'responses to transition' will be used to describe the adaptive,non-adaptive and neutral ways individuals and couples behave while experiencing infertility andwill be assessed in two ways.Responses to the stress of infertility may be observed in a variety of emotional andbehavioral symptoms. Responses commonly reported by infertile individuals include depression,anger, confusion, fear, hypersensitivity, disorganization, distractability, moodiness, and obsessivebehaviors and thoughts (Menning, 1980; Valentine, 1986). The present study is interested in thedegree to which infertile men and women exhibit symptoms of distress, as well as in whether thereare differences in the type of symptoms reported which may be attributable to characteristics of thetransition and/or characteristics of the individual. Symptoms of distress will therefore bemeasured, using a self-report symptoms checklist.While symptoms of distress may be gauged as a measure of the emotional impact ofinfertility, to form a more complete picture of the range of responses to infertility it may also be5Statement of the Problemnecessary to assess the degree to which infertile men and women are adapting or adjusting to thetransition. As a lack of reported symptoms may not necessarily be indicative of positiveadaptation, a separate measure is used to assess the individual's level of adjustment to infertility.Schlossberg (1981) has identified three major groups of factors or variables which may bestudied to understand the impact of a particular event or non-event on an individual. The threecategories of factors identified include the following: the characteristics of the transition, whichinclude factors unique to the specific event or non-event; characteristics of the environment,involving elements of the environoment prior to, during and following the transition; andcharacteristics of the individual, including psychosocial factors unique to the individualexperiencing the transition (Schlossberg).According to the literature, support from family and from friends tends either to be non-existent or actually experienced as negative (Davis, 1987; La_los et al., 1986; Menning, 1980;Sandelowski & Jones, 1986). For infertile individuals, all three levels of interpersonal supportidentified by Schlossberg (1981); intimate relationships, the family unit and the network of friends,may be problematic. The extent of the difficulties associated with obtaining social support is ofsufficient complexity to warrant an independent investigation, which is beyond the scope of thepresent study. Based on the available research, the categories of particular interest in the presentstudy include the characteristics of the infertility transition and of the infertile individual.Characteristics of the T sitionIn recognition of the subjectivity of experiences, Schlossberg (1981) has identified sevencharacteristics of the transition, in terms of the way an individual perceives or defines theirexperience, which could affect the way he or she responds, including whether: it represents a gainor a loss, it is perceived as positive or negative, the perceived origin is an internal or an externalsource, it is on-time or off-time, the onset is perceived to be gradual or sudden, it is seen astemporary, permanent or of uncertain duration, and the degree of stress experienced.Among the most salient findings in recent literature on the perceptions of thoseexperiencing infertility is the issue of loss (Bowers, 1985; Sawatsky, 1981; Valentine, 1986;6Statement of the ProblemWoollett, 1985). There are many losses represented by infertility, including "loss of potentialchildren; loss of genetic continuity; loss of pregnancy, childbearing and breast-feeding experience;loss of a life goal; and loss of control over one's body" (Valentine, p.64.). It may be assumedtherefore, that for those individuals seeking to 'cure' or ameliorate their infertile status, infertilityinvariably represents a loss. Given the universality of this experience, it is assumed for thepurposes of the study that infertility represents a loss.The experience of infertility is almost universally perceived with negative affect. Despite acurrent trend toward childlessness as an active choice, this option is pursued by as few as 5% ofthe married population (Veevers, 1980). For the 95% majority of the married population whowish to have children, the inability to fulfill their expectations of biological parenthood is indeedregarded as negative. Thus the perception of infertility as negative is also assumed.Schlossberg (1981) suggests that transitions with a gradual onset are likely to be moreeasily adapted to than those which occur suddenly, because they may be anticipated and preparedfor. The onset of the infertility transition may be considered gradual, but it is seldom anticipated oreasy to prepare for. Although for a small minority of couples the diagnosis is swift, conclusiveand irreversible, as in a case of emergency hysterectomy (Menning, 1977), the majority of infertilecouples come to a full realization of their situation only gradually, as month after month passeswith no pregnancy. Even after the decision is made to seek medical intervention, which generallycan be received only after a year of unsuccessful attempts to conceive, it may be many moreweeks, months or even years before a conclusive diagnosis is made. Therefore, for the purposesof the study, a gradual onset is presupposed.Schlossberg (1981) suggests that individuals "adapt...more easily to transitions in whichthe source is internal" ( p.9). While it may appear to an observer that the source of infertility isinternal, within the very body of the individual, infertile people often perceive their condition asbeing imposed upon them. The removal of the ability to make the choice to have biologicalchildren means that, for infertile couples and individuals, the source of the infertility is oftenperceived to be external. Thus, for the purposes of the study, it is assumed that the source of the7Statement of the Problemtransition is external.The perception that infertility is imposed from an external source may be exaggerated if thecause of infertility is identified as a malfunction in the reproductive system of the marital partner.For this reason, the diagnosis received may be an important factor in understanding an individual'sresponse to infertility. Conversely, it may also be expected that the member of the couple in whomthe etiology of the infertility has been diagnosed may experience greater distress than an individualwho is not diagnosed as infertile, but who is married to an infertile person (Daniluk, 1988). Thesefactors will be measured, as individuals will be asked to indicate whether the diagnosis implies afemale factor, a male factor, a couple factor or an unknown factor as the cause of infertility in thecouple.Most couples perceive the duration of infertility as very uncertain, as a seemingly endlessseries of tests and treatments continues the cycle of hope and disappointment. Even after a cleardiagnosis is made, the efficacy of many of the treatment procedures remains uncertain (Halpern,1989; Leader, Taylor & Daniluk, 1984). Schlossberg (1981) notes that individuals who perceivethe disruptive phase of a transition to be neverending or of uncertain duration are likely toexperience higher levels of distress than are individuals who believe the changes to be permanentor temporary. The present study investigates this by including the individual's perception of theinfertility as temporary, permanent or uncertain as among the predictors of distress levels.In addition, the actual duration of the expereince of infertility may be an important factor inpredicting distress levels. Duration is measured by the length of time couples have been attemptingto conceive as well as the length of time since seeking medical attention.Timing is also an issue of particular significance to the infertility experience. Whether atransition is on-time or off-time may be seen within the context of both chronological andpsychological development. For those who make a transition 'off-time', either earlier or later thanthe norm, negative social and psychological consequences may be encountered as the individualmay be made to feel 'deviant'. Schlossberg (1981) notes that events such as getting married (and)having children...are linked in people's minds with age" ( p.9.). With the increasing trend for8Statement of the Problemcouples to postpone childbearing until careers and financial comforts are established, many chooseto begin a family when they are both psychologically and chronologically 'behind schedule'.Infertility may not, in fact, be discovered until the woman is nearing the end of what is generallyassumed to be the 'fertile' years. The pressure to succeed in finding a solution to the infertility isoften exacerbated by the inexorable ticking of the 'biological clock'. Thus the age of theindividual, particularly of the woman, may be an important factor to observe. As age is acharacteristic of the individual, this information is collected and analyzed with the second group offactors.For infertile couples, hope becomes a commodity of great importance. As long as theinfertility 'work-up' continues, couples often find themselves caught in a 'cycle of hope anddisappointment', measuring time by the woman's menstrual cycle (Davis, 1987; Kraft et al.,1980). For couples for whom a conclusive diagnosis cannot be made, the 10% to 20% whoseinfertility is of unknown cause, this cycle can be particularly tortuous. As Halpern (1989) notes,"infertile couples are vulnerable people, susceptible to hope however tentatively it is held outbefore them. Where others, learning that a particular treatment has a one-in-10 rate of success,understand that it fails 90 percent of the tithe, the infertile tend to focus exclusively on the fact thatit works 10 percent of the time" (p.148). Thus the degree of hope the individual maintains, asestimated by his or her perception of the chance of a successful outcome, is included as a factor inpredicting the amount of distress felt and the level of adjustment to infertility.Characteristics of the Individual The other group of predictive factors identified in Schlossberg's (1981) model which areincluded for investigation in the present study are the characteristics of the individual. The factorswhich may be useful in predicting or understanding an individual's responses to infertility include:psychosocial competence; gender and sex-role identification; age; physical health; race, ethnicorigin or cultural identification; socio-economic status; values, and; previous experience withtransitions of a similar nature.The construct of 'psychosocial competence' includes a positive self-attitude, a realistic9Statement of the Problemworld attitude and an active behavioral orientation (Schlossberg, 1981; Tyler, 1978). Positive self-attitudes may be described in terms of a sense of self-esteem and an internal locus of control orsense of self-responsibility. Individuals with positive and flexible self-concepts may be likely torespond more adaptively, and with less distress to any transition, than those who have rigid ornegative self-images (Schlossberg).One component of psychosocial competence is self-esteem. This has particular significancefor the experience of infertility, as the inability to fulfill the role of parent may constitute a seriousthreat to an individual's self-image. Infertility may also have a profound effect on the individual's'body-image', as many begin to see their bodies as defective and unattractive (Davis, 1987; Kraftet al., 1980). These negative feelings may spread to other aspects of self-concept, particularlysexual identity, with the physical malfunction coming to represent, in the individual's mind, all thatis wrong with them as a person. As noted by Adler & Boxley (1985) "men and women whoreport low levels of...self-esteem may be at a higher risk for problems associated with infertility"(p.278). Conversely, high self-esteem may help to moderate or 'buffer' the impact of infertility.The buffering effects of self-esteem have been cited by numerous authors (Adler & Boxley, 1985;Chiappone, 1984; Coopersmith, 1981; Sabatelli et al.1988). What is most salient, however, isthat individuals with high self-esteem and individuals with low self-esteem appear to respond toinfertility in different ways. It is the nature of these differences that the present study attempts toexplore as self-esteem is included as a predictor of distress levels in response to infertility.Another element of psychosocial competence may be described as an internal locus ofcontrol. Like self-esteem, the nature of the relationship between locus of control and infertility isunclear. Individuals who perceive themselves to be in control of the events that affect them tend torespond favorably to most life transitions (Schlossberg, 1981). However, when faced with theoverwhelming experience of 'loss of control' reported by infertile men and women (McCormick,1980), an internal locus of control and an active approach to life may be of little use. As such, itseems important to include locus of control in an examination of the factors that may mediate theimpact of infertility.10Statement of the ProblemA second characteristic cited by Schlossberg (1981), which may be important inunderstanding responses to transtions, is the gender of the individual. This is of particular interestin the study of the infertility transition. It may be expected that males and females will responddifferently to the experience of infertility. Infertile women have reported to greater feelings of lossand depression than men (Chiappone, 1984; Daniluk, 1988) as well as a tendency to assume the'blame' and feel guilt for the couple's infertility (Chiappone; Daniluk; Lalos et al., 1986; McEwan,Costello & Taylor, 1987). This may be largely a reflection of social beliefs which tend to seeinfertility as primarily a 'female problem' and hold the woman responsible for its solution(Menning, 1977; Pantesco, 1986). Women also tend to experience distress in response tostressors affecting the significant persons in their lives (Schlossberg, 1981), and may therefore'take on' the pain felt by an infertile husband. Alternatively, women have been shown to employa greater range and variety of coping mechanisms in response to stress (Chiappone, 1984),suggesting an advantage over men in their ability to reduce feelings of distress.Further, although men appear to respond with less intensity than women, it is clear thatmales do experience the negative impact of infertility. For men, infertility often engenders feelingsof humiliation and embarrassment, (Kraft et al., 1980; Valentine, 1986) depression (Feuer, 1983;Kedem, Mikulincer & Nathanson, 1990; Mahlstedt, 1985; Mazor, 1979; Walker, 1978) andanxiety (Kedem et al.). Many men associate the inability to impregnate a woman with sexualinadequacy and a failure to fulfil the male role (Kraft et al., 1980; Snarey et al., 1987).Clearly, the differences between men and women in response to infertiilty do not appear tobe a simple matter of more and less, but rather, it is expected that males and females may exhibitdifferences both in the level and the nature of their responses to infertility. These differences maybe apparent in the pattern of symptom and adjustment scores achieved.Another factor which may be as important as the individual's gender is the degree to whichhe or she identifies with traditional definitions of maleness and femaleness, or 'sex-roles'. Theindividual's sex-role identity may be an important factor in predicting his or her response toinfertility. The ability to reproduce and raise a family is intimately and inextricably connected to11Statement of the Problemboth psychological and social definitions of what it means to be a man or a woman. Many womenassimilate the pervasive sociocultural and interpersonal influences and come to view motherhood ascentral to their self-identity, as an integral "part of their biological and psychological makeup"(Frias & Wilson, 1985, p.43). Women who have strongly identified with traditional views ofwomanhood, and who define their value as women in "uterine terms, and (who) cannot choose tocomplete their image through achieving one or more pregnancies...feel stripped of their self-worth"(Hendricks, 1985, p.152). Thus a woman's identification with traditionally defined femininitymay be related to the level and type of distress she experiences in response to infertility.Similarly, men who identify with traditional views of manhood, and are unable to fulfilltheir role by producing a family to provide for and protect, may feel a threat to their identity asmales (Humphrey, 1977; MacNab, 1985; Mahlstedt, 1985). However, high masculinity hasbeen related to higher levels of self-esteem (Adler & Boxley, 1985). Thus the degree to which aman identifies with traditional sex-roles may also be important in predicting his responses toinfertility.As noted previously, the individual's age may may in an important factor in understandinghis or her responses to infertility. Older individuals may react differently to the experience ofinfertility than do younger persons. Age may be related to increased distress as, the closer theinfertile couple comes to the end of the women's reproductive years, the shorter is the timeremaining to find a successful resolution to infertility. At the same time, however, age may berelated to more effective coping strategies as older individuals may be expected to respond withgreater maturity. Older individuals may also be more likely to have previously encountereddifficult life experiences which may help to prepare them for facing infertility.Another factor, often related to age, as many couples delay attempts to reproduce until theyfeel financially secure, is socio-economic status. Individuals with higher levels of education maybe more likely to seek and obtain information regarding infertility, thereby increasing their feelingsof being in control of an uncontrollable situation. Thus it is expected that both age and socio-economic status, including income and education levels, may be related to the levels of distress and12Statement of the Problemadjustment reported by infertile individuals and will be measured.Race or ethno-cultural background may also be an important element in understanding theimpact of infertility. While virtually all racial and cultural groups value having children, somegroups place a stronger emphasis on reproduction as the central theme of marriage (Pohlman,1970). Therefore, information on race will be collected, as it may be expected that the cultural orethnic background of the individual may be a factor in mediating the impact of infertility, withmembers of some ethnic groups experiencing better adjustment and lower distress than members ofother groups.Similarly, religious affiliation, and the degree to which an individual identifies with theteachings and values of their chosen religion, may also represent a significant cause of strain forthe individual experiencing infertility. There may be pressure from the religious community toreproduce, to 'sanctify' the marriage, while simultaneously proscribing the use of medicalinterventions, many of which are seen as morally wrong (McEwan et al., 1987; Menning, 1982).McEwan et al. found that women who followed non-Protestant religions reported greater distressthan Protestant women. Alternatively, Graham, Thompson, Estrada and Yonekura (1987)reported that highly religious women who blamed God for a miscarriage reported lower distressthan less religious women who miscarried. Thus, an individual's religion and religiosity may playa role in either exacerbating or reducing the distress engendered by the experience of infertility andwill be included for measurement.In addition, the general health of the individual, both prior to the discovery of infertility andduring the time in which it is an active issue, may influence the individual's response to infertility.An individual who has been unhealthy for some time, or who is experiencing other health-relatedcrises concurrently with infertility, may fmd it difficult to rally the resources necessary toeffectively cope with infertility. Conversely, an individual who has enjoyed robust health prior tothe onset of infertility may be more able to remain optimistic of their chances to achieve apregnancy. Thus, the question of whether the individual's general health is poor, fair, good orexcellent may be useful in predicting and understanding his or her responses to infertility.13Statement of the ProblemAs suggested above, previous exposure to similar experiences may also influence anindividual's ability to respond adaptively to infertility. Schlossberg (1981) suggests thatindividuals who have undergone similar transitions in the past will likely be better equipped to dealeffectively with the present experience, especially if they were able to derive some positiveoutcome from the previous experience. An individual who, for example, had previouslyexperienced a family death, may have learned important coping strategies for dealing with loss, aswell as having gained insight and greater closeness with other family members. Another individualundergoing the same type of experience, however, may have coped unsuccessfully with their lossand subsequently suffered continued anguish. Therefore, knowing whether an individual haspreviously experienced transitions of a similar nature may be important in predicting his or hersuccess in responding to infertility and is included in the investigation.Purpose of the Study Each of the characteristics of the individual and the characteristics of the transitiondiscussed above may play a role in influencing the individual's pattern of responding to theexperience of infertility. Eleven characteristics of the individual, including sex, age, socio-economic status, sex-role orientation, self-esteem level, locus of control, ethnic background (race),religion, general health and previous similar experience, as well as four characteristics of thetransition, including length of time attempting to conceive, diagnosis received, perceived chance ofsuccess and perceived outcome have been used as predictor variables. Criterion variables includenine elements or symptoms of distress and a measure of adjustment to infertility. It is notexpected that a single factor will emerge as a dominant predictor of response patterns. Rather, thepurpose of the present study is to identify a combination or group of factors which covary in sucha way as to create a picture or profile of individuals who are at greater risk of experiencing highlevels of distress in response to the experience of infertility, as well as a profile of those individualswho are at lower risk of distress.Furthermore, the need for counselling professionals who are cognizant of the issues facedby infertile couples and individuals is becoming increasing apparent (Daniluk, Leader and Taylor,14Statement of the Problem1987; Seibel & Taymor, 1982). A second purpose of the present study is to increase the level ofrecognition and understanding within the counselling profession, of both the nature and the extentof the impact of infertility on those individuals and couples affected. In an effort to contribute tothe growing body of counselling literature which seeks to understand the nature and impact ofinfertility as a significant life event, it is hoped that this study will provide valuable information forcounsellors, to be used as a guide for assessing risk factors as well as potential sources ofstrength, as they provide support for couples and individuals enduring the transition of infertility.Assumptions. Limitations and DelimitationsAssumptions The most fundamental assumption underlying the present study is in regards to the natureof causality. While it is beyond the capacity of a correlational research design to suggest thatinfertility 'causes' the various psychological symptoms associated with the experience, the authorrejects the notion that psychological symptoms 'cause' infertility. This latter assumption hasmotivated a significant body of research, with varied, often contradictory findings (Noyes &Chapnick, 1964; Pantesco, 1986). The present study approaches the question from afundamentally different theoretical perspective and suggests that the question of whether infertility'causes' psychological symptoms, or the reverse, is not relevant. Rather, the present studyrepresents an attempt to understand the nature of the relationship between characteristics of theindividual and of the infertility experience and the patterns of response to a complex andprofoundly distressing human event.LimitationsThere are a few important limitations to the present study which must be addressed. Thelimitations are consistent with those inherent in survey research. The representativeness of thesample is the most important concern as this affects the ability to generalize the results of the study.Three important concerns may be raised regarding the representativeness of the sample.Due to the nature of the research question, the sample has not been selected randomly and is, ofnecessity, a 'sample of convenience', restricted to a specialized population. The population the15Statement of the Problemsample is recruited from consists of infertile adults who are seeking medical support for infertility-related concerns. This is the population the results may logically be generalized to.Two other concerns may be raised regarding the extent to which the sample isrepresentative of infertile adults in demographic terms. The sample is predominantly (84%)whiteand anglophone, with only minimal representation from other racial and ethnic groups. There areconsiderable restrictions, therefore, in the ability to generalize the results of this study tomulticultural populations. In addition, there is some concern regarding the recruitment of thesample from a single clinic located in an urban area. Foothills Hospital's central location makes itthe primary venue for infertility services in southern Alberta, serving both urban and ruralpopulations. It may be argued, therefore, that the sample population may be representative ofwhite, anglophone, rural and urban infertile adults who seek expert medical attention to addresstheir concerns.Another important concern is with the validity of responses collected on self-reportmeasures. With this form of instrument there is always some difficulty in obtaining candidresponses which are unaffected by social desirability factors. Measures were taken to minimizethese effects. Subjects were assured anonymity prior to consenting to participate and were furtherassured that medical and other treatments received in the clinic were in no way to be influenced bytheir participation in the study. In addition, the importance of providing uncensored responses, tohelp in developing a means of support for other people experiencing infertility, was explained andstressed during these interviews. Nonetheless, it is likely that, despite the assurances andencouragements, the self-consciousness engendered by the act of completing self-report measuresmay have caused some respondents to unintentionally moderate their responses, thus potentiallyaffecting the validity of responses.While the use of survey and correlational design in the present research project serves toplace minor limitations on the researcher's ability to control elements of the process of datacollection, these limitations are not uncommon in research designs of this kind. Measures havebeen taken to address each of these concerns in the present study.16Statement of the ProblemAnother area for concern is in the use of a single trial method of sampling. The infertilitytransition may take many months or years to complete and may involve many changes in mood andaffect. While the focus of the study is primarily on the mediating factors, which may be assumedto be constant, the level of functioning at the time of assessment may not be representative of theindividual's functioning throughout the experience and may limit the validity of the findings.However, the results may be representative of a random selection of infertile adults at a given time.Finally, there are limitations inherent in the ability to accurately measure variables used inthe study. Of particular concern is the measurement of the construct of 'psychosocial competence',(Schlossberg, 1981; Tyler 1978), a complex construct including a variety of attitudinal andbehavioral components. The measures used in the present study represent an attempt toapproximate two of the three primary components of psychosocial competence, 'positive self-attitudes' (self-esteem) and 'realistic world attitudes' (locus of control). There is no corollarymeasure to assess the construct's third primary component of an 'active behavioral orientation'.As no appropriate measure was available for assessment of an active behavioral orientation, itwould be necessary to create such an instrument. Such an exercise may comprise the focus of aseparate study, and was therefore deemed to be beyond the scope of the present study.DelimitationsSchlossberg's (1981) model of transitions in adult development has been used in thepresent study as a guide for identifying and selecting appropriate variables for study in theinvestigation of individual differences in response to infertility. Although Schlossberg identifiedthree sets of factors which may be viewed as significant in mediating the individual's ability toadapt to a transition, including characteristics of the transition, characteristics of the environmentand characteristics of the individual, the present study selected only the characteristics of thetransition and the characteristics of the individual for investigation.Although characteristics of the environment were not directly studied, these factors werenot ignored and were, in fact, largely controlled for. Two elements of the environment werecontrolled through the selection process. Physical surroundings, including such things as climate17Statement of the Problemand geography, were consistent across the sample, as subjects were recruited from a singlegeographical region within the term of one month. The availability of institutional supports wasalso comparable