Key words
infertility - quality of life - gender roles - Germany - Hungary
Schlüsselwörter
Infertilität - Lebensqualität - Geschlechtsrollen - Deutschland - Ungarn
Introduction
For many couples, facing infertility is one of the hardest life crises affecting physical
and emotional well-being, marital and sexual satisfaction and the quality of other
social relations [1], [2], [3], [4], [5]. A number of studies emphasizes marked gender differences in psychological response
to involuntary childlessness [6], [7], [8], [9], [10], [11] although gender role identification could be a better predictor for infertility-related
strains than could only gender [12], [13]. Berg et al. [12] indicated that “masculinity” correlated with emotional stability and marital satisfaction.
Furthermore, infertile women with more “masculine” attitudes are less anxious than
women with a “feminine sex-role type” [14]. When gender roles are realized in a more traditional way, it causes
more distress for a woman, but not for a man. Positively and negatively valued instrumental
(“masculine”) attributes in infertile women were described as predictors of lower
and higher distress in another study [13]. However, gender role orientation did not predict cognitive appraisals of infertility
as stressful and infertility-related distress was neither impacted by “femininity”.
The role of “feminine” attitudes may not be neglected because other authors emphasized
their effect on stress level regarding involuntary childlessness, and women in an
infertile group have more “feminine” attributes than women in the general population
[15], [16], [17], [18]. In addition, desire for a child and consequences of failure to conceive are culturally
and socially contingent: the stronger gender roles are internalized, the stronger
individuals with infertility problems perceive themselves as defected [1], [10], [19], [20], [21], [22], [23], [24].
In this study, we compare some infertility-related conditions of Hungary and Germany.
Analyses based on the Generations and Gender Survey emphasize differences in attitudes
towards social aspects like parenting intentions and gender role orientations [25], [26], [27]: Hungarians attach more importance to traditional concepts, e.g. in regard to gender
roles while women and men in Western regions of Germany share both traditional and
egalitarian values. Other studies summarize that individuals from a European but very
traditional sociocultural context are more affected by infertility-related emotional
strains than those from a less traditional culture [20], [28].
This study investigates the unique domains of infertility-related quality of life
(QoL) and its relations to gender role attitudes in Germany and Hungary. The aim of
the study is twofold.
-
Firstly, we want to describe differences in sociodemographic variables, infertility
specific quality of life and gender role attitudes in German and Hungarian infertile
samples of couples. We hypothesize that strains of infertility are experienced in
different ways in these two countries. We expect that Hungarian couples suffer from
involuntary childlessness in a greater extent and have worse quality of life than
do German couples. At the same time, we suppose that Hungarian individuals follow
a more traditional gender role model than Germans, so that “traditional femininity”
is of greater value for Hungarian women and “traditional masculinity” for Hungarian
men than for their German fellows.
-
Secondly, we want to examine the differences concerning infertility-related quality
of life among persons with different gender role attitudes. As gender roles and reproduction
are strongly linked, it is expected that experiencing infertility is influenced by
how individuals think about and incorporate gender role attitudes. In this sense,
we hypothesize that expression of emotions (“traditional femininity”) decreases the
infertility-related quality of life and that instrumentality (as a part of “traditional
masculinity”) has a positive influence on many domains in quality of life.
Methods
Study population
Data was collected in two university-based and in three private fertility clinics
in Hungary (Clinic of Obstetrics and Gynaecology University of Debrecen, Department
of Obstetrics and Gynaecology Jósa András Teaching Hospital Nyíregyháza, Róbert Károly
Private Clinic Budapest, Kaáli Institutes Győr and Budapest) and in one German fertility
clinic (Department of Gynecological Endocrinilogy and Fertility Disorders, Ruprecht-Karls
University of Heidelberg). All couples attending the first fertility consultation
were invited by a medical assistant to take part in the study. Participants had filled
out the questionnaire set and signed the consent forms before they saw their reproductive
specialist.
Participants were enrolled from February 2012 till April 2013. They had to meet the
diagnostic criteria of infertility stated by International Committee for Monitoring
Assisted Reproductive Technology [29]: i.e. they had failed to reach pregnancy in a time period of one year or more while
having regular, unprotected sexual intercourse. Couples were included if they had
sufficient knowledge in Hungarian or in German language according to the place of
data collection and had not been treated in the clinic before.
The study received approval from the Scientific and Research Ethics Committee of Health
Scientific Board in Hungary and the Ethics Committee of the Medical Faculty of the
Ruprecht-Karls University Heidelberg.