for all subjects, as each was receiving specialized medical support at the time ofstudy.The third element of the environment identified by Schlossberg is interpersonal support.The availability and effectiveness of interpersonal support is an area of specific relevance to a studyof the impact of infertility and has, in fact, generated a notable collection of research efforts. Theresults of these studies consistently suggest that interpersonal support is problematic for infertileindividuals and couples, often appearing to increase levels of distress experienced (Davis, 1987;Lalos et al., 1986; Menning, 1980; Sandelowski & Jones, 1986). As these results appear to behighly consistent, ineffective interpersonal support is assumed in the present study.A final word must be addressed to the issue of recruiting and the resulting number ofsubjects surveyed. An initial design included the use of two separate sites for recruitment ofsubjects, including the Infertility Clinic at Foothills Hospital in Calgary as well as the clinic in theDepartment of Obstetrics and Gynaecology at Grace Hospital in Vancouver. This plan wasdevised primarily in response to concerns that an insufficient number of subjects may be recruitedfrom a single clinic. However, in less than one month of data collection, more than two-thirds(106) of the overall target number of subjects (150) had been contacted. Furthermore, the rate ofreturn for completed questionnaires was encouraging (approximately 70%). A decision was madeto refrain from further data collection, thereby including some control over environmental factorsby recruiting from a single geographical location.Although a larger sample size would undoubtedly provide more complete information, aswell as enhancing the validity of the findings, a review of the available data suggests that thesample is representative of a range of scores on many of the variables. Moreover, it must be notedthat the present study is exploratory in nature and seeks primarily to understand whether there aredifferences between individuals in ways of responding to infertility. Any patterns or trendssuggested by the results of the present study may be understood as indicative of directions forfuture research.18Review of the LiteratureCRaIERIWQReview of the LiteratureIntroduction This chapter will present a review of the literature relevant to the present study's inquiriesregarding psychological and emotional responses to infertility. Following a brief summary of thehistory of research regarding the relationship of infertility to psychological factors, the chapter willfocus on studies which examine the psychological impact of infertility. The chapter will concludewith a review of the literature seeking to identify personal and situational factors which mediate orpredict the nature and intensity of the impact of infertility on men and women.Historical Approach to Psychology and InfertilityHistorically, infertility research is characterized by attempts to determine the causes andpossible cures or treatments for the condition of infertility. Within the past two decades, greatstrides have been made in the medical sector of the field in discovering congenital and trauma-based physical irregularities which correlate with and contribute to repeated difficulties inreproduction. From approximately 50% of cases which were physically explainable thirty yearsago, currently up to 90% of cases can be traced to a physical malfunction in either the male orfemale (Leader & Taylor, 1984). In consideration of this rapid expansion of medicalunderstanding of the factors affecting fertility and the concurrent rapid progress in medicalmicrotechnology, it is not inconceivable that twenty more years, if not fewer, will bring theanswers to the puzzles of the remaining 10% of currently 'unexplainable' instances of infertility.Not surpisingly, considerable attention has been focussed on the issue of unexplainedinfertility. In a recent paper, McBain and Pepperell (1987) outlined a number of possibleexplanations for 'unexplained infertility'and suggest that further investigations may soon result inexplanations, if not solutions, for those cases.A large portion of the research attention is aimed however, not at discovering the organicsource and subsequent treatment for these currently unexplained cases of infertility, but at seekingsupport for the common assumption that psychological or emotional 'blocks' within the individual19Review of the Literatureplay a causative role in impeding reproduction. The present study rejects the idea of a causativelink between psychological factors and infertility. Two reviews of this literature follow, each ofwhich concludes that a search for a psychogenic cause of infertility appears to be futile, andsuggests that the direction of any link may in fact be the reverse (Noyes & Chapnick, 1964;Pantesco, 1986).Noyes and Chapnick (1964) reviewed 75 research articles focussing on the relationshipbetween psychology and infertility, which were published between 1939 and 1963. Utilizing afive-item evaluation format, the authors, each representing a separate discipline (one medical, theother psychological), independently rated each paper on a scale of 0 to 2 on each of the followingdimensions: a clearly stated hypothesis regarding the causative relationship of psychologic factorsto infertility; objectivity of methods and materials for measurement of variables; statements orevidence suggesting that psychologically oriented treatments may be palliative to a condition ofinfertility; statisical support for a conclusion that psychological factors affect infertility, and; thecontribution made by the article to the furtherance of knowledge in the field. There was a fairlyhigh degree of agreement (r= 0.64) between reviewer ratings on each paper.Out of twenty possible points for each article (2 points x 5 diminsions x 2 raters), theaverage score achieved by the 75 papers was 8.6, indicating that the majority of articlesapproaching the question of psychogenic bases for infertility failed to meet even the most basicstandards of experimental rigor, as measured on the rating scale. Interestingly, the three highestscoring papers (two achieving scores of 17, one with 18) described well-controlled studies whichprovided evidence to refute the popular belief that adoption increases fertility.Noyes and Chapnick (1964) found that "many authors took it as axiomatic that psychicfactors influence infertility, and that psychogenic infertility may be diagnosed by the exclusion oforganic factors" ( p.553). Moreover, the large number of psychic factors cited as causative ofinfertility suggests researcher bias, as the cited research "certainly contains enough variety tosupport almost any preconceived opinion" (p.553). Within the 75 articles, 4.0 different factorswere listed and many articles cited multiple factors. Largely because of the "vagueness of20Review of the Literaturehypotheses"(p.553) found in most of the articles reviewed, there was some discrepancy betweenthe two reviewers in recording the factors indicated by each author. While the two researchersagreed on 181 cases of specific factors being cited, each reviewer recorded a number of caseswhich were not recorded by the other, for a total of 487 recorded instances of psychogenic factorsbeing cited as causes of infertility. Despite the abundance of possibilities, "this analysis hasyielded no evidence that specific psychologic factors can affect fertility"(p.554).More recently, Pantesco (1986) critically reviewed a sample of thirty-one research articlespublished between 1942 and 1983 and found that the majority sought to establish the existence ofpsychogenic causes of infertility in women. He noted that, until the early 1970's, the emphasis inthe literature was predominantly on identifying psychodynamic reasons for the inhibition ofpregnancy in women. These included such constructs as the following: masculine-aggressivepersonality, feminine immature personality, functional derangements, anxiety about one's femininerole, unconscious rejection of pregnancy, and hostility (to mother or to husband); many of thesame constructs recorded by Noyes and Chapnick (1964). Pantesco concluded that a "biasedemphasis on women's physical and emotional culpability" (p.733) has, until recently, coloured theapproach to infertility research.An important aspect of the sexist bias inherent in the older infertility research lay in the factthat the overwhelming majority of studies focussed exclusively on women as source as well as theprimary victim of infertility. Two-thirds of the thirty-one studies reviewed by Pantesco focussedexclusively on identifying psychopathology and psychosomatic disorders in infertile women. Lessthan one-third of the articles reported observations of both members of the couple. Only one studyfocussed exclusively on male subjects. Pantesco noted that, while recent researchers haveacknowledged the importance of studying males as important elements in the "system of thecouple" (p.734), the inclusion of men as subjects of study remains infrequent. He also noted,however, that men's restricted availability for research and unwillingness to participate constitute amajor obstacle to rectifying this imbalance.Pantesco's review included a critical look at methodological issues in research relating21Review of the Literaturepsychogenic factors to infertility, and found much of it problematic. Like Noyes and Chapnick(1964) he found a body of research characterized by vaguely stated hypotheses, loosely definedvariables, small sample sizes, reliance on nonstandardized measures, poorly analyzed data and areliance on assumptions in place of evidence. Both reviews also noted the lack of communicationbetween researchers in the field. The result has been a body of literature with often contradictoryand largely inconclusive findings regarding psychogenic causes of infertility (Noyes & Chapnick;Pantesco).While almost half a century of research aimed at seeking psychogenic causes tounexplained infertility has been singularly unsuccessful, the belief in the existence of such arelationship remains strong in popular mythology and such beliefs continue to inspire researchefforts into the question (see Domar, Seibel & Benson, 1990). While no infertility research has yetshown a priori psychological symptomatology, to support a claim for causation, a number ofpsychological symptoms have been found to be associated with infertility. Depression, anxiety,obsessive-compulsive behavior and feelings of guilt have all been observed in subjectsexperiencing infertility (Daniluk, 1988; Lalos et al., 1986; Seibel & Taymor, 1982; Walker, 1978).Among these symptoms, depression has been most consistently reported.In light of the inconclusive nature of research seeking a psychological cause for infertility,an alternative explanation is warranted to account for the prevalence of these various psychologicalsymptoms noted among infertile individuals. The present study adopts the view thatpsychological symptoms found to correlate with infertility can better be understood as the effects,rather than the cause, of a profoundly distressing developmental crisis.Impact of Infertility Much of the early exploratory literature describing the psychological impact of infertilityconsists of anecdotal reports from infertility support group meetings as well as interviewsconducted by social workers, physicians and nurses working with infertile couples (Daniels,Gunby, Legge, Williams & Wynn-Williams, 1984; Kraft, et al., 1980; Menning, 1980;Menning, 1982). Although these studies lack the rigor of experimental methodology, they have22Review of the Literatureprovided more recent researchers with a rich source of information on the impact of infertility. Ahandful of studies have utilized interview methods with infertile subjects in formal attempts toexplore the impact of the experience in an in-depth manner. The following studies arerepresentative of the scope and nature of this research approach.Using a structured interview format, Valentine (1986) sought to identify elements of theemotional impact of infertility on married couples. Twenty-six subjects aged 25 to 38, includingtwelve couples and two women, took part in a two hour semi-structured interview designed toencourage in-depth examination of the individual's emotional responses and coping strategiesassociated with infertility. Issues and concerns raised were reported in terms of five main topics orthemes, including emotional impact, crisis, loss, multiple stressors and coping strategies.In describing the emotional impact of infertility, subjects reported feelings of "sadness,depression, anger, confusion, desperation, hurt, fear, embarrassment, humiliation,disappointment, unfairness and unfulfillment..(as well as)...reactions such as disorganization,distractability, exhaustion and fatigue, moodiness, unpredicatability and obsessive behaviors andthoughts" (Valentine, 1986, p. 63).Other themes identified by Valentine (1986) included the prevalence of feelings of loss, forexample "loss of potential children; loss of genetic continuity; loss of pregnancy, childbearing andbreast-feeding experiences; loss of a life goal; and loss of control over one's body."(p. 64).Subjects also identified numerous sources of stress, including intrusive medical practices and theinsensitivity and ignorance of family and friends, as well as the marital relationship. Valentine alsodescribes the various coping strategies commonly reported by infertile interview subjects,including becoming 'obsessed' with infertility, avoiding contact with parents or pregnant friendsand seeking support from family, friends and infertility support groups.Unfortunately, the usefulness of these results is limited due to some fairly importantmethodological problems. The sample is very small and is skewed toward upper-middle classwhites, making generalization of the results to other populations difficult. More seriously,however, no mention is made of the method by which the reported themes were developed, leaving23Review of the Literaturethe impression that no systematic approach was employed. The study is also marred by asomewhat confused organization and theoretical approach. Of the five topics around which thebody of the article is organized, only the four discussed above represent elements drawn from thecontent of the interviews. The fifth topic is a discussion of the crisis model as it applies to theexperience of infertility. Although this appears to be a theoretical model, it is not identified assuch, but is instead included with the results. In fact, no theoretical basis is stated for the research.These concerns represent significant flaws in Valentine's (1986) study and makegeneralization of the results tenuous. The descriptions of emotional responses, such as sadness,depression, anger, despair, disappointment and obsessive thoughts, as well as the many forms ofloss experienced by infertile couples are supportive of clinical findings (Daniels et al., 1984; Kraftet al., 1980; Menning,1980) . Thus, although flawed, Valentine's study supplements andsupports the literature describing the serious emotional impact of the experience of infertility.Utilizing similar research strategies, Woollett (1985) approached the question of howinfertile individuals cope with the impact of infertility. Subjects included forty-two females andeight males, with primary or secondary infertility. Employing a semi-structured interview format ,Woollett focussed on the individual's feelings and actions in response to their infertility as well ason the impact of the experience on their relationships with others. Four primary issues or themeswere raised by a majority of interview subjects.Infertility represented a major disruption in an individual's life and prompted attempts toregain control. All subjects sought medical help, which initially provided a sense of control. Thisstrategy also provided a means for subjects to redefine their goals and expectations. Manysubjects, however, reported that medical investigations represented a loss of control, as medicalpersonnel virtually took over their lives, dictating the scheduling of monthly appointments andeven sexual intercourse.Interview subjects reported seeking ways to understand their infertility and often became'infertility experts'. This strategy appeared most successful in reducing stress in cases whereresolutions were relatively swift. Although many of the interviewees were highly knowledgeable24Review of the Literatureabout the procedures and investigations employed, many appeared highly optimistic regarding theirchances of successful conception, despite relatively low success rates of many of the procedures(Woollett, 1985).Subjects unanimously reported contending with negative images, held by themselves andothers, associated with infertility. Many women and most of the men appeared to perceive theirdifficulties as evidence of sexual inadequacy. Several subjects reportedly generalized their feelingsof incompetence to include a sense of failure in interpersonal, intrapersonal and work skills. Someinterview subjects appeared to deal with negative feelings by denying infertility, despite ongoinginfertility investigations. As Woollen (1985) notes "strategies of denial seemed to be more readilyavailable to men than women " (p.479). Finally, a major issue identified by the subjects ofWoollett's study was the experience of coping with the many losses associated with infertility.In addition, subjects identified a variety of strategies for coping with infertility. Aside fromthose already mentioned, which included seeking medical help, redefining the problem in medicalterms, becoming infertility experts and denial of infertility, many subjects attempted to seeksupport from friends and family. Like the subjects in Valentine's (1986) study, however, many ofWoollett's (1985) subjects found it diffiicult to obtain helpful support from others because of theirlack of understanding or insensitivity. As a result, many subjects reported feelings of isolation andhaving increased demands placed on the marriage to meet emotional needs, creating an additionalstrain on the relationship.Some subjects reported making attempts to create positive self-images, redefining lifegoals with regards to childbearing and parenting and seeking new ways to meet these needs.Woollett (1985) indicates, however, that these strategies were seldom pursued with enough vigorto operate as successful coping mechanisms. Woollen concludes that the primary methods utilizedfor coping with infertility tend to be focussed on the search for a medical solution to the problem.While this approach is successful in a majority of cases, Woollen suggests that an over-reliance onthis approach may result in a tendency to avoid or ignore alternative strategies and solutions.The methodological flaws in this study are similar to those seen in Valentine (1986).25Review of the LiteratureAlthough Woollett's (1985) sample is larger (50 individuals), the very low representation of males(8), renders any comments regarding the results from this group highly tentative. Furthermore, aswith Valentine, no theoretical or methodological models were described, suggesting none wereutilized.This study and the previous one must be regarded as exploratory and as such, they are notwithout value. The absence of experimental rigor in these studies and others of their kind hasallowed the latitude to explore the issues and concerns raised by infertile couples with a depth andbreadth not usually possible in most controlled studies. Research of this kind provides a richsource of information and direction for those wishing to examine the impact of infertility in morecontrolled settings, using standardized measures and methodology. Indeed, the following studiesrepresent a growing body of research using structured formats and measurements to address anumber of questions regarding the impact of infertility .Sandelowski and Pollock (1986) report on a well-designed phenomenological study aimedat discovering the 'meaning of infertility' to women enduring the experience. Forty-eight womenwho were currently infertile were interviewed by one of the two primary researchers. The first 22interviews were conducted in subject's homes with women receiving medical attention from privatephysicians. These interviews were unstructured and focussed on the general topic of "what it'slike not to be able to have a baby when you want to" (p.140). Using 'phenomenal analysis', theinformation gathered from these interviews was systematically analyzed for dominant and recurrentthemes. Second interviews were then conducted with 20 of these women as well as four morewomen recruited from private physicians, to validate and further refine the themes. At this time, asecond sample of 22 women was recruited from a public infertility clinic for the 'medicallyindigent'. Structured interviews were conducted with these women to validate the themes.Three main themes were identified in the women's descriptions of their experience ofinfertility. The most commonly identified theme was 'ambiguity', a feeling of being "'in limbo,''on hold', of 'dangling', and living in a 'gray area' (p.142). The ambiguity theme represented acollection of similar feelings and experiences reported by almost 94% of respondents. Elements26Review of the Literatureof the ambiguity expressed by the majority of women include a sense of uncertainty regarding thecauses or reasons for their infertility as well as feelings of ambivalence toward medical personnel.Between 12% and 19% of subjects expressed some of the following feelings of ambiguity:confusion and frustration regarding life goals and plans; lack of confidence in ability to cam/ apregnancy successfully; discomfort and ambivalence about the safety and effectiveness of themedical procedures used suspicion and uncertainty regarding own past and future fertility, and;insecurity about the amount of control they have in their lives.A second theme identified was 'temporality', described as "a heightened consciousness ofchronological and biological time" (p.143). The elements of the temporality theme expressed bymost subjects included: a concern with time limits repreatedly being set and reset; frustration overwasted time or time 'running out; time-consuming rituals and the need to follow them accordingto a strict schedule ; awareness of time marked by menstrual cycles; the need to continually plan,wait and review; the delay of other plans contingent on the timing of childbearing; and for a few,a sense of time being slowed.The third theme these researchers identified in the experiences of infertile women was'otherness', or a "feeling or separation and deviance" (p.144). The major elements of the'otherness' theme were the following: a preoccupation with making comparisons between self andother women; a feeling of being unjustly 'singled out' for their fate; a sense of being estranged orexcluded by others; a belief that other women, including fertile women as well as formerly infertilewomen, cannot understand how they feel. A few of the women interviewed expressed theirfeelings of 'otherness' as a belief they were somehow defective.Efforts were made to use systematic procedures and controls in this study. To increase thegeneralizability of the findings from the original sample of volunteers, who were predominantlywhite and middle class (75% of this sample had average family yearly incomes over $36000, 64%had university or technical training), the researchers sought a socioeconomically different group tocorroborate their thematic findings. Of the second group of 22 women, 90% were black, over85% had an average family yearly income of below $36000, only one had university or technical27Review of the Literaturetraining and 27% had not completed high school. Although the inclusion of these two disparategroups demonstrates an effort to be more fully representative of North American women, there isevidence that these two groups were treated differently. Interviews with the first group lasted fromtwo to four hours, as compared with interviews as short as thirty minutes with the second group.Several differences were found in the experiences of these two groups of women, with the clinicgroup providing significantly fewer examples of virtually all elements of the themes than theprivate practice group. Whether this contributed to, or is a result of, the shorter interview periods,is unclear.Although no statistical comparisons were performed, as the study was not designed toaddress any questions of contrast, the researchers suggest that there may be real differences in theway these two groups of women interviewed perceived their infertility experiences. The poorerwomen appeared less likely to express feelings of ambiguity, temporality and otherness in regardsto infertility specifically, perhaps because of being relatively familiar with these experience ingeneral, already having an "acquaintance with doom and fate...(and a)... well-developed sense ofseparation from mainstream American life" (p.144).It is important to note that, although no attempt was made to quantify the differencesthrough statistical comparisons, these researchers suggest that the way an individual womanexperiences infertility may be, in part, a function of her socioeconomic status. In other words,they suggest that socioeconomic status may be a mediating factor in the impact of infertility, suchthat women with a lower socioeconomic status appear to actually report fewer stressful experiencesassociated with infertility than women with higher socioeconomic status. Although thesedifferences may be largely reflective of the differences in the format, content and even the settingsof the interviews conducted with the two groups, the findings nevertheless point to the need forfurther investigation of the effects of socioeconomic status on men's and women's experience ofinfertility.Using the same data collected from the forty-eight women interviewed by Sandelowski andPollock (1986), Sandelowski and Jones (1986) identified a second thematic structure. After28Review of the Literatureexamining the structure and content of the interactions related by interview subjects, theseresearchers suggested that coersion and rejection characterize the social exchanges of infertilewomen.Coersive interaction were identified by many infertile women, who described that theyoften felt forced to explain their childlessness to family, friends and even strangers, who askedquestions which were perceived as intrusive, pushy and overly personal. Several women alsoreported feeling forced to 'put on a happy face', to avoid alienating or offending others with theirnegative feelings. Many reported feeling forced to control the expression of their pain andfrustration, in recognition that friends and spouses quickly tired of hearing about it. Women alsodescribed the effects of their infertility on others, reporting that family and friends habituallywithheld information from them and avoided talk related to pregnancies in their company, makingthem feel 'left out' and 'different'.Interactions wherein infertile women openly or privately rejected the advice and supportoffered by others comprised the second social pattern identified. Infertile women describeddeveloping a covert set of rules relating to who could give advice and support and what kind ofadvice was acceptable. Believing that only those who have gone through the same experience, orone very similar, could possibly understand their feelings, many women tended to reject anyadvice or support from 'normals', perceiving much of it as worthless or offensive. Moreover, thewomen appeared to divide the world into separate spheres, one containing the 'sisterhood' ofinfertile women, with everyone else, even formerly infertile women, occupying the second sphere.The primary weakness of this study, as suggested above, lies in the method by which thesamples were chosen and used. Although an effort was made to promote generalizability of thefindings to a more diverse population, the primary thematic findings of this and the former studyappear to be predominantly reflective of the experience of white middle class infertile women, withthe information gathered from the poor and black women being used primarily to support, ratherthan expand, the themes. Despite this limitation, these two studies provide a comprehensive and in.depth picture of the emotional and psychological turmoil experienced by many infertile women.29Review of the LiteratureAn early study by Wiehe (1976) focussed on how individuals "psychologically react totheir infertility" (p. 863) and how they handle their reactions. Twenty-two couples, who hadreportedly been aware of their infertility for two to six months and were described as having'unsuccessfully sought medical attention for infertility', were recruited from among the applicantsto a private adoption agency in the U.S.Two self-report pencil and paper surveys were mailed to subjects. The primary measurewas a researcher-developed version of the Semantic Differential, designed to reflect attitudestoward specific elements of the experience of infertility. A second measure consisted of scalesmeasuring aspects of personality and adjustment.The mean score for infertile subjects on the Semantic Differential was 4.5 on a scale of oneto seven, indicating a neutral to somewhat positive attitude toward infertility. These scores werecompared with those of the personal adjustment scales, resulting in some significant correlations.Subjects who indicated more positive attitudes toward aspects of infertility tended to score high indefensiveness and also tended to score low on the self-awareness, suggesting that individuals whohave relatively poor self-awareness and who tend to be more defensive in their approach to self-perceptions are less likely to report perceiving infertility in a negative light.The results of the study indicate the surprising fmding that some infertile subjects hold aneutral attitude toward elements of the infertility experience. As this finding appears to be contraryto expectations, based on the results of many of the studies previously cited, some attempt atexplanation is warranted. Wiehe (1976) offers three interpretations of his result. First, hesuggests that response bias to the Semantic Differential may have obscured subjects' true attitudes.He dismisses this possibility because of the measure's 'unobtrusive' qualities, and becausesubjects were assured that their responses would not affect their adoption privileges. It is possible,however, that, despite such assurances, couples in the process of application and adjudication foradoption may have felt pressured to avoid any appearances of negativity. As noted elsewhere"adoption workers expect...(applicants)...to demonstrate that they had resolved their feelings abouttheir infertility" (Valentine, 1986, p.66).30Review of the LiteratureWiehe continues in his explanation of his findings by discrediting the results of earlierstudies which indicated that depression and disappointment were the reactions to infertility, andthat these reactions were readily apparent to both observers and to infertile subjects. Regardless ofpossible methodological flaws in the two studies he cites, substantial evidence of depression anddisappointment in response to infertility have been found repeatedly since the publication ofWiehe's report (Daniluk, 1988; Kedem et al. 1990; Feuer, 1983; Menning, 1980; Valentine,1986; Woollett, 1985).The third and most compelling explanation offered by Wiehe (1976) for the surprisinglyneutral attitude toward infertility expressed by the subjects in his study is suggested by the fact thatthis sample had been aware of their infertility for between two and six months. Wiehe suggeststhat these subjects, having only recently learned of their infertility and having not yet achievedparenthood through adoption, may have been in a period of denial of their feelings. He suggeststhat the couples represented in the other studies cited, who had been dealing with infertility for twoto ten years and had either successfully adopted or had made an "adjustment ..to non-parenthood"(p. 866) were more able, from a 'safe distance', to acknowledge their negative feelings regardinginfertility. This explanation is supported by the fmding that a positive evaluation of infertility wasrelated to poor self-awareness and high defensiveness.An alternative explanation for the unexpected results, not identified by Wiehe, is that thesample of infertile subjects recruited for his study represented a unique sub-population withininfertile people and was not therefore representative of infertile individuals in general. The samplewas drawn from the list of applicants for an adoption agency. It would be reasonable to expectthat most couples seek to adopt only after having exhausted all hope of medical intervention inachieving a pregnancy, a process which takes many months and often years to complete. In fact,the majority of infertile couples seeking interventions, both medical and adoptive, have been awareof their infertility for a minimum of one year. Yet the sample in Wiehe's (1976) study reportedlyhad been aware of their infertiilty for only two to six months and were already seeking adoption.This fact alone may qualify this group as a distinct sub-group.31Review of the LiteratureWhether any of these explanations is valid is impossible to ascertain, as no information onthis sample, other than that already reported, is provided. What is clear is that these results are notconsistent with the majority of research findings, which indicate that infertility is an intensely feltand predominantly negative experience. The following study describes some of the negativeelements of infertility.Bell (1981) conducted an investigation into the 'psychological adjustment' of infertile menand women. This researcher recruited twenty couples attending an infertility clinic withpresentations of primary infertility. One group of ten couples were seeking treatment for infertilityfor the first time. A second group of ten couples had received diagnoses and had been undergoingtreatment for some time. Interviews were conducted separately with each of the forty subjects andwere designed to elicit responses regarding feelings about infertility, as well as to clinically assesslevels of anxiety, depression, as well as the individuals' social, sexual and marital adjustment.Each subject also completed questionnaires measuring sexual motivation, attitude to marriage,social adjustment, anxiety and depression.Descriptive data presented appear to indicate that female subjects reported higher levels ofanxiety and depression than did male subjects, but no statistics were reported describing the extentof these differences. Those subjects who scored higher on measures of anxiety and depressionalso tended to score higher on the measure of social maladjustment. Twenty percent of thefemales were reported to exhibit clinically significant levels of 'social maladjustment', although it isnot stated whether these women represented the pre-diagnosis group or the treatment group.Bell (1981) states that the extent to which the observed symptoms may be attributable theinfertility itself, or to disturbances pre-dating the infertility "is unclear" (p. 3). The lack of clarityin his conclusion is symptomatic of the vagueness of his purpose and of his methodology. Forexample, the recruitment of two distinct (if similar) subject groups suggests a comparison study,but no comparisons were reported. Further, his failure to report on the extent of the differencesreported by men and women on the measure of anxiety and depression is curious. In addition, thesmall sample size (40 individuals) makes generalization of the findings tentative. Nonetheless,32Review of the Literaturethese defects do not discredit the evidence suggesting that anxiety and depression, as well asdecreased sexual and marital satisfaction are among the negative effects of infertility. Bell closeswith an assertion that longitudinal studies are required to address the impact of infertility and todirect the "provision of supportive counselling" (p. 3) for infertile couples. The following studyutilitzes just such an approach to directly address the emotional impact of the infertilityinvestigation on the individual.Many authors have described the tremendous fluctuations in emotions throughout the oftenlong drawn out phases of the infertility work-up as one of the distinguishing and distinctlystressful characteristics of the infertility experience (Davis, 1987; Kraft et al. 1980; Halpern,1989; Woollen, 1985). Edelmann, Connolly and Robson (1989) have reported the preliminaryfindings of a long-term study which follows couples from their initial contact with an infertilityclinic throughout the medical investigation. Data was collected from all new patients attending aninfertility clinic, with results from the first four couples to complete a 22-week investigation beingreported.During the initial medical interview Edelman et al. (1989), collected demographic andbackground information and asked each patient to complete questionnaires measuring personality,general health, depression, state and trait anxiety, marital adjustment, interpersonal support and sexrole orientation. These measures were repeated at the end of the 22 weeks. To chart the week-to-week changes in affect and distress, each patient was asked to complete a questionnaire assessinglevels emotional distress each week and to keep a weekly diary describing any stressorsexperienced, both infertility related and otherwise.Scores on the personality and psychological measures for the eight individuals fell withinnormal ranges. State and trait anxiety scores for both members of two couples were high, ascompared with standardized norms, but were comparable to norms obtained from a population ofsurgical patients. Although no statistics were reported, scores obtained at follow-up tended, ingeneral, to be lower than those obtained at intake. The authors suggest that this may be reflectiveof elevated levels of distress experiences at the initial visit. Due to the small size of the sample, no33Review of the Literaturepredictive statistics are reported regarding the relationship between scores at intake and the weeklylevels of emotional distress.Charts depicting the weekly changes in distress level scores exhibited distinct fluctuationsin mood and affect throughout the 22-weeks for three of the four couples. These charts werecompared with the dates of the various test procedures conducted, and of the stressors reported bythe patients. For all four couples, the 'peaks' (reflecting high levels of negative affect) coincidedstrongly with infertility related stressors, such as testing dates, the beginning of drug treatment, theonset of menses and receipt of diagnosis, as well as such events as a visit from relatives with aninfant.Data collected from such a small sample cannot be generalized to a larger population, andthe authors make no attempt to do so. This study is of interest, however, because it demonstratesthe reported experience of many infertile couples, that, rather than being a single crisis which canbe responded to and then recovered from, infertility consists of a series of large and small crises,eliciting a series of response-and-recovery cycles. Further, the use of case illustrationsdramatically illuminates the differences between individuals. Although there were similarities ingeneral terms, the eight different patients exhibited eight different patterns of response to theexperience, highlighting the need to identify characteristics which might identify those individualswho are most likely to require support and counselling though the experience.The research studies reviewed here describe the emotional impact of infertility. Thesestudies have provided evidence that men and women tend to respond to infertility with attempts toregain control over their bodies and their lives and experience feelings of loss, depression,anxiety, hopelessness, and anger. Although many of these responses are exhibited in a significantsubgroup, or even a majority of infertile people, none of these responses is universally reported.It is evident that some individuals tend to exhibit greater distress and emotional turmoil in responseto infertility than do others. The following section reviews a variety of studies which have moreclosely examined the characteristics of the individual and of the infertility experience which mayhave impact in moderating or otherwise influencing the impact of infertility.34Review of the LiteratureFactors Mediating the Impact of InfertilityThe following review will examine studies which have identified one or more factors asinfluential in mediating the impact of infertility on men and women. The influence of gender isperhaps the most commonly reported mediating factor, but the nature of gender influences remainunclear and often controversial. Evidence has been reviewed suggesting differences in thesymptomatic distress reported by men and women. For example, Bell (1981) and Daniluk (1988)have reported differences in men's and women's assessments of their marital relationship whileundergoing treatment for infertility, but these differences are in opposite directions; Bell reportinga more critical assessment by females than by males, with Daniluk reporting a trend toward morepositive assessments by females than by males.Brand (1989) explored sex differences in acceptance of infertility in a sample of fifty-ninecouples attending an Infertility clinic. Ninety-two percent of couples were diagnosed with femalefactor infertility, with the remaining eight percent receiving a diagnosis of male factor. Brandinterviewed each subject, utilizing a semi-structured interview format designed to elicit subjectiveresponses regarding the effects of infertility on the individual and the relationship.Using a chi-square analysis, Brand (1989) reported a number of significant differencesbetween men and women in their behavior in response to infertility. Women were found to talkmore frequently and more willingly about infertility. As well, women reported feeling moreintense levels of disappointment and feelings of being 'overwhelmed'. Brand also reports that menand women subjects agreed that the 'psychological impact' of infertility was greater for womenthan for men.The 'significant' gender differences reported by Brand (1989) are derived from an analysisof interview data which elicited subject's opinions on their own reactions and the reactions of theirspouse. No standardized measures were utilized. Although the method of data collection isessentially qualitative, the reporting of statistical results suggests an effort to misrepresent the studyas quantitative. The results of Brand's study must therefore be regarded as unreliable.While the methodological flaws described above are sufficiently serious to view Brand's35Review of the Literature(1989) study with serious misgivings, the underlying, unacknowledged gender bias whichinformed the study is of greater concern. Aside from whatever validity Brand's results may ormay not have, the 'gender differences' reported in the study are problematic because they arepresented without interpretation or any real attempt at discussion, as indicative of women beingmore negatively affected by the stress of infertility than men. By comparing males to females andinterpreting the lower reported symptomatology reported by men as a lack of symptomatology,Brand ignores the fact that men and women characteristically demonstrate different patterns ofresponse to stress.The differences in the ways males and females respond to and report stressful events aremany. The following study offers a comprehensive description of gender differences in responseto infertility. Chiappone (1984) used Schlossberg's (1981) model of transition as a framework forexamining the differences, in impact and coping strategies, between men and women experiencinginfertility. Chiappone recruited 111 couples through advertisements in Resolve newsletters.Volunteers were mailed packages including standardized measures of subjective distress, copingstrategies, depression, self-esteem, sense of mastery and a researcher-designed questionnaireassessing the impact of infertility, feelings about infertility and the availability of social supports.Chiappone (1984) found several significant differences between men and women in theirresponses to infertility. Women rated the negative impact of infertility on self-image, marriage,sexuality and career significantly higher than did men, reporting that infertility had affected all fourareas, whereas men reported that their self-image, marriage and sexuality were affected somewhat,but that their careers were not at all affected.Men and women also showed significant differences on a measure of their feelings aboutinfertility, with women tending to indicate significantly greater feelings of frustration, anger,depression, anxiety, defectiveness, desperation, shock, and isolation than men. Women alsoindicated significantly more willingness to do anything, more feelings of stress in the sexualrelationship and a greater sense of being misunderstood, but also indicated greater feelings ofstrength and closeness to their spouses. Women also indicated significanity less feelings of36Review of the Literaturehopefulness for a child, of coping okay, of success, of control in their lives, of being attractivesexually, of happiness and of relief.It must be noted that, despite the statistical significance of the gender differences, theresponse pattern of male and female subjects was very similar. Although no correlational analyseswere performed supporting the pattern, it is apparent from a review of the data that there are moresimilarities than differences between the feelings about infertility reported by these men andwomen. This pattern was also seen on other measures, with women's average scores onemotional distress and depression being significantly higher than men's and their scores onmastery and self-esteem being significantly lower. Although all of these differences werestatistically significant, none were large. These patterns suggest that both men and womenexperience infertility as deeply distressing. The differences between the sexes in their responses toinfertility appears to largely one of degree, with women displaying a tendency to report feelings,both positive and negative, with somewhat greater intensity than men.For both men and women, a number of factors were found to be predictive of depressionand of the duration of infertility. For men, high mastery and positive self-esteem were negativelyrelated to depression. For both men and women, depression scores were positively correlated withthe tendency to report intrusive thoughts and feelings. For women, a report of intrusive thoughtswas the best predictor of depression. In addition, as with men, women who scored high inmastery tended to report low levels of depression.For both women and men, self-esteem was found to negatively correlate with duration ofinfertility. In addition, for women only, the duration of infertility was found to correlate positivelywith the number of coping strategies utilized, such that the longer a woman was infertile, the morecoping strategies she used.Women also reported a significantly broader range of coping strategies. Although malesubjects reported using only 51% of the strategies included on the Ways of Coping Checklist,women reported that they used 63% of the strategies listed. Women and men were also found todiffer in the type and variety of coping strategies utilized, with women using considerably more37Review of the Literaturetypes of strategies than men. For example, women sought social support, engaged in wishfulthinking and self-blame, utilized problem-solving strategies and adopted tension-reductionstrategies significantly more than did men. The ways of coping most often reported by men werestrategies such as 'maintaining pride', 'keeping a stiff upper lip', 'refusing to think about it' and'taking things one step at a time; strategies which could appropriately be described as methodsinvolving suppression or avoidance.Methodologically, Chiappone's (1984) study is not without problems. Over fifty separate ttests were conducted. Most of these were based on individual items of standardized measures,with only a minimal effort to distinguish clusters or patterns in the responses. With such a largenumber of individual calculations being performed, it is possible that a proportion of the significantdifferences were a result of chance error. A second, and perhaps more serious area of weaknessin the study is in its structural composition. Although it is clear that Schlossberg's model ofresponses to transition is the underlying framework defining the investigation, the way in whichthis framework is utilized is somewhat confusing. Gender is the only one of Schlossberg'scharacteristics of the individual identified by the research questions as a predictor variable. Self-esteem, another characteristic of the individual, is used in the correlational analyses as a criterionvariable. For these questions, Chiappone uses a selection of variables to predict scores ondepression and duration of infertility, but the rationale for the particular selection of scores in eachequation is not evident.Despite these cautions, Chiappone's (1984) study offers a comprehensive and inclusiveexplication of the different ways men and women may respond to the experience of infertility.While Chiappone's findings support the position that women tend to respond with greater evidenceof symptomatology than do males, a careful review of her findings reveals that the differences,although significant, are not large. In general, Chiappone's results indicate that men and womentend to report similar feelings in response to infertility, and that women tend to exhibit greaterintensity in both positive and negative responses. This pattern is consistent with sociallyprescribed gender roles which allow women more freedom in the expression of emotion than men.38Review of the LiteratureWhile it appears clear that men may be more likely to report lower levels of distress andhigher levels of adjustment than women, Chiappone's (1984) results show that men may also bemore likely to employ coping strategies involving avoidance, denial and suppression of emotions.As noted by Murray and Callan (1988) "sex roles depicting males as stronger and less emotionalmay inhibit (men) from expressing or reporting their (feelings)" (p. 243).These authors suggest that an individual's sex role orientation, rather than their gender mayin fact be the important mediating element in the observed differences between males and femalesin the levels of distress each group reports in response to events such as infertility. The followingstudy directly address the influence of gender roles on an individual's responses to infertility.Adler and Boxley (1985) conducted a study examining the impact of sex-role identity forindividuals experiencing infertility. These researchers recruited a large sample (N=164) of menand women, including 103 infertile individuals, 41 formerly infertile individuals and 20 peoplewith no history of infertility, with each group being approximately half men and half women. Datacollection involved the completion of standardized measures of sex-role orientation, maritaladjustment, self-defeating behaviors, self-esteem, psychiatric symptoms and body-image. Foreach subject group, masculinity and femininity scores were used to predict each of the criterion'coping' variables of self-esteem, body image, marital adjustment, psychiatric symptoms and self-defeating behavior.For all three groups, masculinity for both males and females was strongly positivelycorrelated with self-esteem. For infertile men and women, masculinity was also positivelycorrelated with several aspects of body image. Femininity was negatively correlated with the bodyimage subscale relating to build, as well as with the measure of self-defeating behavior. Inaddition, higher femininity scores tended to covary with higher levels of marital adjustment. Inaddition, femininity was positively related with the body-image subscale assessing facial-image inthe group of formerly infertile patients.Subjects were identified as androgynous, masculine, feminine or undifferentiated in termsof sex-role and compared on criterion measures. For infertile subjects, those identified as39Review of the Literatureandrogynous scored significantly higher on self-esteem measures than did those identified asfeminine or undifferentiated. In addition, a significant difference was found for androgynous menand women on overall body-image, with individuals identified as undifferentiated scoringsignificantly lower than the other three sex-role groups.In the formerly infertile group, androgynous subjects scored significantly higher thanfeminine or undifferentiated subjects on self-esteem and significantly lower than these two groupson psychiatric symptoms. In addition, undifferentiated subjects scored significanity higher on self-defeating behaviors than either the androgynous or the masculine subjects. No significant groupdifferences were reported for fertile subjects. Comparisons were also made of the three fertilitystatus groups, with no differences being found between groups on any of the coping variables.Finally, the authors compared males with females on each of the outcome variables, withno significant differences between sexes being found on any of the measures for either the infertileor the formerly infertile subjects. The single significant difference reported was on the levels ofmarital adjustment of fertile subjects, with fertile women reporting higher levels of maritaladjustment than fertile men.In general, the study appears to be methodologically sound. It is apparent that Adler andBoxley (1985) have made attempts to include and control possible extraneous or confoundingvariables (the effects of sex, education and religiosity were statistically controlled in the regressionanalyses) and the number of separate equations performed is not unreasonable. There is,however, an area for concern, specifically regarding the authors' lack of thoroughness in reportingof results. In at least two cases, statistically significant relationships are referred to, but nodescriptive data is provided. In other cases, the authors have chosen to include in their tables onlythose results which achieved statistically significant levels, preventing the reader from examiningthe data and drawing his or her own conclusions. While these omissions do not invalidate theresults of the study, they do lead the reader to question why more complete results were notincluded.The results which are included indicate that, in general, men and women who identified40Review of the Literaturewith masculine or androgynous characteristics tended to exhibit higher self-esteem, a more positivebody-images and to report fewer psychiatric symptoms and self-defeating behaviors, than didthose whose sex-role identify was undifferentiated. Individuals who identify with feminine sex-role traits also indicated a more positive evaluation of some aspects of body image and of theirmarital relationships. In describing both the positive and negative ways sex-roles may affect anindividual's self-image, Adler and Boxley (1985) support the need to examine an individual's sex-role identity in gaining a more comprehensive understanding of the complexity of factors involvedin shaping an individual's response to the stress of infertility.Although few researchers have looked exclusively at psychological factors associated withinfertility in males, a recent research project by Kedem, Mikulincer, Nathanson and Bartoov(1990) represents a comprehensive effort to fill the void. Employing a two-part design, theseresearchers conducted a between-group comparison of infertile and fertile men on a number ofpsychological dimensions, as well as examining objective and subjective elements of theexperience of infertility to predict individual differences on the psychological variables within theexperimental group of infertile men.One hundred and seven infertile males were recruited through attendance at an Israeliuniversity semen analysis clinic. The researchers collected demographic data as well as objectivemeasures of infertility (duration, diagnosis and whether infertility was primary or secondary).Subjects completed questionnaires measuring the degree of hope for a successful outcome, thedegree of stress posed by infertility as well as whether negative events were attributed to internal,stable & global factors or to external, unstable, specific factors. Subjects also completed a self-esteem questionnaire and a symptom checklist measuring six symptoms of stress, including sexualinadequacy.A control group of thirty men who had not sought treatment for infertility was recruitedfrom occupational groups listed by the infertile men and carefully selected to match proportionallyto the experimental group on the basis of the demographic variables. These men completed themeasure of self-esteem and the symptom checklist, including the additional 'sexual inadequacy'41Review of the Literaturequestions.In the comparison study, a few significant differences were found between infertile andfertile males. While infertile males tended to score lower on self-esteem than their fertilecounterparts, they indicated higher scores on symptom scales of anxiety and somatization. Nodifferences between groups were reported on the other four symptoms measured.In the second stage of the study, regressions were performed to predict the relationship ofthe objective, attributional and subjective elements of the men's infertility to each of the sevencriterion measures (self-esteem and six symptoms). These analyses yielded two significantresults: Men who perceived their infertility to be a global problem and who rated infertility as morestressful tended to score higher in depression. Also, men who perceived their infertility as global,who viewed the prognosis as hopeless and whose wives had also been diagnosed with fertilityproblems, tended to score higher on the measure of sexual inadequacy.Both the primary strengths and the weakness in this study lie in the selection of the controlgroup of fertile men. The control group was painstakingly selected to provide an exactproportional representation of the demographics found in the infertile research sample, therebysignificantly increasing the validity of the fmdings. This strategy also resulted in a fairly smallcomparison group, restricting the likelihood of discovering significant differences between thegroups.Despite the small size of the comparison group, some important psychological differenceswere found between fertile and infertile men. The findings that infertile men report lowered self-esteem and increased levels of anxiety and somatic complaints is important. Unlike the majority ofstudies which compare infertile men to infertile women and interpret men's lower reported distressas lack of distress, this study compared men to men, thereby controlling for any gender effects andproviding evidence that males also respond to the stress of infertility with feelings of depression,sexual inadequacy and decreased self-esteem.An exploratory study on the impact of infertility on men was conducted by Feuer (1983).In this unpublished research, Feuer tested 93 infertile men on six variables.Interviews were42Review of the Literatureconducted to assess levels of masculinity, locus of control and social isolation. Standardizedquestionnaires were used to measure depression, self-esteem and the quality of the maritalrelationship. Men representing two diagnostic conditions, oligospermia (low sperm count) andazoospermia (zero sperm count) were compared on the several variables.All of the infertile men reported significant levels of depression. Men diagnosed asoligospermic demonstrated a more severe impact, in levels of depression, quality of maritalrelationship, and social isolation than did men diagnosed with azoospermia. Feuer (1983)suggests that the feelings of uncertainty surrounding a diagnosis of oligospermia, as contrastedwith the finality of an azoospermic diagnosis, may account for the increased levels of distressobserved in these men. In interviews, each of the infertile men identified some aspect of his lifewhich was negatively impacted by his infertility. Feuer (1983) also noted that men tended to revealmore evidence of negative impact in interviews than they reported on standardized measures,noting the men's 'tendency to deny' the impact of infertility.Like the previous study, Feuer (1983) focussed on men's perceptions and feelingsregarding infertility. Both studies demonstrated that the distress experienced by infertile men issignificant and real. Also highlighted by Feuer was men's apparent tendency to under-report theirdistress, suggesting that results indicating higher levels of distress for women than men (Bell,1981; Chiappone, 1984) may be more a reflection of men's 'tendency to deny' than of actualdifferences. On the other hand, the distress reported by men may actually be different in qualityand content than distress reported by women. For example, while both men and women have beenshown to report elevated levels of anxiety, depression and social isolation (Bell, 1981; Chiappone,1984; Feuer; Kedem et al. 1990; Sandelowski & Jones, 1986) only men have been reported todisplay somatization (Kedem et al.) or denial (Feuer, Chiappone; Woollett, 1985). It is this formof gender differences that is of interest in the present study.Aside from variables concerned with gender and gender-roles, a variety of other factorsmay be instrumental in mediating or influencing the impact of the stress of infertility. As alreadynoted, diagnosis (Feuer, 1983) attributions (Kedem et al., 1990) as well as a sense of mastery and43Review of the Literatureself-esteem (Chiappone, 1984) have been shown to have a noticeable effect on shaping theindividual's response to infertility. The following study examines the mediating impact of a factorwhich may be described as a characteristic of the transition, specifically, whether infertility isprimary or secondary.Callan and Hennessey (1988) sought to determine the "life circumstances" (p,137) whichinfluence a woman's psychological adjustment to infertility. Suggesting that motherhood(previous successful reproduction) may be an important mitigating factor in adjustment, theseresearchers compared 53 primary infertile women who were undergoing IVF treatment with 24mothers who were seeking IVF treatment for infertility related to a subsequent pregnancy. Eachsubject was sent a questionnaire package, which elicited demographic data and information onfertility history, as well as assessments of personal happiness, including standardized measures ofwell-being, self-esteem, general affect and life satisfaction.Both groups of women scored within normal range on all measures of personal happiness.No differences were found between infertile mothers and infertile non-mothers in measures of self-esteem or on reports of positive or negative affect. Non-mothers did report lower satisfaction withlife and less happiness over the past month and, on the semantic differential, rated life as lessinteresting and more lonely than did mothers.In comparison studies, the crucial factor which must be studied is the similarity of samplegroups. The two groups are similar in demographic terms, but close inspection reveals thatprimary infertile women appear to have married and begun their attempts to have children at asomewhat later age than the secondary infertile women. Although these differences are minimal,they may in fact reflect differences between the groups in social or psychological factors such assex-role identity, socio-economic status or career and occupational goals. As no data are reportedin the study on any of these factors, these queries are not answerable.While the relevancy of the possible differences between the groups may be debated, theyare on a minor scale. What is clear is that both groups of women were highly motivated to becomeparents and were actively seeking pregnancy at the time of the study. These researchers suggest44Review of the Literaturethat women who choose to pursue the often lengthy and arduous procedures involved in IVF "are aselect group among the infertile...(and)...less motivated and possibly less adjusted women areunwilling to bear these demands and do not pursue IVF treatments" (p.139). As women who donot pursue IVF treatments were not included in this study, this conclusion remains conjecture.However, the exclusive use of women seeking IVF treatments does impede the ability to generalizethese authors' findings to other groups of infertile women or to men.The major contribution of the study are the scores which suggest that these non-mothersperceive their lives as less satisfying, less interesting and more lonely than did mothers, suggestingthat a characteristic of infertility, in this case, whether it is primary or secondary, may have animpact on some women's response to the experience. The following study utilizes a longitudinalapproach to explore the impact of a number of important factors related to the transition, includingtime spent dealing with infertility, stage of the medical investigation and diagnosis received as wellas the gender of the individual.Daniluk (1988) conducted a comprehensive longitudinal study of several factors associatedwith the psychological impact of infertility. Forty-four couples undergoing medical examinationsfor primary infertility were recruited from patients attending a university clinic specializing in thetreatment of infertility. Subjects were surveyed on four occasions; immediately following theirinitial medical visit, four weeks later, one week after diagnosis and six weeks following diagnosis.Four questions defined the scope of the study, which examined whether changes occurred onmeasures of psychological distress, marital adjustment, relationship quality, sexual satisfaction andperceived need for counselling during the course of the medical investigation for infertility; at whatpoint or points during the investigation these changes occurred; the nature of the changes; andwhether there were differences in the changes experienced by men and women.No significant differences across testing sessions were found on measures of sexualsatisfaction, marital adjustment or relationship change on the basis of gender, diagnosis, identifiedsource or time spent trying to conceive. Significantly higher levels of psychological distress werereported for both men and women at the initial medical interview, prior to any testing or diagnosis,45Review of the Literaturethan at subsequent testings. Significant differences were reported between male and femaleparticipants on measures of marital adjustment at all four testing sessions, with femalesconsistently scoring higher than males.Differences in sexual satisfaction scores were reported by men and women receiving aneutral (unexplained) diagnosis as compared with those receiving a positive (treatable) or negative(untreatable) diagnosis. Individuals who received the diagnosis of unexplained infertility reporteda higher level of sexual dissatisfaction than men and women with a definite diagnoses. Thisfinding supports the contention that uncertainty is among the most stressful elements of theinfertility experience.The primary strength of this study lies in its longitudinal approach. By examining theexperience of infertility from the perpective of four distinct phases or stages, this researcheremphasizes the complex and long-term nature of the transition to childlessness. The study alsodemonstrates that characteristics of the transition such as duration and diagnosis may be importantin shaping an individual's response to infertility. Although no differences were reported on thedependent measures on the basis of time spent dealing with infertility, the finding that distresslevels peaked at the initial interview suggests that distress may decrease as men and womenproceed through the infertility investigation. In addition, some evidence of increased distress wasshown for individuals whose diagnosis was unknown, suggesting that this characteristic of thetransition may be important in shaping the individual's response to infertility. Finally, Daniluk(1988) demonstrates that, although both men and women experienced elevated distress in responseto infertility, women tended to maintain higher levels of marital satisfaction than men, suggestingthat, in terms of their relationships, women displayed higher levels of adjustment than men. Theimplication of this finding is that the mediating influence of sex, perhaps the most basiccharacteristic of the individual, may be much more complex than a matter of more or less distressreported in response to infertility.Sabatelli, Meth and Gavazzi (1988) studied the mediating effects of several characteristicsof the individual as well as some characteristics of the infertility on married couples' adjustment to46Review of the Literatureinvoluntary childlessness. A sample recruited from Resolve membership lists consisted of 52women and 29 men (twenty-nine couples plus 23 women) who were at various stages throughoutthe infertility investigation. The study included two major questions. The first question wasexploratory and sought to quantify the changes attributed by an individual to infertility. Thesecond question, which comprised the chief investigation, addressed a number of predictorvariables or mediators of adjustment to infertility. The researchers used measures of self-esteem,economic independence, marital locus of control, marital commitment and satisfaction, past copingstrategies used as well as the duration of infertility to predict subjects' scores on measures ofdepression, anxiety and adjustment to infertility.On the first question, exploring the changes attributed to the infertility experience, a numberof interesting results appeared. In general, women reported changes almost twice as often as didmen. Women reported decreases in self-confidence, frequency of contact with friends andcomfort with friends, but also reported increases in emotional support from spouse as well as inconflicts with spouse. The greatest changes were reported in the area of sexuality, with over halfof the women reporting decreases in satisfaction, frequency and comfort with sex. Men alsoreported decreases in this area, with about half reporting decreases in frequency and satisfactionwith sex. Thus the majority of changes attributed to the infertility experience were negative.The chief investigation of the study revealed five predictor variables which were moderatelyto strongly related to coping efficacy. Men and women who reported high self-esteem were verylikely to indicate high levels of adjustment to infertility and low depression and anxiety. Womenwho reported a strong marital commitment and an internal locus of control were likely to reporthigh adjustment to infertility and low depression and anxiety. Men who reported a high maritalcommitment and an internal marital locus of control also showed a moderate tendency score higherin adjustment to infertility and lower in depression.Men and women who indicated high marital satisfaction also scored somewhat higher inadjustment to infertility and somewhat lower in depression. For both men and women, the longerthey had been experiencing infertility, the less anxiety was reported. For men, longer duration was47Review of the Literaturealso related positively to adjustment and negatively to depression. Thus, for both men andwomen, self-esteem, marital commitment, internal locus of control, marital satisfaction as well asmore time spent dealing with infertility appeared to be important predictors of coping efficacy inresponse to infertility. Further analysis revealed that, for women, self-esteem and commitment tomarriage accounted for the majority of the variance on all three measures of coping efficacy.Coping scores for the twenty-nine couples were compared and although couples' adjustment toinfertility tended to covary, wives reported lower adjustment and higher anxiety than theirhusbands.Two coping strategies showed moderate to strong correlations with coping efficacy.Women and men who reported having reframed or redefined past crisis situations indicated highpositive adjustment to infertility. For women, reframing was also strongly related to low reportedlevels of anxiety and depression. 'Spirituality' and 'social networking' strategies for women anda 'help seeking' strategy for men were mildly to moderately related to lower depression scores.However, men and women who reported using passive coping strategies, including avoidance anddenial, indicated a strong tendency to display poor adjustment to infertility and a moderate to strongtendency to indicate high levels of anxiety and depression. Thus, the tendency to approach eventspassively appeared to be less effective in mitigating the negative impact of transitional crises suchas infertility than was the tendency to reframe or redefine situations into more manageable terms.Although this study offers a number of interesting fmdings, there are some importantconcerns which must be addressed. Although it is clear that the investigators sought to studyinvoluntary childlessness, it is not made clear whether subjects were limited to those with primaryinfertility. Further, as the sample is drawn from a population of Resolve members, it may not berepresentative of the majority of infertile couples, but may be skewed toward a sub-population witha pro-active approach to coping, suggesting higher levels of adjustment. As coping strategies andadjustment levels were major elements of the investigation, this may be an important considerationin using the results of the study for predictive purposes.In addition, as Chiappone (1984) found, women are more likely to seek support through48Review of the Literaturesources external to the marriage than are men. It is not surprising therefore, almost twice as manywomen than men volunteered to participate. The relatively small size of the male sample (29),therefore makes generalization of the results for men, tentative.With these caveats in mind, a number of interesting results may nonetheless be extractedfrom the study. Sabatelli and his colleagues (1988) demonstrated that a number of personal orattitudinal characteristics of the individual, including high self-esteem, an internal locus of controlregarding their marriage and a high degree of marital commitment tended to have a positive impacton adjustment to infertility and helped to minimize feelings of depression and anxiety. In addition,an important characteristic of the transition, time spent dealing with infertility also appeared tocontribute to increased adjustment and decreased distress. Finally, the finding that the use ofreframing as a coping strategy in past crises predicted better adjustment to infertility supports thecontention that, as Schlossberg (1981) noted, "the individual who has successfully weathered atransition in the past will probably be successful at adapting to another transition of a similarnature" (p.15).The mediating effect of a number of demographic, medical, cognitive and environmentalfactors on men's and women's adjustment to infertility was investigated in a complex andcomprehensive study by McEwan, Costello and Taylor (1987). Sixty-two women and forty-fivemen (N=107) were recruited from among the patients at an Infertility clinic. Data for predictorvariables was collected through medical files and interviews. Information from medical filesincluded time trying to conceive, time seeking medical support, diagnosis, infertility status(primary or secondary), medication prescribed, and the medical estimate of probability ofconception, as well as demographic information such as age, sex, religion and socioeconomicstatus. Interviews were directed to elicit information on stressful events experienced within thepast year, perceptions of the availability of social support, cause of infertility, perceived chancesfor success, feelings about infertility and the acceptability of alternatives to conception.Standardized questionnaires were used to measure the dependent variables of emotionaldisturbance, perceived social role performance, sexual satisfaction, quality of sexual relations and49Review of the Literaturedrinking patterns.Initially, a comparison of scores for males and females on the measure of emotionaldisturbance revealed that significantly more women than men (40% of women and 13% of men)reported serious symptoms of distress. When compared with the expected rates of distress foundin the general population, however, (37% of women and 1% of men), the infertile males reportedproportionately greater distress levels. This suggests, as do Chiappone's (1984) results, thatalthough women tend to report greater levels of distress than men, many men do experienceserious levels of distress in response to infertility.Dependent measures were condensed into composite factors of related elements ofadjustment, which were then used in regression equations with sets of predictor variables. Forwomen the strongest predictors of the first composite, emotional and social adjustment, werereligion and increased age, with recent life events and a confiding relationship with their spousealso showing a postive correlation with positive adjustment. In addition, women who made self-attributions regarding infertility and those who had not received a diagnosis tended to showsignificantly more distress. Two other composites, sexual adjustment and alcohol consumptionwere identified, but no significant relationships with predictor variables were found. For men, nosignificant relationships were reported between any of the predictor variables and the threecomposites factors of sexual adjustment, emotional and social adjustment and alcoholconsumption combined with family unit relationships.A final analysis was performed to test the relationship of distress levels to women'stendency to accurately predict their chances of successful conception. Although both distressedand non-distressed women were aware of the official medical prognosis, the results suggest thatdistressed women tended to underestimate and non-distressed women tended to overestimate theprobability of success.This complex and sophisticated study provides several useful fmdings and presents onlyminor areas for concern, methodologically. Data from a relatively small number of subjects (62women and 45 men) is used to answer a large number of questions. In recognition of this, results50Review of the Literaturefor male subjects were reported in a limited fashion, leaving the burden of answers to be providedby female subjects, who outnumber males by a ratio of only 1.4 to 1.McEwan et al. (1987) suggested that women reported higher levels of distress than didmen in response to infertility and provided evidence of several factors with a mediating impact oninfertile women's adjustment levels. Those individuals who appeared to be at highest risk ofsuffering serious emotional distress in relation to infertility were young, non-Protestant womenwho blamed themselves for their infertility, who had no previous experience with stressful events(characteristics of the individual) who did not feel able to confide in their husbands (characteristicsof their environment) and who had not yet received a diagnosis and were therefore still facing ahigh degree of uncertainty (characteristics of the transition). This study suggests thatcharacteristics of the individual, their environment and the transition may all be important inshaping the complex nature of a woman's response to infertility.The following study explored the relationship between a number of psychological andpersonality factors for infertile women. Fouad and Fahje (1989) recruited 61 infertile womenthrough infertility support groups and the offices of specialists and administered measures of self-esteem, depression, locus of control and perceived social support. Information on time dealingwith infertility and whether infertility was primary or secondary was also collected.When compared with standardized norms provided with the instruments, the infertilewomen studied indicated average levels of self-esteem, a slight tendency to be internally controlled,mild levels of depression, a higher than average need for support, less than average supportreceived and a moderate level of satisfaction with the support received. These results suggest that,in general, these women were somewhat distressed, but appeared nonetheless to be fairly welladjusted.A number of significant relationships were found between the four measures. High levelsof depression were negatively related to internal locus of control and positively related to greaterperceived needs for social support and lower levels of satisfaction with support received. Theseresults suggest that women who perceived their lives as controlled by external forces and who51Review of the Literatureperceived the support they received as inadeqate were at greater risk of experiencing feelings ofdepression in response to infertility.High self-esteem was positively related to internal locus of control, high levels ofsatisfaction with support received and to a minimal discrepancy between support required andsupport received, suggesting that the more comfortable an infertile woman was with herself, theless support she required, the happier she was with the support received and the more likely shewas to perceive events and consequences as within her own control. In addition, although nohypothesis addressed this relationship, a strong negative correlation between self-esteem anddepression was found, indicating that women who indicated high levels of self-esteem also tendedto report low levels of depression.A critical review of Fouad and Fahje's (1989) investigation reveals a fairly well-constructedcorrelational study. The primary concerns regard the possible influence of the duration ofinfertility as well as the individual's infertility status. Although this information was apparentlycollected, it is not clear how it was used, if at all. With this caution noted, however, the studydoes highlight several interesting relationships.The finding that infertile women with high self-esteem and high internal locus of controlwere less likely to report being depressed is suggestive that these personality factors may act asmediators in reducing the negative impact of infertility. Further,results suggesting that womenwho perceive that available social support is adequate to meet their needs and who are satisfiedwith the social support received, are less likely to exhibit signs of depression, add strength toSchlossberg's (1981) contention that effective social support may provide some protection fromthe emotional impact of infertility.Obversely, these researchers found that women with low self-esteem reported that theirsupport needs were being inadequately met by the available resources. These women and thosewith an external locus of control also indicated high levels of depression. These results suggestthat women with low self-esteem and a limited sense of control of their lives are at high risk forfeelings of isolation and depression in response to infertility. Each of these results suggests that52Review of the Literatureself-esteem and locus of control may be important characteristics of the individual to consider in anexamination of the factors shaping an individual's reponse to infertility.Summary of FindingsThe studies reviewed demonstrate that a variety of factors appear to be useful in gaining anunderstanding of the nature and extent of the impact of infertility on an individual. Included in thisreview were characteristics of the individual, characteristics of the environment as well ascharacteristics of the transition.Of the characteristics of the infertility transition investigated, two were shown to mediateits impact. The duration of infertility, often measured as the length of time since discovery ofinfertility, appeared to be related to lower distress, such that the more time an individual spentliving with infertility, the better able he or she was to adjust to the transition (Daniluk, 1988;Sabatelli, 1988) and, for women, the more coping strategies used (Chiappone, 1984). On theother hand, Chiappone also found that longer time spent dealing with infertility was related todecreases in self-esteem. While these results appear to be contradictory, they may not be.Although men and women may gradually develop effective strategies for coping with the ongoingdistress engendered by infertility, the individual's perceptions of their own effectiveness over time,particularly if no 'cure' is found, may suffer.Diagnosis also appeared to play a role in mediating the impact of infertility as individualswho had received a specific diagnosis tended to exhibit less distress than those whose diagnosisremained uncertain (Daniluk, 1988). Similarly, Feuer (1983) found that men who received theunequivocal diagnosis of azoospermia demonstrated less distress than did men whose diagnosis ofoligospermia left an element of uncertainty and possible hope. It appears that, as long as diagnosesor the efficacy of prescribed treatment remains uncertain, infertile men and women remain in a stateof anxiety and distress. It may be that, once a conclusive diagnosis is made, even if the implicationis that no treatment is available, infertile couples and individuals may begin to move from a state ofbeing in transition, into a process of adjustment or adaptation.Several characteristics of the person's social environment were also investigated. Among53Review of the Literaturethose factors which appeared to facilitate better adjustment to infertility were the ability to confidein one's spouse (McEwan et al., 1987) and the 'perceived fit' between needs for support andsupport received (Fouad & Fahje, 1989). These results suggest that, as Sclossberg (1981) noted,effective social support may be an important factor in helping an individual to cope with thechanges engendered by experiences such as infertility.The largest group of factors investigated as possible mediators of the impact of infertilitywere a collection of characteristics of the individual. The most often investigated personalitycharacteristic is self-esteem. High self-esteem was repeatedly indicated as the strongest correlate ofbetter adjustment and lower levels of distress for both men and women (Chiappone, 1984; Fouad& Fahje, 1989; Sabatelli et al., 1988). In a similar way, internal locus of control (Fouad &Fahje, 1989; Sabatelli et al.), a sense of mastery (Chiappone, 1984) and a proactive approach tocoping (Chiappone) have also been shown to be related to higher levels of adjustment anddecreased distress in response to infertility, while a tendency to blame oneself for the infertility wasrelated to poorer adjustment (McEwan et al., 1987). These findings suggest that an individual'ssense of self-worth and efficacy, or 'psychosocial competence' (Schlossberg 1981) may beamong the most important elements in shaping his or her response to the experience of inferility.An interesting pattern of findings emerged regarding the nature of sex differences inresponses to infertility. While Chiappone (1984), Daniluk (1988) and Bell (1981) reporteddifferences between men and women in the intensity of responses, with women consistentlyreporting more anxiety, depression and other elements of distress than men, as well as greatermarital adjustment (Daniluk). Chiappone's results suggest that women tend to report both positiveand negative feelings with greater intensity and frequency than men. These results, as well asthose of Kedem et al. (1990) and Feuer (1983) indicate that men experience significant levels ofdistress in response to infertility and that men's and women's responses may actually differ inquality as well as intensity, with men appearing more likely to exhibit evidence of somatization(Kedem et al.) and denial (Feuer; Chiappone; Woollett, 1985), and women appearing more likelyto exhibit depression (Chiappone; Woollett) and to utilize a variety of coping strategies54Review of the Literature(Chiappone). It appears that sex-role identity may also play a role in the observed differencesbetween men and women, as men and women who identify with androgynous or masculine sex-role characteristics tended to demonstrate higher levels of coping and lower levels of distress(Adler & Boxley, 1985).A variety of other characteristics of the individual were also indicated as having a possibleimpact on levels of subjective distress and adjustment for some people. Religious beliefs appearedto have some impact on adjustment, such that women who described themselves as Protestantindicated higher adjustment and less distress than women who identified with other religiousgroups (McEwan et al., 1987). In addition, a strong sense of commitment to the maritalrelationship was shown to be related to better adjustment (Sabatelli et al., 1988). Finally, ageappeared to be related to adjustment such that older women exhibited less distress than youngerwomen (McEwan et al.). These last two findings appear to suggest the possibiiliy of a relationshipbetween maturity or stability and the ability to cope effectively with the experience of infertility.HypothesesResearch HypothesesNull Hypothesis # 1: There will be no statistically significant canonical correlation at the a= 0.05 level on the mean scores on a weighted linear composite of scores for the dependentvariables of Somatization, Obsessive Compulsiveness, Interpersonal Sensitivity, Depression,Anxiety, Hostility, Psychoticism and Adjustment to Infertility for the Independent variables ofDiagnosis, Duration, Perception of Outcome and Perception of Success and the joint effects ofthese factors.Null Hypothesis # 2:  There will be no statistically significant canonical correlation at the= 0.05 level on the mean scores on a weighted linear composite of scores for the dependentvariables of Somatization, Obsessive Compulsiveness, Interpersonal Sensitivity, Depression,Anxiety, Hostility, Psychoticism and Adjustment to Infertility for the Independent variables of SelfEsteem, Locus of Control, Sex-Role, General Health, Age, Sex, Religion, Race, Socio-economic55Review of the LiteratureStatus and Previous Experience and the joint effects of these factors.Alternative HypothesesIn the event that the either of the null hypotheses are unsupported by the data, the followingalternative hypotheses have been generated for testing:Alternative Hypothesis #1: The canonical correlation between the dependent variables ofSomatization, Obsessive Compulsiveness, Interpersonal Sensitivity, Depression, Anxiety,Hostility, Psychoticism and Adjustment to Infertility and the independent variables of Diagnosis,Duration, Perception of Outcome and Perception of Success will be significant at the a = 0.05level.Alternative Hypothesis #2: The canonical correlation between the dependent variables ofSomatization, Obsessive Compulsiveness, Interpersonal Sensitivity, Depression, Anxiety,Hostility, Psychoticism and Adjustment to Infertility and the independent variables of Self-Esteem,Locus of Control, Sex-Role, General Health, Age, Sex, Religion, Race, Socio-economic Statusand Previous Experience will be significant at the a = 0.05 level.56MethodologyCHAPTER THREEMethodologyThe SampleA sample of 106 subjects was recruited from the population of couples attending theInfertility clinic in the Obstetrics and Gynaecology Department of Foothills Hospital at theUniversity of Calgary in Alberta. Individuals and couples interviewed included those in all stagesof the infertility transition, from those making their initial visit to the clinic, to those whose fertilityinvestigations were ongoing for several months or years. Eligible participants were men andwomen who were members of couples experiencing primary infertility, defined as never havingcarried a pregnancy to full term, with no known history of psychiatric illness or use of mood-altering drugs.Demographic information (Characteristics of the Individual) for all participants wascollected through the Personal Information Survey. A summary of the results is shown in Table 1.In total, seventy-one (71) of the 106 volunteers who agreed to participate in the study returnedcompleted questionnaire packages, representing a 67% response rate. Of these 43 (61%) werefemale and 28 (39%) were male. Men ranged in age from 27 to 48 with a mean age of 33.Women ranged in age from 23 to 40, with an average age of 31 years. Seventy-three percent ofrespondents indicated family income levels at or above $40,000 per year and 92% reportedincomes of $25000 or greater. Education was measured by level achieved, with 34% reportingcompletion of high school and 65% reporting the completion of two or more years of college oruniversity. Most subjects (99%) reported their general physical health as good (category 3) orexcellent (cat. 4).Race or ethnic origin categories were derived from a logical grouping of those ethnicgroups identified by respondents in an open-ended question. The great majority (84%) identifiedthemselves as White, Canadian, or of British or Northern European origin (cat. 1); 4% reportedbeing French Canadian (cat. 2); 6% reported being Asian or Chinese (cat. 3); with the remaining6% (Other (cat. 4)) identifying themselves as Native, Jewish or Latin American. An auxiliary57Methodologyquestion was included with this item, asking whether having children is regarded as an importantcultural or family value. Ninety-three percent (93%) indicated 'Yes' in response to this item.Respondents also completed an open-ended question regarding their religious affiliation.The largest single group (51%) reported no religious affiliation, 20%identified themselves asCatholic, 13% indicated affiliation with Protestant churches, including United, Lutheran andAnglican, another 14% identified themselves with traditional Christian groups, including theMennonite Church or Church of God, and 3% indicated other religions such as Judaism orMuslim.Characteristics Relating to InfertilityA number of questions relevant to the transition were also included on the PersonalInformation Survey (See Table 2). The first related to the 'duration' of the transition, measured inmonths. Subjects reported that they had been attempting to conceive for between 12 months and144 months, with an average of approximately 48 months, or four years. In addition, subjectsreported a range of 5 months to 132 months ( X= 28.16 ± 27.6, or approximately two and one-half years) since first seeking medical attention for infertility.Subjects were also asked to identify their diagnosis received, by category. The largestgroup (41%) identified their infertility as 'Female Factor', with only 10% 'Male Factor' and 4%identified as 'Couple Factor'. Almost half of the sample had no clear diagnosis, however, with21% reporting an 'Unknown factor' diagnosis and 24% having received no diagnosis.On an item asking respondents to describe their perception of their infertility status, 55%reported being 'very uncertain', 25% perceived infertility as 'a temporary condition' and 18%identified it as 'a permanent condition'. Subjects were also asked to assess their chances ofachieving a successful pregnancy. A majority (62%) assessed their chances of success as less than50%, with 37% reporting a less than 25% chance of success and another 25% of respondentsreporting between 25% and 50% chance of success. Twenty-five percent of respondents thoughttheir chances of success were between 50% and 75% and 15% of the sample believed that theirchances were better than 75%.58MethodologyTable 1:	 P.I.S. Demographic Characteristics: Responders v 	 Non-RespondersVariable Category Responders NonResp T Stat P ValueAge Females 30.71 ± 4.59 31.06 ± 3.55 -.31 .76Males 32.68 ± 5.24 32.93 ± 3.79 -.18 .86Sex (1)Female: 61% 49% -.72 .48(2)Male: 39% 51%Race (1)White/Anglo: 84% 89% 1.08 .28/Ethnic Background (2)French Canadian: 4% 6%(3)Asian: 6% 6%(4)Other: 6% 0%Income (1)< $15000/Yr 3% 0% -.63 .53(2)$15-25000/Yr 6% 6%(3)$25-40000/Yr 18% 23%(4)> $40000/Yr 73% 69%Education Completed (1)Elementary 1% 3% .08 .93(2)High School 34% 37%(3)College or Univ. 54% 51%(4)Post Graduate 11% 9%General Health (1 - 4) 1=Poor, 4=Excellent 3.58 ± .5 3.45 ± .5 1.16 .25Religion (1)Catholic: 20% 26%(2)Protestant: 13% 23%(3)Christian (Other): 14% 11% 1.81 .08(4)Other: 3% 6%(5) None: 51% 34%Children Valued (1)Yes 93% 83% -1.34 .19(2)No: 7% 17%59MethodologyTable 2: P.I.S. Characteristics of the Transition Responders v Non-RespondersVariable	 Category	 Responders NonResp T Stat P ValueTime Trying	 No. of Months	 47.77 ± 28.9 46.23 ± 23.9 .28 .78Time Seeking Medical Help No. of Months	 28.16 ± 27.6 32.81 ± 19.3 -.97 .33Diagnosis	 (1) Female Factor: 41% 48%(2)Male Factor:	 10% 34%(3)Couple Factor: 4% 3% -1.39 .17(4)Unknown:	 21% 11%(5)No Diagnosis: 24% 6%Perception of Outcome	 (1) Uncertain:	 55% 34%(2)Temporary:	 25% 34% -2.45 **.02(3)Permanent:	 18% 31%Perceived Chance 	 (1) < 25%:	 37% 34% -.17 .87of Success (Hope) 	 (2) 25 to 50%:	 25% 29%(3)50 to 75%:	 25% 20%(4)> 75%:	 15% 17%Previous Experience	 (1) Yes:	 45% 63% 1.71 .09(2) No:	 55% 37%About half (45%) of the respondents reported being faced with similar life experiences inthe past. More than half of those who responded positively to this question identified experienceswhich they found similar to infertility. These included such experiences as their own or a familymember's serious illness, the death of family members, serious financial loss, divorce, abortion aswell as multiple miscarriages and previous failed pregnancies.Comparison of Respondents to Non-RespondentsAll volunteers recruited through the medical clinic completed the Personal InformationSurvey, which was collected by the researcher immediately. Therefore, it was possible to comparethe characteristics of those who completed and returned the questionnaire packages with thosevolunteers who did not. Using BMDP3D (Sockne & Forsythe, 1988), a series of Hotelling t-tests were performed to compare respondents with non-respondents on each item of the Personal60MethodologyInformation Survey. Cases with missing scores were excluded from these calculations.As can be seen in Tables 1 and 2, no significant differences were found betweenrespondents and non-respondents on age, sex, income, education, general health, race, religion,duration of infertility, diagnosis, hope or previous relevant experience. A significant difference(p < .05) was shown between respondents and non-respondents on perceptions of the outcome oftheir infertility, with respondents being more likely to report their infertility as uncertain (55%)than as temporary or permanent and non-respondents tending to be evenly split in theirperceptions of the outcome.Instrumentation The response package completed by each subject included three instruments measuringpredictor variables: the BEM Sex-Role Inventory (Bem, 1974), the Coopersmith Self-EsteemInventory (Coopersmith, 1981) and Rotter's Personal Belief Questionnaire (Rotter, 1966). Twocriterion measures were also included: the SCL-90-R (Derogatis, 1975) and the Adjustment toInfertility Scale (Sabatelli, Meth & Gavazzi, 1988).Personal Information Survey (PIS) The Personal Information Survey (Appendix A) was designed by the researcher to elicitdemographic, personal and diagnostic information of specific relevance to the present study. Thequestionnaire consisted of 14 items and required subjects to answer fact-based questions byselecting from an array of alternatives or by giving a brief written response to open-ended items.Subjects took 5 to10 minutes to complete the survey.Demographic data elicited by the P.I.S. included gender, age, ethnic background, socio-economic status (yearly income and level of education attained) and religion. These factors havebeen identified by Schlossberg (1981) as characteristics of the individual which may be importantin assessing the impact of negotiating a psychosocial transition such as infertility.In addition, the P.I.S. included questions regarding the subject's general health andprevious experience with transitions of a similar nature. These were among the characteristics ofthe individual identified by Schlossberg (1981) as of potential importance in adapting to a61Methodologytransition. Recognizing that the 'similar' previous experiences may include a limitless number ofevents, and that the degree of similarity is subjective, the question addressing previous experiencewas left open ended and included an invitation to briefly describe the experience. There were nopredetermined categories of similar transitions, nor of their impact. The only information used instatistical analysis was the Yes/No response.Six questions addressed subject-specific characteristics of the infertility experience.Duration of infertility was measured as the length of time (in months) each subject had beenattempting to conceive as well as the length of time since each subject originally sought medicaltreatment for infertility. In addition, the individual's subjective perception of whether theirinfertility was permanent, temporary or of uncertain duration was assessed, as well as the subject'sperceptions of the chances (in percent) of achieving a successful pregnancy. Finally, subjectswere asked to identify whether a diagnosis had been made, and if so, whether it indicated a malefactor, a female factor or a couple factor as the primary cause of infertility, or if the cause was asyet unknown.Bem Sex-Role Inventory (BSRD The Bem Sex-Role Inventory -Short Form (Bem, 1974) was used to to assess theindividual's degree of identification with 'traditional' definitions of masculinity and femininity.The BSRI is a measure of sex-role identity, a psychological or attitudinal construct relating to theway in which individuals perceive themselves relative to social definitions of 'Masculinity' and'Femininity'. Sex-role identity has been identified as an important characteristic of the individual,relevant to the assessment of adaptation to developmental transitions (Schlossberg, 1981). Sex-role identity is of particular relevance to the transition instigated by infertility, as many peopleequate the ability to have children with their 'sexual identity' (Hendricks, 1985; Humphrey, 1977;MacNab, 1985; Mahlstedt, 1985).The BSRI-Short Form is a self-report scale consisting of thirty adjectives which have beenrated as 'masculine', 'feminine' or 'neutral' personality characteristics by a panel of college studentjudges. Responses are recorded on a 7-point Likert-type scale indicating to what extent the subject62Methodologybelieves that each adjective describes themselves. Responses range from 'always or almost alwaystrue' to 'never or almost never true'. Average length of time to complete is ten minutes or less(Bern).'Masculine' and 'feminine' identity scores were achieved through calculating the arithmeticaverage of the respondents self-ratings on items from the masculine scale and the feminine scale.Subjects with scores above a cutoff point for either scale were categorized accordingly.Respondents with scores above the cutoff score on both scales were described as 'Androgynous'.Respondents whose scores on both scales were below the cutoff score were categorized as'Undifferentiated'. In the present study, subjects were categorized on the basis of their scores andeach category was coded as follows: androgynous = 1, masculine = 2, feminine = 3 andundifferentiated = 4.Reliability and validity of the BSRI have been demonstrated in a series of studies by thetest author, as well as others. Reliability coefficients on test-retest trials over a four-week span onthe original normative sample of the BSRI ranged from .75 for males to .94 for females (Bern,1974). Internal consistency coefficients ranged from .75 for females to .90 for males (Bern).Discriminant validity was reported in the BSRI manual (Bern) with coefficients ranging from -.14to +.33 between Masculinity and Femininity scales. Construct validity of the BSRI has beendemonstrated through a number of experiments in which subjects behavioral responses to a varietyof tasks were correctly predicted based upon BSRI scores. Specifically, subjects scoring high in'Androgyny' tended to respond with behaviors not typical of their own sex, in both clearly definedand in ambiguous tasks, more often than did subjects who scored high on either the Masculinity orFemininity scales (Bern, 1974b; Bern, 1976). Normative data was provided in the BSRI manual(Bem, 1974) for a range of age and ethnicity groups, including adult men and women ofchildbearing age.The BSRI is perhaps the most widely used measure of sex-role identity. It has clearly beenwell researched and tested and is easy to administer, with clear directions designed for use byindividuals from secondary-school age through older adulthood. Conceptually, the BSRI rejects63Methodologyearlier notions of masculinity and femininity as bipolar opposites. Consistent with currentsociocultural definitions of sex-roles, Bem (1974) was the first to develop an instrument adoptinga two-dimensional definition of masculinity and femininity which recognizes that a singleindividual can endorse both masculine-valued and feminine-valued characteristics (Kelly &Worrell, 1977; Spence, Helmreich & Stapp, 1975). For individuals coping with infertility, therelative tendency to endorse characteristics valued as masculine or feminine may be related to theindividual's pattern of responses to the experience.Coopersmith Self-Esteem Inventory (SEI) Adult FormThe Coopersmith Self-Esteem Inventory (Coopersmith, 1981) was one of the twomeasures used to assess aspects of an individual's 'Psychosocial Competence' (Tyler, 1978).Included by Schlossberg (1981) as a primary trait affecting an individual's adaptation to atransition, 'psychosocial competence' refers to a collection of corresponding attitudes toward selfand the world, which provide an individual with a sense of competence and confidence. AlthoughTyler (1978) included a variety of self-attitudes within the construct of psychosocial competence,many of these may be understood as elements of the principal attitudes of self-esteem and a senseof personal competence.Coopersmith's SEI (1981) was utilized in the current study to measure the degree of self-esteem or positive self-evaluation, held by each subject. The SEI is a brief self-report inventoryconsisting of 25 self-statements and taking typically 10 minutes or less to complete. Eight self-statements reflect a positive appraisal, (ie. "My family understands me"), with the remaining 17indicating a negative self-appraisal (ie. "I give in very easily"). Respondents indicate for eachstatement, whether it described how he or she usually feels, by marking one of two boxes, labelled'Like Me' and 'Unlike Me'. Positive statements marked 'Like Me' and negative statementsmarked 'Unlike Me' are scored as 'correct'. Raw scores are multiplied by four to obtain the TotalSelf Score. High scores indicate high self-esteem.Numerous studies concerning various forms of validity and reliability of the School Formare reported in the SEI Manual (Coopersmith, 1981), with reliability coefficients ranging from .8064Methodologyto .92. While the majority of studies cite validations specifically relevant to children and schoolperformance criteria, a handful of validation studies of the school form provide useful informationrelating to adult functioning. Coopersmith (1967) demonstrated that SEI scores tend to correlatepositively with measures of creativity, resistance to group pressures, perceived reciprocal likingand willingness to express unpopular opinions. In addition, Matteson (1974), found SEI scoresto be positively correlated with measures of effective communication between family members andfamily adjustment.The Coopersmith Adult Form is essentially identical to the school form, with several itemsreworded slightly to reflect age-appropriate social and work situations. This form was normed ona group of over 200 college and university volunteers, aged 16 to 34. Norms reported for subjectsaged 20 to 34 (N=148) include the mean score (g=66.7± 18.8) and Cronbach alpha (a..81).Minor gender differences were reported, with females scoring slightly higher on average (p.=71.6)than males (1.58.4). No other reliability or validity data is available for the SEI Adult Form.Rotter Personal Beliefs Ouestionnaire (I-E Scale) The Rotter Personal Beliefs Questionnaire (Rotter, 1966) is a self-report inventorydesigned to assess the extent to which an individual perceives the locus of control of events asinternal or external. The questionnaire consists of twenty-nine pairs of statements which reflectcommonly held beliefs about personal causality and responsibility. For example, item #15 reads:a) "In my case getting what I want has little or nothing to do with luck", reflecting an internal senseof control; and b) "Many times we might just as well decide what to do by flipping a coin",reflecting a belief in externally controlled events. Twenty-three statement pairs contribute to thescore, with the remaining six included as 'filler' items. Respondents are required to select the onestatement from each pair which they most strongly believe to be true. The order of 'internal'statements and 'external' statements are randomly alternated. Scores are calculated by a simpletally of the number of 'internal' statements. Higher scores reflect greater internal locus of control.The average time required to complete the inventory is between five and ten minutes.Reliability and validity of the I-E Scale have been demonstrated in a series of studies by the65Methodologytest author, as well as others (Rotter, 1966). Reliability coefficients on test-retest trials over a one-month span ranged from .60 to .78 for males and .83 for females (Rotter). Retest scores aftertwo months correlated .55 with original test scores, for men and women combined. Internalconsistency coefficients ranged from .65 to .79 (Rotter).Item validity for the I-E Scale was established through repeated trials and refinements, inwhich 77 of the 100 original test items were eliminated on the basis of high social desirabilityscores or their lack of discriminant value. Construct validity for the remaining 23 items wasdemonstrated in a study in which medical patients were compared on the basis of observedpassivity versus self-effort toward recovery (Seeman & Evans; as reported in Rotter, 1966).Since its publication in 1966, Rotter's instrument has been used widely in a range ofexperimental conditions to measure the cognitive dimension of locus of control. In the presentstudy, Rotter's instrument is used to measure an aspect of 'psychosocial competence' (Tyler.,1978), a cognitive-emotional contruct consisting of an individual's sense of self-worth and self-efficacy.Derogatis SCL-90-RThe Derogatis SCL-90-R (Derogatis, 1975) is a widely used inventory designed tomeasure symptoms of psychological distress. In the present study, the SCL-90-R will be used asa dependent measure, to gauge the level of emotional and physical distress felt by subjectsexperiencing infertility.The SCL-90-R consists of 90 indicators of psychological distress. Respondents indicatethe extent to which they have experienced each over the past week. Most respondents completethe survey in approximately 15 minutes (Derogatis, 1975). Scale range is from 0 = 'not at all' to4 = 'extremely'. The scoring of the SCL-90-R produces nine subscales corresponding withdistress symptoms often reported by infertile couples, as well as three general distress indices.The symptoms identified are a) Somatization (SOM), b) Obsessive-Compulsive (OBS),c) Interpersonal Sensitivity (INT), d) Depression (DEP), e) Anxiety (ANX), f) Hostility (HOS),g) Phobic Anxiety (PHOB), h) Paranoid Ideation (PAR), and i) Psychoticism (PSY). The three66Methodologygeneral indices are derived through combinations and summations of the symptom scores, andinclude; a) The General Severity Index (GSI), reflecting both number and intensity of symptomsreported; b) The Positive Symptom Total (PST), reflecting number of symptoms reported; and c)The Positive Symptom Distress Index (PSDI) reflecting intensity of symptoms reported. Due tothe potential problem with regards to multicollinearity presnted by the use of additive scores inconjuction with subscales, only the scores from the nine symptom subscales were included in thestatistical analysis. High correlations between subscales scores are a normal feature of this test,resulting in possibly inflated numbers of significant variates. However, the depth and breadth ofinformation available through the subscale scores was viewed as the preferred alternative in a studyof differences between individuals.Reliability and validity information reported in the SCL-90-R manual (Derogatis, 1975)suggests that the instrument is well-researched. Correlational coefficients comparing the ninesymptom subscales range from .77 to .90 (Derogatis, 1975), suggesting high internal consistency.Such high coefficients, however, suggest that distinctions between subscales should be made withcaution. Test-retest coefficients ranging from .78 to .94 (Derogatis, 1977; Edwards, 1978) havebeen reported.Concurrent validity of the SCL-90-R has been demonstrated with high reportedcorrelations with symptom scores on the MMPI and the Middlesex Hospital Questionnaire(Boleoucky & Horvath, 1974; Derogatis, Rickels & Rock, 1976). Normative data is provided inthe SCL-90-R manual (Derogatis, 1975) for both psychiatric and non-psychiatric adult andadolescent populations.The SCL-90-R has been tested extensively, in a wide range of clinical and medicalresearch. Of interest in the present context, several studies have found the SCL-90-R to be usefulin assessing changes in stress levels in populations responding to a variety of health-relateddifficulties. Clinical levels of distress were detected in individuals with sexual dysfunctions(Derogatis, 1976), cancer patients (Craig & Abelhoff, 1974), and chronic pain patients (Hendler,Derogatis, Avella & Long, 1977). Derogatis (1980) also utilized the SCL-90-R to develop a67Methodologyprofile of the psychological impact of breast and gynaecological cancers on women. In these andother studies, the SCL-90-R has demonstrated a high degree of sensitivity to changes in stresslevels, as well as the ability to discriminate between categories of patients, and between patient andnon-patient populations (Derogatis, 1975).For the present study the demonstrated sensitivity of the SCL-90-R to stress levels is ofgreatest interest. It may be expected that non-psychiatric-case levels of distress may be indicatedin a variety of the symptom categories, many of which are consistent with stress-related symptomsreported by infertility patients (Menning, 1980). Finally, the substantial validity and reliability datareported (Derogatis, 1975), the provision of relevant normative data, as well as the ease ofadministration and brevity of the SCL-90-R make it a useful instrument in the measurement ofsymptomatic distress levels of individuals responding to the experience of infertility.Adjustment to Infertility (AIS)The Adjustment to Infertility Scale (Sabatelli, Meth & Gavazzi, 1988) was used to measurethe level of adjustment to, or acceptance of a number of issues which have been identified asrelevant to the experience of infertility. The MS consists of thirty-two 'I-statements' aboutfeelings, perceptions and behaviors of the individual relative to the experience of infertility.Respondents indicate their degree of agreement with each statement on a 5-point Likert-type scale,ranging from 1='strongly disagree' to 5='strongly agree'. Areas of focus assessed by the AISinclude the impact of infertility upon the respondents self-concept, sexual identity, maritalrelationship and sexual relationship. Higher scores indicate better adjustment. Completion time isapproximately five minutes.Sabatelli et al. (1988) provided normative data on sample of 52 women and 29 men, all ofwhom were members of infertile couples. A reliability coefficient of .91 was reported (Sabatelli etal., 1988), although it is unclear how this was achieved. Moderate to high negative correlationswith measures of anxiety and depression, ranging from -.29 to -.70 (Sabatelli et al., 1988), lendsupport to claims of construct validity. Based upon much of the literature previously cited (Frias& Wilson, 1985; Kraft et al., 1980; Menning, 1980; Sabatelli et al., 1988; Valentine, 1986;68MethodologyWoollett, 1985), the measure appears to address many of the issues of greatest relevance to thoseexperiencing infertility, frequently echoing statements reported by infertile subjects. While themeasure at present appears to lack sufficient supportive data to warrant its exclusive use as acriterion measure, the focus upon the primary issue of infertility provides a valuable adjunct to themore general factors assessed by the SCL-90-R (Derogatis, 1975). For this reason, as well as itsease of administration, the AIS was selected as a measure in the study of adults experiencing theinfertility transition.ProcedureFor the period of just over one month, all eligible patients attending scheduledappointments at the the Infertility clinic in the Obstetrics and Gynaecology Department at FoothillsHospital in Calgary, Alberta were informed of the study. The assistance and cooperation of clinicphysicians was enlisted in identifying patients who met the eligibility criteria. Physicians informedall eligible patients of the study and invited each to volunteer as subjects. Only one couple wasreported to have declined at this point. After signing a release (Appendix B), agreeing to allow thephysician to provide the researcher with their name(s), interested couples and individualsproceeded directly to the researcher, located in a spare office or examining room within the clinic.Interviews were conducted with all candidates by the principal investigator, to explain thepurpose, the structure and the requirements of the study and to provide an opportunity forcandidates to ask questions. In cases where both members of the couple participated, the interviewwas held jointly. To guide the explanation, the letter of introduction (Appendix C) was read aloudby the interviewer as volunteers read along. Volunteers were then given an opportunity to raisequestions and concerns. The interviewer endeavored to respond as completely as possible,without revealing the hypotheses of the study. At this time, candidates were offered theopportunity to withdraw from participation. All volunteers interviewed agreed to proceed at thispoint. All participants then read and signed a consent form which articulated each subject's rights,including the right to confidentiality and the right to withdraw at any time, as well as an assurancethat their participation as subjects would be entirely independent of any and all medical treatment69Methodologyreceived at the clinic (Appendix D). Addresses were collected on this form, for purposes of follow.up correspondence. Completed consent forms were held in a file separate from all responsematerials.Once consent forms were completed, subjects were given the P.I.S. (see Appendix A),containing questions seeking demographic and factual data. Subjects were asked to complete thissurvey before leaving the clinic. To facilitate this, the researcher left the room to allow for privacy.After approximately five minutes, the researcher returned to collect the completed P.I.S.forms. Each participant was then given the questionnaire package, containing a second copy ofthe introductory letter, the five measurement instruments and a large, stamped envelope, pre-addressed to the investigator. The five instruments were counter-balanced for order ofpresentation, using a randomized Latin square design, to address any effects order of presentationmay have on subject responses. The average time required to complete each of the fiveinstruments was between 5 and 15 minutes. The entire questionnaire package required between 45minutes and one hour to complete.Subjects were specifically instructed to complete the contents independent of their partner,to control for the effects of interpersonal influence on subject responses. To reduce the effects ofsocial desirability, subjects were encouraged to respond to the measures as candidly as possible,reiterating that anonymity of responses was assured. Subjects were instructed to omit their namesfrom all material in the questionnaire package. Individual response forms were identified only bynumerical codes, to facilitate analysis of the data.Questionnaire packages were taken home to be completed and returned through the mail inthe pre-addressed, stamped envelope provided. Subjects who did not return questionnairepackages within one month of the interview were sent a follow-up letter (Appendix E)encouraging participants to return the instruments as soon as possible. Participants who had notreturned the completed package within one month of the distribution of the follow-up letter wereidentified as having withdrawn from the study and no further contact was made.70MethodologyAnalysis of DataThe goal of the present study was to determine the degree to which the characteristics of theindividual and characteristics of the particular transition were related to the individual's levels ofadaptation and psychological distress in response to the experience of infertility. The questionwas of relatedness and a procedure describing a multi-correlational relationship was thereforerequired. Although several formulae are adequate to describe the relationships of the severalindependent variables, the inclusion of multiple dependent measures restricted the choice ofappropriate analysis to Canonical correlation (Tabachnick & Fidell, 1983), a procedure ideallysuited to answering the questions asked within the study.Two canonical correlations were performed, one for each of the two sets of independentvariables; characteristics of the transition and characteristics of the individual. Canonicalcorrelations produce pairs of linear combinations, or 'canonical variates', representing eachsignificant correlation between predictor and criterion variables. The use of this procedureprovides extensive descriptive data which reveals the various dimensions along which the two setsof predictor variables and criterion variables are related.Following the two canonical analyses, which constituted the primary investigation, anumber of additional statistical procedures were performed to clarify various elements of the data.T-tests were performed to compare subjects by gender on the new canonical variates. In addition,a series of multivariate analysis of variance procedures were performed to compare groups by raceand sex-role on the newly created canonical variables. New canonical analyses were performedwith these variables removed to facilitate the comparisons. All statistical procedures wereaccomplished with the use of the BMDP statistical package for computers.71ResultsCHAPTER FOURResultsIn this chapter the results of all statistical analyses performed on the collected data arepresented. Descriptive statistics of the scores obtained by the sample on the standardizedmeasures are reported, as well as the results of the canonical correlational analyses depicting therelationship between the predictor variables and the criterion variables.Assumptions and Data HandlingIn this section the manipulations or deletions made to the raw data are described. Includedin this description are an explanation of the handling of missing data as well as an examination ofthe assumptions underlying the statistical analyses and the procedures used to handle data whichfailed to conform to these assumptions.Cases including missing data were handled in one of two ways. On variables for which amathematical average could be obtained (any variables scored on an interval or ordinal scale), themissing score was replaced with the average score. For those items which were measured on anominal (categorical) scale, missing cases were left blank.An examination of the assumption of normality basic to a canonical analysis revealedabnormally high skewness and kurtosis for a number of variables. Each variable was examinedindividually for the effect of its non-normal distribution and was either deleted or included,according to the impact of the distribution on the overall result.The distribution of scores on one predictor variable and one criterion variable were extremein their abnormality. As reported in Chapter 3, the Yes/No split on the dichotomous predictorvariable regarding the cultural value of children was 93% to 7%, producing abnormally highskewness (2.90) and kurtosis (6.48). This imbalance rendered the effect on the canonical variatesdifficult to interpret, and resulted in the variable being dropped from further correlational analyses.The distribution of scores on the Phobic Anxiety' subtest of the Derogatis SCL-90-R wasalso strongly positively skewed (2.88) with extreme kurtosis (8.42). Examination of the raw data72Resultsrevealed that 69% of respondents scored '0.00' on this subtest. As this variable had a very lowloading on the output canonical variates, it was removed from subsequent calculations to eliminatethe possible negative effects of its abnormal distribution.Scores on three other criterion variables, 'Somatization', 'Anxiety' and 'Psychoticism',were sufficiently abnormally distributed to require closer scrutiny. Distributions for each of thesevariables were moderately positively skewed (-2.00) with moderately high kurtosis (-4.4). Afterremoving each variable singly as well as cumulatively from successive runs of the canonicalcorrelation, it was noted that the pattern of relative loadings of the remaining variables remainedstable across trials, suggesting little negative effect of the distribution patterns. To maintain theintegrity of the study, as well as to increase the interpretability of the results, these variables wereincluded in the final analysis.Five additional predictor variables received treatment of note. Two characteristics of theindividual variables (religion and previous experience) consistently exhibited extremely lowcorrelations with significant canonical variables on successive runs of the program and weretherefore dropped from subsequent runs. A third predictor variable, sex, demonstratedconsistently low contributions to the variates and was removed from the pool of input variables tofacilitate comparisons by sex on the outcome canonical variate scores (reported in AdditionalAnalyses). Fourth, the number of months seeking medical assistance was highly correlated withthe number of months attempting to conceive. To avoid the effects of multicollinearity, only thelatter measure was used. Finally, the distribution of the sample by race or ethnic origin wasmoderately uneven, with a disproportionate number being grouped into a single category(skewness = 2.16; kurtosis = 3.18). Although the distribution was of some concern, thecontribution of this variable to the outcome variate scores was consistently significant, althoughdifficult to interpret. Scores for race were therefore included in the main analysis, but excludedfrom one run so that outcome canonical variate scores might be compared by racial category todetermine the nature of their influence.73ResultsDescriptive Data: Independent VariablesA summary of the descriptive data for all variables entered into the canonical equation asindependent variables is included in Table 3. Mean scores for Self-Esteem (78.45 ± 15.68) andLocus of Control (13.65 ± 3.81) compared favorably with standardized norms for similarpopulations. Scores for Income level and Education level were combined arithmetically (Income xEducation) to derive the new variable Socioeconomic Status (SES). Participants tended to berepresentative of a somewhat high socioeconomic group.Table 3: Descriptive Data for Independent VariablesCharacteristics of the Individual Characteristics of the TransitionVariable Mean SD Variable Mean SDSelf-Esteem 78.45 15.68 Diagnosis *2.83 1.31Locus of Control 13.65 3.81 Duration (in months) 48.11 28.88Age 31.52 4.87 Perceived Outcome * 1.63 .78SES 10.00 3.25 Hope *2.21 1.09Sex-Role *2.34 1.13Health *3.59 .52Race *1.36 .88* See following paragraph for explanationThe remaining independent variables included in the canonical analyses were categorical innature and therefore require more complete description. Of the Characteristics of the Individualentered into the analysis, scores for the variables of Sex-Role Identity, General Health and Racereflect categorical groupings. As noted in Chapter 3, individuals were assigned to one of four sex-role categories based on their mean scores on the subscales of masculinity and femininity. Thefour categories were #1 Androgynous (32%), #2 Masculine (18%), #3 Feminine (30%) and #4Undifferentiated (20%). The group mean (II = 2.34 ± 1.13) reflects the fairly even distribution ofthe scores.Scores on the variable Race reflect four racial and ethnic categories, including White/Anglo(1), French Canadian (2), Asian (3) and Other (4). The mean score (1.1 = 1.36 ± .88) indicates aclustering of scores in the first two categories. The mean score of the categorical variable General74ResultsHealth (II = 3.59 ± .52) reflects a clustering of scores at the higher end of the range (1 = Poor, 2 =Fair, 3 = Good, 4 = Excellent), indicating a majority of the sample reported good or excellenthealth.Three variables included in Characteristics of the Transition, including Diagnosis,Perceived Outcome and Hope, were also measured categorically. Diagnosis was measured in fivecategories, including No diagnosis (1), Unknown Cause (2), Male Factor (3), Female Factor (4)and Couple Factor (5). For the present analysis, the mean score of II. = 2.83± 1.31 is included.The mean score of perceived outcome (II = 1.63 ± .78) represents scores in three categories,Uncertain (1), Temporary (2) and Permanent (3). Finally, the individual's perceived chances ofsuccess (Hope) were measured in ordered categories with (1) representing a less than 25% chance,(2) reflecting a 25 to 50% chance, (3) indicating a 50 to 75% chance and (4) reflecting a better than75% chance of success. Distributions for each of these variables are detailed in Chapter 3.Descriptive Data: Dependent VariablesA summary of descriptive data for the scores entered into the canonical analysis asdependent variables is included in Table 4. Subject scores for symptom subscales on the SCL-90-R were compared with standardized norms for men and women provided by Derogatis (1975). Onaverage, subject means were approximately one standard deviation above non-patient populationmeans, indicating elevated distress levels. Data for all subjects (males and females) was combinedfor entry into the canonical analyses.Table 4: Dependent VariablesWomen Men CombinedVariable Mean	 SD Mean	 SD Mean	 SDSomatization .44	 .36 .31	 .30 .44	 .45Obsessive Compulsiveness .55	 .54 .60	 .44 .61	 .56Interpersonal Sensitivity .57	 .46 .40	 .40 .54	 .49Depression .58	 .48 .50	 .45 .58	 .50Anxiety .38	 .45 .35	 .31 .40	 .42Hostility .45	 .48 .43	 .45 .46	 .47Paranoid Ideation .40	 .54 .31	 .39 .40	 .52Psychoticism .22	 .30 .20	 .34 .23	 .32Adjustment to Infertility 119.05	 15.98 122.67	 16.84 120.13	 16.9975ResultsCanonical Correlational AnalysesCanonical correlational analyses were performed using BMDP6M (Frane, 1988) betweenthe set of predictor variables and the two sets of criterion variables. Separate analyses werecomputed for those variables included in the 'characteristics of the individual' cluster and thoseincluded in the 'characteristics of the transition' cluster.Characteristics of the Transition Four characteristics of the transition variables were entered into a canonical correlationalanalysis as predictor variables. These were: Infertility diagnosis (five levels), Perception ofOutcome (three levels), Perception of Chances for Success (four levels: ordinal) and Duration ofInfertility (number of months trying to conceive). 	 Eight symptom subscale scores as well as anAdjustment to Infertility score were entered into the correlation as criterion variables.Hypothesis One: The first research hypothesis predicted that there would be no statistically significantcanonical correlation at the a = .05 level on the mean scores on a weighted linear composite ofscores for the dependent variables of Somatization, Obsessive Compulsiveness, InterpersonalSensitivity, Depression, Anxiety, Hostility, Psychoticism and Adjustment to Infertility for theindependent variables of Diagnosis, Duration, Perception of Outcome and Perception of Successand the joint effects of these factors.The results of the first canonical correlational analysis supported the null hypothesis. Thefirst canonical correlation was .58 (X 2 = 49.04; df = 36; a = .07). Although it was notsignificant at the a = .05 level, the correlation coefficient suggested that the two sets of variableswere correlated at approximately r =.6, indicating that some relationship existed between thedependent and independent variables (see Figure 1).Canonical loadings, which are the correlations between the new canonical variables and theoriginal variables, are presented in Table 5. An examination of these statistics revealed that, of theindependent variables, Perception of Outcome (r = .5) and Duration (r = .48) appeared to76Resultscontribute most strongly to this relationship. Canonical loadings of the dependent variablesindicated that 'Interpersonal Sensitivity' was the single strongest contributor to the correlation.The direction of these scores relative to each other appeared to suggest that symptoms ofInterpersonal Sensitivity tended to decrease as the duration of infertility increased and were alsoless for individuals who perceived their infertility to be a permanent condition.Figure 1	Linearity of Correlation Between First Canonical VariatesCharacteristics of the Transition2 1	 111 1 111 1 11 1 1111111 11 112 11 1 12 11 111 111 1 1 11 11 111 1 1 11	 111-1 11 1 1 1-	 1 1	 112 +	 1 11+ + + + + + + +	 +-1.8	 -.60	 .60	 1.8-2.4	 -1.2	 0.0	 1.2	 2.4CNVRS177ResultsTable 5: Loadings for First Canonical Variable(Correlations of Canonical Variables with Original Variables)Independent Variables Dependent VariablesVariable	 CNVRF1 Variable CNVRS1Diagnosis	 -.392 Somatization .065Duration	 .477 Obsessive Compulsiveness .013Outcome	 .500 Interpersonal Sensitivity -.403Chances	 .037 Depression -.154Anxiety .244Hostility .312Paranoid Ideation .114Psychoticism .016Adjustment to Infertility -.148Characteristics of the IndividualEight 'characteristics of the individual' variables were entered into a canonical correlationalanalysis as predictor variables. These were: Self-Esteem, Locus of Control, Sex-Role (fourcategories), General Health (four levels), Age, Race (four categories), Income (four levels) andEducation (four levels). The latter two variables were arithmetically combined using a transformparagraph to create a new variable SES (socioeconomic status). Eight symptom subscale scores aswell as an Adjustment to Infertility score were entered into the correlation as criterion variables.Hypothesis Two: The second research hypothesis predicted that there would be no statistically significantcanonical correlation at the a = .05 level on the mean scores on a weighted linear composite ofscores for the dependent variables of Somatization, Obsessive Compulsiveness, InterpersonalSensitivity, Depression, Anxiety, Hostility, Psychoticism and Adjustment to Infertility for theindependent variables of Self-Esteem, Locus of Control, Sex-Role, General Health, Age, Race andSES and the joint effects of these factors.The canonical correlations and the results of the Chi-square test for statistical significanceof the canonical correlations are displayed in Table 6. The first canonical correlation was .70and was significant at the a = .01 level. The second canonical correlation was .59 and wassignificant at the a = .05 level. The third canonical correlation was .49 and was not significant.78Table 6: Results of Canonical CorrelationsEigenvalue	 Canonical Con.	 Chi-Square	 df	 Probability.497 .70 110.25 63 .00.351 .59 67.99 48 .03ResultsThese results indicated that two significant and non-orthogonal links exist between the two sets ofvariables (See Figures 2 & 3) and required a rejection of the null hypothesis for this set ofvariables.Figure 2 	Linearity of Correlation Between First Canonical VariatesCharacteristics of the Individual2111121 2 121 11 21 1 11	 1 1- 1 1 12 11 1+ 11 11111	 11	 21	 1	1	 1	 12	 1	 1	 1	 11	 12-2-2.5	 -1.5	 -.50	 50	 1.5-3.0	 -2.0	 -1.0	 0.0	1.0CNN/RS 179ResultsFigure 3	 Linearity of Correlation Between Second Canonical VariatesCharacteristics of the Individual 3121 111 + 22 111	 111 1	 12 11 121	 1 1 11 112	 11	 11 1	 111	 1 112	 1	 21 12 1	 1 11 1 11 1 11 11 14-.90 .90 2.7 4.5-1.8 0.0 1.8 3.6CNVRS2A summary of the canonical loadings of the independent variables on the first two canonicalvariates is presented in Table 7. An examination of these statistics revealed that five independentvariables contributed to the first canonical variable. Self-esteem (r = .57), SES (r = .53), and Race(r = .51) all contributed quite strongly to the new variable, with self-esteem contributing thestrongest effect. Locus of control (r = .47) and Age (r = .43) also contributed at moderate butsignificant levels. As self-esteem and locus of control appeared to play a significant part in this80Table 7: Loadings for First and Second Canonical Variables(Correlations of Canonical Variables with Original Variables)Independent Variables CNVRF1 CNVRF2Self-Esteem .57 -.59Locus of Control .47 -.19Sex-Role -.16 .41Health -.06 -.21Age .43 .69Race .51 .26SES .53 -.11Resultsvariable, as well as high socioeconomic status, the underlying dimension linking the variablesappeared to be related to a sense of well-being or physical and psychological 'Security'. tThis may involve what Schlossberg (1981) refers to as 'Psycholosocial Competence'. Theinfluence of Race was not easily understood within this context and was addressed separately in alater section.Canonical loadings of the first two canonical variables for the second set (dependent) ofvariables are presented in Table 8. A number of the original variables contributed at a significantlevel to the new variables, with Hostility (r = -.78) and Somatization (r = -.7) exhibiting verystrong correlations and Interpersonal Sensitivity (r = -.57), Paranoid Ideation (r = -.5), Depression(r = -.5) and Obsessive-Compulsiveness (r = -.5) exhibiting a moderately strong effect. Anxiety(r = -.44) and Adjustment to Infertility (r = .45) also contributed to the overall correlation. Thedimension underlying this first canonical variate appeared to be related to the effects of irritabilityand anger, both internalized and externalized .By examining the content and the direction of the loadings on first canonical variable, itwas possible to suggest the nature of the relationship between the two sets of original variables.The results obtained suggested that those individuals who reported a high level of psychosocialcompetence, or security with themselves and their surroundings were less likely to respond toinfertility with symptoms of tension and anger and were somewhat more likely to report higherlevels of adjustment to infertility, than those individuals who indicated less physical or81Table 8: Loadings of First and Second Canonical Variates(Correlations of Canonical Variables with Original Variables)Dependent Variables CNVRS1 CNVRS2Somatization -.70 .32Obsessive Compulsiveness -.50 .70Interpersonal Sensitivity -.57 .51Depression -.51 .60Anxiety -.44 .80Hostility -.78 .19Paranoid Ideation -.51 .33Psychoticism -.32 .55Adjustment to Infertility .45 -.09Resultspsychosocial security.Examination of the canonical loadings for the second new canonical variable revealed a newset of links between the two sets of original variables. The second canonical variable wasindependent of the first, as it represented the linkages which exist between the two sets of variablesafter the effects of the first canonical variable were removed.Loadings of the predictor variables into the second canonical variate indicated that three ofthe independent variables played a significant role in the relationship. In this second new variable,the effect of Age (r = .69) appeared to be the strongest contributor, with Self-Esteem (r = -.59)contributing a significant negative effect. Sex-Role also appeared to be correlated moderatelystrongly (r = .40) to this new variable, although it showed only a negligible effect on the firstcanonical variate. The structural dimension represented by this variable was more difficult todefine than was the first. It was clear that higher age and lower self-esteem appeared to beclustered. The influence of Sex-Role was less clear and required some interpretation. Higherscores on the categorical variable of sex-role were achieved by individuals who identified withpredominantly feminine characteristics (category 3) or who showed low identification withdescriptors of either gender-type (undifferentiated: category 4). Both categories are distinguishedby low identification with (masculine) traits which reflect a sense of self-directedness or personalefficacy. Individuals in the latter category, undifferentiated, have also failed to identify with82Results(feminine) traits reflecting qualities such as emotional warmth and nurturance. Taken together, themasculine and feminine character traits included in the Bern (1974) instrument constitute a fairlycomprehensive listing of those personality traits considered valued in our society. Individuals whodeny having any of these traits may be indicating an image of themselves as lacking in manypersonality traits. Thus the higher sex-role scores loading on this variate appeared to indicate agroup of individuals who characterize themselves as lacking in those aspects of personality mostvalued by society. In combination with the low self-esteem and higher age reported by theseindividuals, it appeared that the construct informing this second canonical variate was a measurereflective of a poorly defined and negative self-image.On the other side of this second new variate, Anxiety (r = .8) and Obsessive-Compulsiveness (r = .7) exhibited very strong correlations, with Depression (r =.6), Psychoticism(r = .55) and Interpersonal Sensitivity (r = .5) all contributing moderately strongly. Takentogether, it appeared that the underlying dimension measured by this canonical variate related to thefeelings and behavior symptomatic of anxiety or nervousness.In examining the structure of the canonical loadings for the second canonical variable, it waspossible to determine the nature and shape of the relationship identified between the two sets ofpredictor and criterion variables. Unlike the first canonical variate-pair, which primarily measuredthe positive impact of individual strengths on levels of distress experienced by the participants, thesecond variable appeared to measure the effect of individual weaknesses. The results suggestedthat those infertile individuals who were older and who had low self-esteem and an undifferentiatedgender identity also tended to exhibit elevated levels of anxiety and nervousness, expressed asincreased emotional and behavioral symptoms of distress.Additional AnalysesIn an effort to further clarify the pattern of results obtained through the canonicalcorrelational analyses, a series of comparison tests were performed. Using individual scores onthe newly created canonical variates as raw data, subjects were compared on the basis of gender,race and sex-role.83ResultsComparison on Canonical Variates by GenderUsing BMDP3D (Sockne & Forsythe, 1988) independent t-tests were performed tocompare males and females on the two canonical variate pairs. The results are presented in Table9. As indicated, no significant differences were found between males and females on either of thecanonical variables.Table 9:	 Comparison of Males & Females on First and SecondCanonical Variate PairsVariable Women Men T Score df P Value11 	SD I.1	 SDCONVRF1 -.12	 .97 .21	 1.03 -1.35 55.1 .18CONVRF2 -.05	 .97 .08	 1.06 -.53 54.2 .60CONVRS1 -.10	 1.03 .15	 .95 -1.07 60.9 .29CONVRS2 -.07	 1.13 .11	 .78 -.82 68.7 .42Comparison of Canonical Variables by Race As previously reported (see Table 7), scores on the variable Race showed a strong positivecorrelation (r = .51) with the first new canonical variable (CNVRF1). The nature or the meaningof this relationship was difficult to interpret within the context of the underlying dimension ofpsychosocial competence or security. To clarify the role played by race, a new canonical analysiswas performed. For this run, scores for race were removed from the pool of predictor variables sothat the outcome canonical variables could be compared by racial group.Using the BMDP6M (Frane 1988), a canonical correlational analysis was performed withrace excluded. Input variables in the first set included: Self-Esteem, Locus of Control, Sex-role,Health, Age and SES. Input variables for the second set were: Somatization, ObsessiveCompulsiveness, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Paranoid Ideation,Psychoticism and Adjustment to Infertility. The results of this new canonical correlation (SeeTable 10) reveal that the percentage of variance, as indicated by the Eigenvalue, dropped fromalmost 50% of the variance accounted for in the first analysis, to 39% of the variance accounted for84Table 10: Canonical Correlations - Race ExcludedEigenvalue	 Canonical	 Chi-Square	 df	 ProbabilityCorrelation.386 .621 88.33 54 .002.339 .582 58.05 40 .032Resultswhen race was removed. However, this appears to be the only change. There are still two stronglinks between the two sets of variables, with the first canonical link having a correlation of r = .62and the second also showing a strong correlation of r = .58.Furthermore, as can be seen in Table 11, the pattern of correlations between the originalvariables and the new canonical variables (canonical loadings) remains essentially unchanged. Thecontributions of each of the variables, relative to one another, is virtually the same as was seen inTables 5 and 6.Table 11:	 Loadings for First and Second Canonical Variates(Correlation of Canonical Variables with Original Variables)Independent Variables Dependent VariablesVariable	CNVRF1 CNVRF2 Variable	 CNVRS1 CNVRS2Self-Esteem	 .873 -.190 Somatization -.667 .070Locus of Control	 .600 .113 Obsessive-Compulsive -.815 .351Sex-Role	 -.145 .481 Interpersonal Sensitivity -.800 .150Health	 .054 -.196 Depression -.746 .296Age	 .123 .828 Anxiety -.748 .525SES	 .639 .240 Hostility -.718 -.112Paranoid Ideation -.728 -.046Psychoticism -.663 .228Adjustment to Infertility .567 .24085ResultsUsing BMDP7D (Dixon, Sampson & Mindle, 1988) to conduct a one-way analysis ofvariance, subject scores were compared by racial group (White/Anglo, French Canadian, Asian &Other) on the four new outcome variables, CNVRF1, CNVRF2, CNVRS 1 and CNVRS2.Separate analyses were performed for each of the outcome variables. Descriptive data andprobability values are reported in Table 12. As can be seen, no significant differences were shownbetween groups.Table 12: Comparison of Group Means by RaceVariable Anglo Fr. Can. Asian Other df F Value P-Value1.1.	 SD pt	 SD p.	 SD pi.	 SDCNVRF1 .06 ± .9 .44 ± .5 -.17 ± 1.4 -.82 ±	 .7 3 1.46 .233CNVRF2 -.04 ± 1.0 .51 ± .4 -.34 ±	 .4 .45 ± 1.5 3 .81 .495CNVRS1 -.02 ± 1.0 .76 ± .3 -.40 ± 2.0 .09 ±	 .8 3 .80 .499CNVRS2 -.06 ± 1.0 .09 ± .4 .29 ± 1.1 .57 ± 1.4 3 .72 .545Group sizes were dramatically disproportionate however, as White/Anglos outnumbered allthe other groups combined by a factor of five to one. Although statistical corrections for thisimbalance are provided with the BMDP program, the extremely small numbers in the otherrepresentative groups (French Canadian, Asian and Other) renders this comparison relativelymeaningless. As no group differences could be identified on the variable of race, it is suggestedthat the high loading observed on this variable in the first canonical variate may have been merely afactor of the skewness found in these scores.Comparison of Canonical Variates by Sex-Role Although the variable sex-role was not significantly related to the first new canonicalvariable formed, it played an important role in defining the underlying dimension of the secondcanonical variable (See Table 7). In an effort to further clarify the relationship between sex-roleidentity and the new canonical variables formed, a new canonical analysis was performed in whichsex-role was removed from the pool of original predictor variables, so that the outcome canonical86Table 13: Canonical Correlations - Sex-Role ExcludedEigenvalue Canonical	 Chi-Square	 df	 ProbabilityCorrelation.496 .705 98.25 54 .00.342 .585 55.73 40 .05Resultsvariables could be compared by sex-role category.Using the BMDP6M (Frane, 1988), a canonical correlational analysis was performed withsex-role excluded. Input variables in the first set included: Self-Esteem, Locus of Control,Health, Age, Race and SES. Input variables for the second set included: Somatization, ObsessiveCompulsiveness, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Paranoid Ideation,Psychoticism and Adjustment to Infertility. The results of this new canonical correlation (SeeTable 13) revealed two strong links between the two sets of variables. The first canonical linkshowed a strong correlation (r = .70) and was significant at the a < .001 level. The secondcanonical correlation was also high (r = .58), and was significant (a =.05).As can be seen in Table 14, the pattern of correlations between the original variables andthe new canonical variables (canonical loadings) remained essentially unchanged. Thecontributions of each of the variables, relative to one another, were virtually the same as was seenin Tables 7 and 8.Table 14: Loadings for the First and Second Canonical Variables(Correlations of Canonical Variables with Original Variables)Independent Variables Dependent VariablesVariable CNVRF1 CNVRF2 Variable CNVRS 1 CNVRS2Self-Esteem .56 -.65 Somatization -.69	 .31Locus of Control .47 -.24 Obsessive-Compulsiveness -.50	 .74Health -.06 -.21 Interpersonal Sensitivity -.57	 -.55Age .44 .65 Depression -.50	 .62Race .50 .35 Anxiety -.42	 .80SES .54 -.19 Hostility -.77	 .18Paranoid Ideation -.51	 .44Psychoticism -.32	 .62Adjustment to Infertility .46	 -.2087ResultsUsing BMDP7D (Dixon et al, 1988) to conduct a one-way analysis of variance, subjectscores were compared by sex-role category (Androgynous, Masculine, Feminine&Undifferentiated) on the four new outcome variates, CNVRF1, CNVRF2, CNVRS 1 andCNVRS2. Separate analyses were performed for each of the outcome variables. Descriptive dataand probability values are reported in Table 15.Table 15: Comparison of Group Means by Sex-RoleVariable Androgynous Masculine Feminine Undifferentiated df F Value P-ValueCNVRF1CNVRF2CNVRS1CNVRS2A	 SD IA	 SD g	 SD g	 SD3333.46.76.40.87.714.520.750.459.08 ± 1.0-.19 ± .8.14 ± 1.0-.16 ± .9.21 ± 1.0-.06 ±	 .8-.13 ±	 .9.02 ±	 .7-.07 ± 1.0.04 ± 1.1.04 ±	 .9-.06 ±	 .9-.22 ± 1.1.33 ± 1.3-.20 ± 1.2.39 ± 1.6No statistically significant group differences were found. However, the pattern of groupmeans suggested some interesting trends. Undifferentiated subjects appeared to score somewhathigher than the other three groups on CNVRF2 and CNVRS2, the two variables which suggesteda relationship between a negative self-image and high anxiety. Although these differences were notsignificant, the trend appeared to support the inclusion of undifferentiated sex-role as an identifyingcharacteristic of the group represented by the canonical link. Conversely, these same subjectsappeared to score lower than the other three groups on CNVRF1 and CNVRS1, the linkedcorrelates which reflect low distress and high psychosocial security, suggesting the possibility thatundifferentiated indiviudals may tend to report less psychosocial security and more hostility andsomatization.Scores for high masculine subjects also appeared to indicate a possible trend. Highmasculine individuals scored quite high on CNVRF1, but scored very low on the outcome variable(CNVRS 1). This trend appeared to indicate the possibility that, although high masculine subjects88Resultstended to indicate a high level of psychosocial security, they may have actually exhibitedheightened levels of hostility and somatization as compared with feminine and androgynoussubjects.SummaryIn summary, a series of statistical analyses were performed with the data. Twohypotheses were offered regarding the relationships between a group of dependent variables andthe two groups of independent variables. No significant relationship was detected for the first setof independent variables (characteristics of the transition) and the dependent variables (responses toinfertility) and the null hypothesis was therefore accepted.For the second hypothesis, however, the null was rejected as two distinct correlationallinks were shown between the set of independent variables (characteristics of the individual) andthe dependent variables (responses to infertility). The first link illuminated a relationship betweenphysical and psychological security and a decreased tendency to respond to infertility with anger.The second link was characterized by a tendency for older individuals with low self-esteem and anundifferentiated sex-role to demonstrate elevated levels of anxiety and tension in response toinfertility.Additional analyses were conducted to clarify the role of individual variables.Comparisons by gender indicated no significant differences between men and women on any of thecanonical outcome variables. While race appeared to exhibit a strong influence on the firstsignificant canonical link, subsequent analyses suggested that this effect may have been largely anartifact of the disproportionate weighting of a single racial category (White/Anglo). Finally,subsequent analyses to isolate the effects of sex-role revealed that, although no significantdifferences between sex-role types was detected, there was a tendency for undifferentiatedindividuals to score somewhat higher on the variates reflecting high anxiety and low-self-esteemand for masculine individuals to score somewhat lower on the variate measuring emotionalcalmness.89Discussion ConclusionsCLIAMEMEDiscussionIn this final chapter a discussion of the results is presented, including an attempt tointerpret their meaning and relevance, as well as a brief commentary on the limitations of the studyand recommendations for future directions in research. In addition, some considerations forcounsellors working with infertile couples and individuals will be addressed.Discussion of the Findings The explicit purpose of the present study has been to identify the characteristics of theindividual and of the specifics of the transition, which may help counsellors and other helpers topredict how individuals and couples may respond to infertility. The implicit purpose of the studyhas been to provide counsellors with information which may help to identify and arrangeappropriate interventions for those who are at high risk of experiencing serious difficulties incoping with the experience of infertility.While the focus has been on individual differences, it must be noted that the resultsindicated that, as a whole, the sample of infertile subjects exhibited moderately high levels ofdistress on all symptom subscales, as compared with standardized norms. Although elevatedscores were noted on all symptom subscales, of particular note were elevated scores on measuresof obsessive-compulsiveness, interpersonal sensitivity, depression, hostility and psychoticsymptoms, all characterized by physical and emotional agitation. The distress scores achieved bythe infertile sample were similar to those achieved by a sample of patients with chronic medicalillness, but were well below scores achieved by a psychiatric population (Derogatis, 1975). Thus,infertility may be comparable in emotional impact to conditions such as cancer or kidney disease.While it must be recognized that the impact of infertility was felt by all the subjects, thepurpose of this study was to identify individual differences in response. A series of canonicalcorrelational analyses were employed because of the ability of this procedure to describe thenumber of different ways in which two sets of variables relate to one another. The analysis90Discussion Conclusionsproduced a series of independent, non-orthogonal canonical variates which represented the uniqueways in which the predictor variables, the characteristics of the individual and the characteristics ofthe transition, were related to the criterion variables, the measures of psychological distress andadjustment to infertility. The fact that more than one link between the two sets of variables wasdiscovered is important because, instead of observing how infertile people as an aggregate grouprespond to infertility, the results allowed for an understanding of how different individuals respondto the experience.Characteristics of the Transition The first analysis was performed to determine the link between specific characteristics ofthe transition, including the duration of infertility and the diagnosis, as well as the individual'sperceptions regarding the outcome and the chances for success. Although no significantrelationships were detected at the a =.05 level between any of the characteristics of the transitionand the outcome indices of distress and adjustment, the high correlation (r = .6) was significant ata = .07, and does suggest that the two sets of variables are related in some way. An examinationof the data revealed that symptoms of interpersonal sensitivity, including self-consciousness andfeelings of not being understood appeared to decrease somewhat as the duration of infertilityincreased. While these results may not be used for predictive purposes, they do lend support to thefindings of Daniluk (1988) and others (Sabatelli et al., 1988), who found that distress levelstended to decrease as the length of time men and women lived with their infertility increased.Within the same canonical link, subject's perception of outcome also appeared to contributestrongly. In this case, it appeared that individuals who perceived their infertility to be permanent,rather than uncertain or temporary, reported somewhat fewer interpersonal distress symptoms.Again, this result is not significant at a = .05, but it does tend to support previous findings. Feuer(1983) reported that men who had received a diagnosis of azoospermia, a permanent and finalcondition, reported significantly lower distress levels than did men whose less final diagnosis leftthe outcome uncertain. The stress of uncertainty also appeared to play a role in Daniluk's (1988)findings that couples who had not yet received any diagnosis, or whose diagnosis was unclear or91Discussion Conclusionsambiguous, demonstrated significantly higher levels of distress than couples who had received adiagnosis, even if that diagnosis was of permanent infertility. Thus, although the relationshipshown by these data between decreased interpersonal sensitivity and the perception of infertility aspermanent was not statistically significant, the findings appeared to corroborate a relationshipdemonstrated elsewhere.The remaining characteristics of the transition, diagnosis received and perceived chances ofsuccessful pregnancy, did not appear to contribute in any meaningful way to the link. Nor did anysymptoms of distress other than interpersonal sensitivity appear to play any part in the relationship.The poor performance of diagnosis as a factor predicting distress levels may be understoodas an artifact of the research methodology, providing an opportunity to address certain concernsregarding the choice of approach. The use of the general correlational procedure of canonicalanalysis restricted the ability to make fine distinctions regarding individual factors. In the case ofdiagnosis, subjects were not matched to diagnosis (ie. own factor/ partner's factor) nor was acomparison made on the basis of which partner was identified as being the cause of infertility.Rather, diagnosis by category was one of several possible factors within the pool. While thisprocedure may well have served to dilute or obscure the effects of individual factors, such asdiagnosis, it did allow the researcher to examine a wide range of possible factors and to observethose factors which appeared to have the strongest predictive value.Thus, while there may or may not be differences in the way members of infertile couplesrespond on the basis of who is diagnosed as infertile, no effect was shown for this factor in thepresent study. What did appear to be evident, however, was a trend in which individuals whohave been enduring infertility for an extended period of time, and who perceive infertility to be apermanent condition, demonstrated a decrease in self-consciousness and in the tendency to besensitive or reactive to other people's inability to understand or empathize with their situation. Itappears that the longer an individual lives with infertility, the more he or she becomes accustomedto being infertile. As time goes on, the insensitive and personal questions, and the illogicalsuggestions that infertile people are frequently subjected to (Sandelowski & Jones, 1986) become a92Discussion Conclusionsfamiliar and predictable occurrence, no longer engendering the feelings of pain, humiliation andanger they once did.With familiarity often comes a sense of comfort or acceptance of infertility. For thoseindividuals and couples for whom infertility is permanent and final, acceptance of infertility maylead to the inclusion of infertility as a part of identity, an essential and final step in the process ofsuccessful adaptation to a transition (Schlossberg, 1981). It may be suggested that, for theseindividuals, the process of adaptation may be somewhat more rapid than for those individualswhose outcome is uncertain or ambiguous.Characteristics of the IndividualA majority of the sample scored high on the first canonical variable (See Fig. 2). Thecharacteristics this group of individuals have in common may be described as 'psychosocialsecurity', as reflected in the tendency for high self-esteem, an internal locus of control and higherSES to covary. It appeared that these men and women had a fairly solid and secure sense ofthemselves and their abilities in the world as they tended to indicate a positive evaluation ofthemselves and their abilities to effect change. By and large, they were mature in age and had ahigh level of education and a comfortable standard of living.Although group means for the sample indicated elevated levels of distress in general, thegroup whose scores contributed to the first canonical variable tended to exhibit an 'emotional calm'as indicated by the relatively low incidence of symptoms of distress overall, reflected in themoderate to high negative correlations of the symptom subscales with the new variable. Inparticular, this group exhibited fewer symptoms of anger, as measured by the symptom subscalesof somatization and hostility, and of irritability or self-consciousness, as reflected by scores on theinterpersonal sensitivity subscale.The positive effects of self-esteem on the individual's ability to cope effectively withinfertility have been demonstrated repeatedly (Adler & Boxley, 1985; Chiappone, 1984; Fouad &Fahje, 1989; Murray & Callan, 1988; Sabatelli, Meth & Gavazzi, 1988). In accordance withthese findings, self-esteem scores provided the single largest contribution to this first canonical93Discussion Conclusionsvariate, accounting for the majority of the variance in the outcome variate representing lower levelsof anger and interpersonal sensitivity.It is interesting to note that age contributed to this first canonical variate, indicating thathigher age is moderately correlated with lower distress. This concurs with previous findings,(McEwan, et al., 1987; Sabatelli et al., 1988) which showed older women tending to report lowerlevels of distress. These fmdings appear to challenge the popular notion that, because age isinversely related to a woman's childbearing capability, increased age should lead to increasedfeelings of distress in response to infertility. However, age is only moderately correlated with thenew canonical variate (r = .43). It may be that although these women and men are somewhat olderthan the mean, they are not the oldest in the sample. In fact, age is correlated much more stronglywith the second canonical variate (r= .69), suggesting that those men and women contributing tothe second link were, on average, an older group than those represented here.The meaning of age in this canonical variable may best be understood in conjunction withthe covariates, higher SES, higher self-esteem and higher internal locus of control. The men andwomen who scored high on this variable were those individuals who have achieved a level ofmaturity, stability and material comfort, and who were not yet at the 'critical stage' when the timeleft on the woman's 'biological clock' would make further attempts to become pregnant highlyrisky and increasingly futile. As this is obviously an issue of greater salience to women than men,the mean scores on this variate were compared for the two sexes. A very slight nonsignificantdifference was found between males and females for these paired canonical variates, with menscoring marginally higher than women on both, indicating little advantage for men over women inthis group in terms of psychosocial security and emotional calmness.Individual scores on the first pair of canonical variates were compared for the four groupsof sex-role types (androgynous, masculine, feminine and undifferentiated). Although thedifferences between group means were not statistically significant, the pattern of scores for thedifferent groups were interesting. Undifferentiated individuals scored markedly low on the'psychosocial security' variable. This observation was consistent with Adler and Boxley's (1985)94Discussion Conclusionsfinding that undifferentiated sex-role types scored low on measures of self-esteem and body image.These results suggest that an undifferentiated sex-role identity may be indicative of a poorlydefined sense of self overall, characterized by a lack of identification with positively valuedcharacteristics of either men or women.These non-significant trends suggested that undifferentiated men and women also appearedto indicate a high level of anger, irritability and somatic symptoms. This trend may be reflective ofa general pattern of vulnerability to distress which may, in turn, reflect poor coping skills. In fact,undifferentiated individuals also appear to display heightened levels of a variety of distresssymptoms. This pattern may be more fully clarified with the results of the second canonical link.The second pair of canonical variates represented a relatively small but distinct group ofsubjects (Fig. 3). The dominant characteristics linking the group of people who scored high on thefirst (predictor) variable of the pair were low self-esteem, an undifferentiated sex-role identity andhigher age. These characteristics were linked with an outcome variable comprised of high levels ofemotional distress symptoms, marked primarily by heightened symptoms of anxiety, includingnervousness, fearfulness and obsessive behaviors.As with the first variate, self-esteem scores contributed strongly to the new predictorvariable. In this case, however, a strong negative correlation with self-esteem scores indicated anegative identity as a predominant defining feature. It appeared that the relationship demonstratedby this link is one between low self-esteem or a poorly defined self-image and a pattern of highlevels of distress symptoms. This result supports the numerous studies which cite low self-esteemas a reliable predictor of poor coping efficacy (Chiappone, 1984; Fouad & Fahje, 1989; Sabatelliet al., 1988).Two other scores contributed strongly to the 'negative identity' variable. Among these wasan undifferentiated sex-role identity, as suggested by a moderately high positive loading of sex-rolescores. As the categorical nature of the sex-role scores made this result somewhat ambiguous, afurther statistical analysis was conducted in which sex-role scores were removed from the pool ofinput variables and comparisons by sex-role score made on these new variables. Undifferentiated95Discussion Conclusionsindividuals scored very high on both the new predictor variate (negative identity) and on the newoutcome variate (high anxiety), in comparison to the mean scores for the other three sex-rolegroups. Although the differences observed were not statistically significant, this procedure servedto clarify the relationship between sex-role scores and the new variable. It appeared that anundifferentiated sex-role score, indicating low identification with a variety of masculine andfeminine characteristics, was linked with low self-esteem in predicting elevated feelings of anxietyin response to infertility. These findings concurred with the results of Adler and Boxley (1985),as cited above, that undifferentiated sex-role scores are related to low scores on measures of self-esteem and body image and to higher levels of distress in response to infertility.In addition to low self-esteem and an undifferentiated sex-role identity, age contributedvery strongly to the 'negative self-image' variable, and in fact represented the strongest factor.This suggested that these highly anxious subjects were among the oldest of the sample. This resultappeared to be in contradiction with earlier results in which age contributed to the 'psychosocialsecurity' variate, as well as with the findings of McEwan et al. (1987) and Sabatelli et al. (1988),that older women reported lower levels of distress.In light of this apparent conflict, this finding required further investigation and clarification.Individual canonical variable scores were examined to identify those individuals who scored high(> .9) on the 'negative self-image' and 'high anxiety' variates. Of this group, over half were age37 or older. The average age for men in this group was 39.0 years. The average age of womenwas 34.3 years, but this included one 26 year old. The median age for women in this group was37 years. These results were compared with age means for high scorers (> .9) on the first variatepair linking 'psychosocial security' with 'emotional calmness' (32.0 years for women; 35.7 yearsfor men) as well as with the age means for the sample as a whole (30.7 years for women; 32.7years for men). Thus, it appeared that, although the men and women who scored high on the firstvariate pair were somewhat older than the sample mean, many of the men and women who scoredhigh on negative identity and high anxiety were, in fact, the oldest members of the sample.Thus, these results would appear to indicate that the relationship between age and96Discussion Conclusionsemotional distress levels for infertile men and women may not be linear, as suggested by earlierresults (McEwan et al., 1987; Sabatelli et al., 1988). Instead, these results suggest that there mayactually be a curvilinear relationship between aging and distress levels for infertile men andwomen, with coping efficacy increasing with maturity up to a point, after which increased ageappears to be related to an increase in feelings of anxiety and fearfulness for infertile men andwomen. The point at which the positive effects of age on responses to infertility cease and thenegative effects begin cannot be identified with the data available. As such a relationship has notbeen reported elsewhere, further research would be required to validate and support thisobservation.In seeking to explain the reasons for the observed results regarding age, a number ofpossibilities may be examined. The most readily apparent theory would explain the results in termsof a race against the 'biological clock', suggesting that a woman experiencing infertility woulddevelop increased symptoms of anxiety and distress as she nears the end of her naturalreproductive years and the time remaining to seek a solution diminishes. This theory, however, isunsupported by other research. Moreover, it fails to adequately explain the fact that distress levelsappear also to increase for men in the older age group. While it may be argued that older men aremore likely to be married to older women who are facing a reproductive deadline, this argumentdoes not satisfactorily explain the observed increase in older men's distress levels.As was the case with the first variate of psychosocial security, the influence of higher ageon increased levels of distress may best be understood when examined in conjunction with the twoother factors contributing to the variable of 'negative identity', low self-esteem and anundifferentiated sex-role. Taken together, these three factors appear to suggest a possible profileof individuals who have progressed through adulthood without having developed a definite senseof who they are or what they can accomplish. These men and women appear to have definedthemselves in negative terms, and appear to be able to identify what they are not, but not what theyare. They may have passively 'drifted', neglecting career, educational and personal development,with perhaps a long-held belief, that whatever else fails, they may always become parents. Faced97Discussion Conclusionswith infertility when there is little time left to realize this option, these individuals may be facing aprofound crisis of identity.Schlossberg (1984) notes that identity issues are fundamental to the individual's ability toadjust to transitions. Individuals with a negative identity, who are unable to identify their strengthsand resources, may be ill-prepared to face a transition if they see themselves as ill-equipped tocope. Such individuals may find the loss of fertility particularly overwhelming as it may in factrepresent the perceived loss of the 'last chance' to develop a sense of purpose or meaning in life.A similar but distinctly different profile may also be derived of individuals who haveactively postponed or eschewed self-development because they have long expected to assume theidentity of parenthood. Matthews and Matthews (1986) have suggested that couples andindividuals whose commitment to a 'parenthood identity' is high, and who fail to fulfil theexpectations of that identity, may suffer an 'identity shock'. They note that "the greater thecommitment to biological parenthood, the greater will be the identity shock brought about byinfertility and involuntary childlessness, and the more negative the affect (sic) on self-esteem"(p.646). Schlossberg (1984) also suggests that an individual whose sense of identity is derivedprimarily from a role, or the assumption of such a role, will find "the very foundations of (his or)her life shaken" (p. 22) when faced with the loss of that role.The levels of distress reported by the group of subjects identified as having a 'negativeidentity' may certainly be described as symptoms of a profound disruption of identity. These menand women scored high on measures of anxiety, obsessive-compulsiveness, depression,psychoticism and interpersonal sensitivity, indicating signs of an acute state of mental andemotional disorientation, irrational thoughts and behavior, and agitation.SummaryThe results of the correlational analyses conducted appear to describe a number of factorswhich may be related to an individual's pattern of responses to infertility. Men and women whoreported positive evaluations of themselves and who appeared to have higher levels of lifestylesecurity and comfort appeared also to report fewer symptoms of distress, especially symptoms of98Discussion Conclusionsanger. Men and women with undifferentiated sex-role identities, who have low self-esteem andwho are considerably older than the average first-time parent appear to be at the greatest risk offeelings of distress and anxiety in response to infertility and may experience infertility as a crisis ofidentity. In addition, although the relationship was not observed at a statistically significant level,actual and perceived duration of infertility appeared to be strongly related to feelings of distress.Men and women who had been infertile for longer periods of time and who perceived theirinfertility to be permanent appeared to report fewer symptoms of distress than did those men andwomen who had been infertile for less time or who perceived the duration of their infertility to betemporary or uncertain.Implications for Counsellors In discussing the implications and recommendations for counsellors, the purpose is topresent a profile of those individuals who may be most at risk of experiencing difficulties inresponse to the experience of infertility. In this context, two risk groups may be identified anddiscussed. The specific counselling needs of each group will be outlined with recommendationsfor appropriate counselling approaches.Recently Infertile: The first group identified as being at risk of emotional distress inresponse to infertility may be described as the 'newly infertile'. Although the results of the presentstudy failed to show the link between duration of infertility and levels of distress at significantlevels, the trend observed herein has been demonstrated elsewhere. Daniluk (1988), as well asSabatelli et 0.(1988) observed that distress levels tended to decrease with time spent dealing withinfertility. The implicit inference is that couples and individuals who have only recently soughtmedical attention regarding an inability to conceive, or who have just received a diagnosis ofinfertile, may be at high risk of experiencing feelings of disorientation, confusion and anger(Menning, 1980).It is during the initial days and weeks of the infertility investigation that couples may bemost in need of supportive counselling. Menning (1980) has noted that, in response to the newsof infertility, many people feel a profound sense of shock and surprise, often followed by denial99Discussion Conclusionsand anger. Daniluk (1988) has reported that infertile couples identified the first few weeks of theinfertility investigation as the time when counselling would be most useful.The primary goals of counselling for those who are dealing with recent news of infertilitywould be to provide a safe environment, to validate the couple's feelings and to provideinformation. Many adults may have difficulty acknowledging the often overwhelming feelings ofhurt, frustration, anger, guilt and sadness engendered by infertility, as they "may be so painful that(couples) must deny the reality of these feelings" (Wiehe, 1976, p.29). The most important taskis to validate the client's experience. By encouraging the expression of feelings and demonstratingnon-judgmental acceptance and reflection of emergent emotions, the counsellor provides thenecessary environment in which the infertile couple can begin to recognize and express the extentto which infertility has affected their lives (Menning, 1980; Sabatelli et al, 1988; Sawatzky,1981).Another important goal of counselling for this group is to provide information for thecouple or individual about infertility and its impact. It is important to normalize the experience byexplaining that feelings of anger, hurt, guilt, depression and blame are normal and predictableresponses to both the fact of infertility and to the infertility investigation (Born, 1989; Menning,1980). In addition, information regarding the incidence of infertility may help couples to normalizetheir experience by realizing that they are not alone, that in fact infertility affects as many as one insix couples.In addition, information about the causes of infertility, as well as details of the diagnosticand treatment procedures involved in the infertility investigation, are very important to manycouples in providing a sense of control as they work through their feelings. If the counsellor is notconnected with an infertility clinic he or she is unlikely to be well-versed in this information andcan be most helpful by providing material or references for clients to read. Books by Menning(1977) and by Pfeffer and Woollett (1983), which explain the procedures in clear, non-technicallanguage are useful resources for recommended reading.Counselling for this group of recently infertile men and women may be most effective100Discussion Conclusionswhen both partners attend. By modelling acceptance and validating the experience of theindividual, the counsellor's acknowledgement of different ways of responding can help to facilitateacceptance by each member of the couple of the validity of their partner's experience (Born, 1989;Hendricks, 1985).Older/ Negative Self-Image: The second identifiable risk group may be described by thefactors which covaried to create a profile of individuals at risk of experiencing high levels ofanxiety, obsessive-compulsiveness and depression. The most striking feature of this group is theiradvanced age. More than half of the men and women contributing to this profile were over the ageof 37. This fact alone may represent a significant risk factor if the primary cause for distress is theperception of diminishing time left to successfully reproduce.Two additional factors contributed strongly to the profile, however, providing a morecomplete picture of the individual at risk. The men and women in this group reported verynegative self-appraisals. In addition to scoring low in self-esteem, a majority of these people ratedthemselves very low on a wide range of personality characteristics typically described as masculineor feminine. In other words, these men and women appeared reluctant or unable to identifythemselves as possessing any gender-identity related strengths or weaknesses, as being essentiallylacking in salient gender traits.As with age, a poorly defined self-image and low self-esteem may be sufficient criteria toplace these infertile individuals at risk of having difficulties coping with infertility. The resultssuggest, however, that these factors tend to covary and therefore may be related in somemeaningful way. Whether these are individuals who have passively 'drifted' through adulthood,or who have actively postponed their own development in favor of the expected parenthood role,they appear to lack a positive sense of identity. The intense feelings of anxiety, agitation anddepression these individuals exhibit may be a result of having arrived near the end of theirreproductive years threatened with the loss of what may be perceived as the only role still availableto them. For these people, the perceived loss of the ability to become parents may represent, in avery real sense, a complete loss of identity.101Discussion ConclusionsThe goals of the counsellor working with such clients would be complex and multi-level.In most cases, individual therapy would be recommended, although work including the partner orother family members may be useful at various point of the therapy. Initially, therapy mayresemble the supportive counselling described above, as the counsellor builds a relationship,validates the client's experience, and facilitates the expression of feelings of anger and grief. Astherapy progresses, however, it will be necessary for the counsellor to become more active and tofocus more on helping the client to build self-esteem and a realistic self-image. This may involvean accurate assessment of the individual's strengths and capabilities as well as an examination ofhis or her needs, hopes and dreams. The use of exercises and techniques which promote self-awareness and challenge negative self-appraisals may be useful.As the individual begins to identify his or her unique strengths and capabilities, thecounsellor may begin to encourage exploration of the motivations for becoming a parent. Motivesfor parenthood may be simple or complex and may include the individual's desire to meet his orher own needs for ego expansion, dependency, affiliation, conformity, status, occupation, virilityor a sense of purpose, as well as more selfless motives as the desire to care for and protect ahelpless infant or a desire to create something worthwhile and permanent (Pohlman, 1970; Turner& Helms, 1983; Sawatzky, 1981).An examination of motives for parenthood may be extremely painful for those individualswho have low self-esteem and a poorly defined self-image, and should therefore be approachedwith extreme care. This task is likely to raise some of the most challenging issues regardingidentity, prompting questions such as "If I can't be a mother/father, who or what am I?"As difficult as it is, the examination of motives is an essential step in identifying theindividual's needs and is a prerequisite to the next step of generating alternative ways of meetingthose needs (Daniluk, 1991; Mahlstedt, 1987). Dependent on the outcome of the process ofevaluation, individuals may need to examine a number of options which meet their needs to a lesseror greater extent. At this point in therapy, it may be desirable to include the partner, as many of theavailable options may require cooperation or accommodations on the part of either or both partners.102Discussion ConclusionsFor example, if an individual decides that his/her desire to have a child is primarilymotivated by the need for ego expansion, creativity, control or occupation, he/she may choose tofind alternative means for meeting these needs, through increased pursuit of career or educationalgoals, changes in occupation or otherwise. Some may discover that their desire is primarily aresponse to social pressures, and may choose to live childfree. Many, however, will determinethat their needs can best be met through becoming a parent and will choose to pursue adoption.For older couples, however, this option may also be fraught with difficulties.Although often seen as the end of the infertility saga, the decision to adopt is often just thebeginning of a new episode of the experience. At the minimum, the initial decision to adopt leadsto a variety of further considerations, including whether the age, sex, race and health of theadopted child are important, whether to adopt privately or through public agencies, and the natureand extent of the relationship desired with the birth mother. In addition, many experience theadoption process as highly stressful and experience a resurgence of feelings of grief as the finalityof the infertility is underscored. For those who have not effectively resolved feelings regardingtheir identity as an infertile person, adoption may be seen as a confirmation of their inadequacyand failure. The process of adoption also contains reflections of many of the issues raised byinfertility, and couples often find feelings of anger and loss of control being reactivated in responseto the probings and scrutiny of the adoption worker (Hendricks, 1985).The adoption investigation, conducted with the purpose of ascertaining the appropriatenessof the couple as adoptive parents, is often referred to as intrusive and insulting, as the adoptionworker attempts to determine whether the couple have effectively resolved their feelings aboutinfertility. As offensive as this indignity may seem, the purpose may be a valid one. There issome evidence that ineffective or incomplete resolution of feelings regarding infertility may havedetrimental effects on future parenting. Burns (1990) found that parents who had been treated forinfertility were significantly more likely to exhibit disturbed patterns of parenting, includingoverprotectiveness, abuse and neglect. These parents included those who had adopted as well asthose who had achieved pregnancies through IVF or AI.103Discussion ConclusionsThe counsellor's role in this final phase of therapy is multidimensional and idiosyncratic.For those clients who have resolved their feelings surrounding infertility and parenthood more orless effectively, therapy will consist primarily of facilitating the decision-making process. Thismay be achieved by using exercises and counselling techniques which help couples to generateoptions, evaluate them in light of available resources, prioritize and select those which have thegreatest potential to both meet their needs and be successful.Those who continue to struggle with issues regarding infertility and identity willnevertheless need to make decisions. For these individuals, the process of decision-making will bemost effective if it is integrated with repeated returns to a focus on self-esteem and identitydevelopment.Implications for ResearchersIn this final section, a discussion of implications and recommendations for researchers ispresented. The purpose of this section is to present a brief review of some of the materials andmethodology utilized in the present study, with a view to evaluating the efficacy and usefulness ofeach. In addition, the author presents a brief discussion regarding recommendations for possibledirections for future investigations in the study of individual responses to infertility.Review of Methods and MaterialsThe present investigation was designed to examine how personality, demographic andsituational characteristics of the individual may affect the nature of his or her responses to theexperience of infertility. Despite, or perhaps because of, an ambitious research design, including alarge number of elements for consideration, the findings represent only a glimpse of the"extraordinarily complex reality that accompanies and defines the capacity of human beings to copewith change in their lives" (Schlossberg, 1981, p.3). In this context, the present study may beregarded as exploratory and, it is hoped, as a contribution to a growing body of research designedto clarify and describe the complex nature of how personality and situational factors define thecapacity of men and women to cope with infertility.In evaluating the present attempt, an important point of concern may be raised regarding the104Discussion Conclusionsuse of a single trial measure of a transition which may take many months or years to complete. Asa one-time-only sampling, the study essentially represented a 'snapshot' of the state andfunctioning of the subjects at a particular point in time. The primary focus of the present study,however, was on the characteristics of the individual such as gender, self-esteem and sex-roleidentity, as well as characteristics of the infertility which may affect the way individuals respond toinfertility. There is reason to assume that the measures used to assess individual characteristics arestable, (ie. that Subject X would score the same or very similar on, for example, the measure ofself-esteem, if taken one week, one month or one year from the original test date). Repeated use ofthe standardized measures used in the study has indicated fairly high reliability (Bern, 1974;Coopersmith, 1981; Rotter, 1966).An important consideration, however, is the apparent assumption of stability of the levelsof distress measured. Within the context of the infertility transition, an experience which has beenrepeatedly described as one with many fluctuations in mood and affect, it is a potential point ofargument whether the results achieved are more representative of the global functioning level of theindividuals surveyed, or of a temporary state.To achieve a more comprehensive understanding of the mediating effects of personalityand situational variables on individuals responses to infertility, it is suggested that future researchstudies make greater efforts to control for the changeable nature of the infertility transition. Thismay be done in one of two ways. One possible design is to selectively sample individualsexclusively at a specific step of the infertility work-up, (ie. immediately post-diagnosis). Such adesign would likely necessitate a lengthy period of data collection, as it may take several months toidentify and contact a sufficiently large sample. In the event that such a time commitment ispossible, it is arguable that time and efforts may be more profitably spent in employing alongitudinal or repeated measures approach, such as was employed by Daniluk (1988) or Edelman,Connolly and Robson (1989). In such a design, infertile individuals would be surveyed atspecified intervals throughout the infertility work-up. In this way, the assumed stability of theindividual's personal and situational factors may be confirmed or disconfirmed. Such a design105Discussion Conclusionsmay provide more complete information regarding who may be most at risk of emotional distressin response to infertility, as well as whether different types of individuals are more vulnerable atdifferent stages of the transition.Finally, comment must be made regarding the use of the Adjustment to Infertility Scale(Sabatelli, et al., 1988) as an outcome measure. This instrument was obtained with permissionfrom the designer prior to having been substantiated through use in published research other thanby its author. As such, use of the instrument in the present study may be considered a trial, andtherefore requires comment regarding its validity as well as its applicability as a research tool.The validity of the instrument may be gauged, in part, by the degree to which it correlateswith measures designed to assess constructs of a similar nature. Within this context, it may beexpected that higher levels of adjustment to infertility may be related to decreased evidence ofsymptomatic distress in response to infertility. To this end, correlations with SCL-90-R scores,for both males and females, were examined. No relationship was seen between AIS scores andglobal SCL scores for men. For women, however, a mild negative correlation (r= -.35) wasshown between AIS scores and SCL global scores, indicating a slight tendency for women whoindicated lower global distress levels to report higher levels of adjustment to infertility.An examination of correlations between AIS scores and scores for individual subscales ofthe SCL-90-R suggested a pattern of symptoms which may be related to adjustment to infertility.For women, mild negative correlations were observed between MS scores and scores on the SCLsubscales of Interpersonal Sensitivity ( r = -.42), Depression (r = -.39) and Phobic Anxiety(r = -.47), suggesting that women who reported higher levels of adjustment to infertility alsoindicated somewhat lower levels of interpersonal sensitivity, depression and anxiety. For men, theonly relationship observed between AIS scores and SCL subscale scores was for Depression (r= -.3), suggesting that men who reported high adjustment to infertility appeared to also report slightlylower levels of depression. These were only mild correlations, however, suggesting that, althoughthere may be some connection between the levels of distress symptoms and individual's adjustmentto infertility, the AIS did not appear to be measuring distress levels.106Discussion ConclusionsOf more immediate salience to the needs of the present study was the ability of the AIS tocontribute to the picture of how men and women respond to infertility. AIS scores were includedin each of the three Canonical analyses, but in each case failed to contribute to the pattern ofresponses to infertility. This suggests that the AIS may lack the sensitivity to discriminate in adiscernible way between individuals who are at risk of poor adjustment to infertility and those whoare adjusting well.On the other hand, it may be inappropriate to apply the concept of 'adjustment' in a studyexamining individuals who are in the process of undergoing the infertility work-up. It may be thatadjustment is a state only achievable by individuals who have terminated the infertility investigationand who are in the process of evaluating and considering alternatives to biological parenthood. Inthis context, it may be suggested that the Adjustment to Infertility Scale may best be utilized as anassessment tool in working with subjects seeking adoption or other alternatives.Thus, although the AIS may be of use for research assessing responses to infertility, it wasnot found to provide and useful information in the present study. It is suggested however, that theAIS may be useful both as a clinical and a research tool for working with individuals preparing tomove through the final stages of the infertility transition, to gauge the success with which thetransition was made.Directions for Future Research While the present study demonstrated two clear links between characteristics of theindividual and responses to infertility, the data also provided suggestive evidence of a handful ofrelationships which may be indicative of possible directions for further study. Chief among therelationships suggested by the non-significant findings was the observed correlation between actualand perceived duration of infertility and distress levels. As demonstrated by Daniluk (1988) andSabatelli et al. (1988), increased duration of infertility appears to be related to fewer symptoms ofdistress reported. The failure of this relationship to be shown significantly in the present studymay indicate that duration of infertility is less useful in predicting distress levels than are othervariables. However, the fact that duration has been demonstrated as a significant predictor of107Discussion Conclusionsdistress in other studies, but not here, suggests that the relationship between these variables may bemoderated by a third, as yet unknown, factor. To clarify this relationship, these questions warrantfurther attention.A second potential area for future investigations was suggested by the observed pattern ofscores for individuals in the different sex-role categories. When scores on the new canonicalvariates of psychosocial security, emotional calmness, negative self-image and anxiety werecompared, the data suggested that men and women with masculine sex-role identities, as well asthose people with undifferentiated sex-role identifies, appeared to score markedly low on theoutcome variable representing emotional calmness. This non-significant trend appeared to suggestthe possibility that men and women who identify with masculine traits may have actually exhibitedheightened levels of anger and irritability as well as increased incidence of somatic symptoms suchas headaches, chest pains, nausea, dizziness and muscle aches.These trends may reflect social role expectations for masculinity. O'Neil (1981) notes thatmen are traditionally socialized to restrict the direct expression of grief and sadness, which may beseen as signs of 'emotional weakness'. In their place, many men are taught that expressions ofaggressiveness, including anger and hostility, are the legitimate outlet for the masculine male'sfeelings (O'Neil). Therefore, men and women who identify with the masculine ideal, assuggested by high masculinity scores, may be more likely to respond to the stress of infertility withexpressions of anger and hostility, rather than with sadness or grief. Such a restriction orredirection of emotion may result in a buildup of tension which could lead to somatic symptoms,such as headaches, muscle and chest pains, nausea and dizziness.The evidence for a relationship between masculine sex-role identity and heightened levelsof anger and irritability in response to infertility is only suggestive in the present data. However, ifsuch a relationship between sex-role identity and responses to infertility can be substantiated, itsimplications are many. In addition to increasing the counsellor's ability to identify men andwomen who are at risk of experiencing difficulty with infertility, the identification of such arelationship may serve to further our understanding of men's and women's social roles.108Discussion ConclusionsMoreover, it may be useful to discover whether responses such as hostility and somatization arespecific to infertility, or whether these symptoms represent a typical response pattern for masculineindividuals. Further investigation will be required to answer these and other questions.Conclusion The purpose of the present study was to identify characteristics of the individual andcharacteristics of the infertility transition which may help counsellors and other helpingprofessionals to understand the differences in individual responses to infertility, as well as toidentify those individuals who may potentially be at risk of experiencing heightened distress andcrisis feelings in response to infertility. 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Overview: Sex roles, fertility and the motherhood mandate. Psychology ofWomen Quarterly, 4, 7-15.Sabatelli, R.M., Meth, R.L. & Gavazzi, S.M. (1988). Factors mediating the adjustment toinvoluntary childlessness. Family Relations, 31, 338-343.Sandelowski, M. & Jones, L.C. (1986). Social exchanges of infertile women. Issues in MentalHealth Nursing, 173-189.Sandelowski, M. & Pollock, C. (1986). Women's experiences of infertility. Image: Journal ofNursing Scholarship, la, 140-144.Sawatzky, M. (1981). Tasks of infertile couples. Journal of Obstetrics. Gynaecological and Neo-Natal Nursing, (Mar/Apr), 132-133.Schlossberg, N.K. (1981). A model analyzing human adaptation to transition. The CounsellingPsychologist, E 2-18.Schlossberg, N.K. (1981b) Reactions to reactions. The Counselling Psychologist, E 49-50.Schlossberg, N.K. (1984). Counseling Adults in Transition: Linking Practice with Theory,New York: Springer Publishing Company.Seibel, M.M. & Taymor, M.L. (1982). Emotional aspects of infertility. Fertility and Sterility, 12,137-145.Short, J. (1989). Infertility tales. Self Magazine, (May), 188-192.Sockne, D. & Forsythe, A. (1988). T-tests. In, W.J. Dixon, M.B. Brown, L. Engelman, M.A.Hill & R.I. Jennrich (Eds). BMDP statistical software manual. Berkeley: University ofCalifornia Press.Snarey, J., Son, L., Kuehne, V.S., Hauser, S. & Vaillant, G. (1987). The role of parenting inmen's psychosocial development: A longitudinal study of early adulthood infertility andmidlife generativity. Developmental Psychology, 22, 593-603.Snarey, J. (1988). Men without children. Psychology Today, (Mar), 61-62.Spence, J.T., Helmreich, R. & Stapp, J. (1975). Ratings of self and peers on sex role attributesand their relation to self-esteem and conceptions of masculinity and femininity, Journal ofPersonality and Social Psychology, 31, 29-39.114ReferencesTabachnick, B.G. & Fidel!, L.S. (1983). Using multivariate statistics. New York: Harper &Row.Trepanier, K. (1985). Infertile couples: Alone in a crowd. The Canadian Nurse, al,42-45.Turner, J.S. & Helms, D.B. (1983). Lifespan development (2nd ed.), New York: Holt, Rinehart& Winston.Tyler, F. (1978). Individual psychosocial competence: A personality configuration. Educationaland Psychological Measurement, 31, 309-323.Valentine, D.P. (1986). Psychological impact of infertility: Identifying issues and needs. SocialWork in Health Care, 11, 61-69.Veevers, J.E. (1980). Childless by choice. Toronto: Butterworths.Walker, H.E. (1978). Psychiatric aspects of infertility. Urologic Clinics of North America, 1,481-488.Walker, H.E. (1978b). Sexual problems and infertility. Psychosomatics, 12, 477-484.Wiehe, V.R. (1976). Psychological reaction to infertiltiy. Psychological Reports, ,'i$, 863-866.Wiehe, V.R. (1976b). Psychological reactions to infertility: implications for nursing in resolvingfeelings of disappointment and inadequacy. journal of Obstetric. Gynecologic andNeonatal Nursing, ¢, 28-32.Woollett, A. (1985). Childlessness: Strategies for coping with infertility. International Journal ofBehavioral Development, a, 473-482.Woollett, A. & Pfeffer, N. (1983). The experience of infertility. London: Virago Press.115APPENDIX APERSONAL INFORMATION SURVEYThe following questions address some facts about you. Pleaseselect the answer which most closely applies to you. Indicateyour answers in the spaces provided, or by circling the appropriateletter.1. Age:	 2. Sex: a) Male	 b) Female3. What is your primary ethnic/cultural background?3a. Is having children an important value in your family/cultural background?a) Yes b) No4. Do you subscribe to the values of a particular faith/religion?a) Yes b) NoIf yes, please specify5. Family's yearly income:	 a) Up to $15000/yearb) Between $15000 - $25000/yearc) Between $25000 - $40000/yeard) Over $40000/year6. Education completed:	 a) elementary schoolb) high schoolc) college or universityd) post-graduate education1167. General physical health:	 a) Excellentb) Goodc) Faird) Poor8. How long (in months) have you and your partner been attemptingto conceive a child?9. How long ago (in months) did you first choose to seek medicalattention for your fertility concerns? 	10. Have you at present received a diagnosis regarding your fertilityconcerns?a) Yes	 b) No11. If yes, is your diagnosis:	 a) Male factorb) Female factorc) Couple factord) Unknown12. Do you see your present fertility status as:a) a temporary conditionb) a permanent conditionc) very uncertain13. In your own assessment, how do you rate your chances of achievinga successful pregnancy?a) less than 25% Chanceb) between 25% and 50% chancec) between 50% and 75% chanced) better than 75% chance11714. Prior to this time, have you been faced with any life experiencesof a similar nature? (eg. termination of a pregnancy,significant personal loss, serious illness, etc.)a) Yes b) No14a. If yes, please briefly describe:14b.How would you rate the long term effects of this previousexperience on your life?a) completely or mostly positiveb) both positive and negativec) completely or mostly negative118APPENDIX BResearch ReferralThe following patients have expressed aninterest in participating in the research project"Individual Responses to Infertility", conductedby Stephanie Koropatnick.Referring PhysicianDate119SincerelStephan oropac/o Dept. of Comselling Psychology,University of B.C.APPENDIX C(Form A)Individual Responses 	 InfertilityThank-you for agreeing to participate in our research project.In this study, we hope to learn more about how different typesof people respond to the experience of infertility. The informationyou provide us with will help counsellors and otner helpingprofessionals to better understand the many emotions associatedwith infertility. In turn, counsellors will be better equippedto help others who face the experience you are currently dealingwith.You are asked to complete the five questionnaires includedin this envelope in the order in which they are presented to you.There are no right or wrong answers, so please feel free to respondin a straightforward and spontaneous manner. Same of thequestionnaires may continue onto the reverse side, so please becertain to complete both sides of the forms, where applicable.Also, it is important that you do not consult with your partneror compare answers while completing the questionnaires, althoughyou may feel free to discuss your impressions of the questionsafter the questionnaires have been completed and returned.Each questionnaire will take between five and fifteen minutesto complete. In total, your participation in this study will takeapproximately one hour. When the five questionnaires have beencompleted, please place all of the forms (excluding Forms A & B)into the stamped, pre-addressed envelope provided, and return thisat your earliest possible convenience.All information, including your responses on all questionnaireswill be kept in the strictest confidence. In fact, we ask thatyou not place your name on any of your response forms. Your answerswill be identified only by a code number. Please remember thatyou are free to refuse to participate, or to withdraw your consentat any time, without jeopardizing your medical treatment.If you have any further questions regarding the study, pleasefeel free to contact the researcher, Stephanie Koropatnick at (604)733-2334, or Dr. Judith Daniluk (604-228-5768). Thank-you againfor your participation.120APPENDIX D(Form B)Consent Form	 , voluntarily agree toparticipate in the study "Individual Responses to Infertility",being conducted through the Dept of Counselling Psychology at U.B.C.I further agree to grant the researcher, Stephanie Koropatnick,confidential access to information contained in my medical recordsmaintained at the Fertility clinic.I have been informed of the purposes of the study, and havebeen given an opportunity to raise questions regarding it. I havereceived copies of Form A, explaining the study, and of Form B,granting my informed consent.I understand that I will be asked to complete six briefquestionnaires and that no further requests will be made of meat this time. I have been assured that all information, includingmy questionnaire responses, will be kept in the strictest confidence.I understand that my participation in this study will in no wayjeopardize the course of my medical treatment and that, in fact,no medical personnel at the clinic are directly involved inconducting this research project. In addition, I recognize thatI may choose to withdraw my participation at any point withoutprejudicing my present or future medical treatment.(Signature)(Name - please print)(Address)(Telephone)121APPENDIX ESeptember 29, 1989DearIn reviewing our files, it has come to my attention that ithas been one month since you first received the questionnaire packagefor the research project "Individual Responses to Infertility".We value your input into this important issue and we areawaiting your response. If you have not already done so, pleasecomplete the queStionnaires and return them in the envelope providedat your earliest possible convenience.If you have already completed the questionnaire package andreturned it, please disregard this notification. In any event,I wish to take this opportunity again to thank-you for your parti-cipation in this research project. Your assistance is a valuablecontribution to the increased understanding of the experience ofinfertility.Yours very truly,Stephanie KoropatnickDept. of Counselling PsychologyUniversity of B.C.5780 Toronto Road,Vancouver, B.C.	 V6T 1L2122Appendix FSchlossberg's Model of Adaptation to Transition 	 (Schlossberg, 1981, p.5)TRANSITIONPERCEPTIONOF THEPARTICULARTRANSITIONEvent or nonevent resulting inchange or assumptionChange of social networksResulting in growth or deteriorationCHARACTERISTICSOF PRE-TRANSITION& POST-TRANSITIONENVIRONMENTSCHARACTERISTICSOF THEINDIVIDUALRole Change: gain or lossAspect: positive or negativeSource:internal or externalTiming:on-time or off-timeOnset: gradual or suddenDuration: permanent,temporary oruncertainInternal Support SystemsIntimate relationshipsFamily unitNetwork of FriendsInstitutional SupportsPhysical SettingPsychosocialCompetenceSex and Sex-RoleIdentificationAge (and Life Stage)State of HealthRace/EthnicitySocioeconomic StatusValue Orientation(religiosity)Previous Experiencewith atransition44	of a similarnatureADAPTATIONMovement through phases followingtransition: pervasiveness throughreorganizationDepends on:1) Balance of individual's resourcesand deficits2) Differences in pre- and post transitionenvironments re perception,supports and individual123BIOGRAPHICAL INFORMATION NAME:	 Stephanie Jean KonopatnickMAILING ADDRESS: 3167 West 5th AvenueVancouver, B.C.V6K 1V1PLACE AND DATE OF BIRTH: New Weztminatek, B.C.Aptit 26, 1957EDUCATION (Colleges and Universities attended, dates, and degrees):University o4 B.C. 1987 - 1991: Mcatek of AntsSimon Fnasen Univensity, 1980 - 1984: Bachetok o4 AntsDougta6 Cottege, 1976 - 1978POSITIONS HELD: reacher: Vancouver Schoot BoardPUBLICATIONS (if necessary, use a second sheet):AWARDS:Complete one biographical form for each copy of a thesis presentedto the Special Collections Division, University Library.DE•5

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