Data assessment: infertility specific quality of life
The infertility specific quality of life was measured using the internationally developed
and validated FertiQoL [30]. Its Core module consists of 24 items regarding five domains: Emotional (e.g. “Do
you fluctuate between hope and despair because of fertility problems?”), Mind-Body
(e.g. “Are your attention and concentration impaired by thoughts of infertility?”),
Relational (e.g. “Have fertility problems strengthened your commitment to your partner?”),
Social (e.g. “Do you feel your family can understand what you are going through?”)
and a Global sum scale. In this study, German and Hungarian versions of FertiQoL Core
were used. Internal consistency on the total scale and the subscales had a good Cronbach
reliability statistics ranging 0.63 to 0.88. Higher scores indicate higher quality
of life.
The German version of FertiQoL [31] also contained a self-constructed socio-demographic questionnaire and a medical
sheet which were also translated into Hungarian.
Data assessment: gender role attitudes
The Personal Attribute Questionnaire (PAQ, [32], [33] German version: GEPAQ, [34]) was used to assess personal gender roles attitudes. This is a 16-item measure with
two scales to assess desirable instrumental, acting (I scale, e.g. “not at all independent/very
independent”) and expressive, communicating (E scale, e.g. “not at all understanding
of others/very understanding of others”) attitudes, respectively. Personality traits
of women and men are not measured. Instrumental traits had been judged to be more
characteristic for men (also termed traditional “masculine” attitudes by the PAQ author),
but socially desirable for both genders; and expressive traits had been considered
to be more characteristic for women (also termed traditional “feminine” attitudes
by the PAQ author) [32]. The scales were internally consistent: α = 0.69 and α = 0.60, respectively.
Statistical analysis
Analyses were performed with the use of SPSS for Windows, release 22.0 (Chicago, IL,
USA). T-tests were used to calculate differences between German and Hungarian participants
in some continuous variables and the scales of FertiQoL and PAQ. T-Tests were performed
also for gender differences. As FertiQoL has a correlation with higher level of education
[11] what could also determine cross-country QoL-differences, we carried out MANOVA to
test main effect and post hoc test for education. In order to identify interdependent
correlations between gender role attitudes and quality of life, we constructed a four-fold
typology of the two PAQ scales with two-step cluster analysis, resulting in four groups
(“combined” = high I and E scores, “instrumental” = high I and low E scores, “expressive”
= high E and low I scores, and “neutral” = low I and E scores). In order to find differences
among gender role attitude groups, MANCOVA was calculated with FertiQoL scales as
dependent variables, gender and education as covariates. Significance level was set
at p < 0.05.
Results
Study population
288 participants (response rate 81 %) in Germany and 252 participants (response rate
43 %) in Hungary completed the questionnaire set, thus the initial database was composed
of data of 540 participants (270 couples). Some German members who agreed to participate
in our study did not fill out either FertiQoL or PAQ, therefore 498 participants (249
couples) were left for final analysis.
Comparing the two study populations regarding age, education level, type of relationship,
type of diagnosis, duration of partnership, and duration of child wish, we found that
German couples were older and lived for longer in a partnership ([Table 1]). More Hungarian participants had higher secondary education and less primary or
lower secondary education. Hungarian women also had significant higher education than
German women. In the German study population, there was a lower, but still high number
of unexplained infertility (or no information about the cause) and there were fewer
cases of infertility affecting both partners in Hungarian couples.
Table 1 Cross-country differences in socio-demographic and medical characteristics of subjects.
|
German subjects (n = 246)
|
Hungarian subjects (n = 252)
|
|
M: mean, SD: standard deviation
* Cross-country difference is significant at level p < 0.05
** Cross-country difference is significant at level p < 0.01
*** Cross-country difference is significant at level p < 0.001
|
|
M
|
SD
|
M
|
SD
|
|
Age – women
|
34.4
|
4.6
|
32.3**
|
4.9
|
|
Age – men
|
37.9
|
6.3
|
34.5***
|
5.0
|
|
Duration of relationship
|
8.4
|
5.0
|
7.3**
|
3.7
|
|
Duration of child wish
|
2.8
|
2.1
|
2.7
|
1.9
|
|
%
|
|
%
|
|
|
Education – Women
|
|
|
|
|
|
|
48.8
|
|
17.5***
|
|
|
|
14.6
|
|
31.7**
|
|
|
|
31.7
|
|
50.8*
|
|
|
Education – Men
|
|
|
|
|
|
|
52.8
|
|
37.3*
|
|
|
|
15.4
|
|
31.0**
|
|
|
|
31.7
|
|
31.7
|
|
|
Diagnosis
|
|
|
|
|
|
|
25.0
|
|
43.7***
|
|
|
|
30.8
|
|
31.7
|
|
|
|
26.7
|
|
20.6
|
|
|
|
17.5
|
|
4.0***
|
|
Differences between countries and genders: Hungarian infertile couples and men show
better QoL
Hungarian women and men scored higher on QoL scales than German women and men. Therefore
Hungarians seem to feel less burdens of infertility on their emotional, mind/body
status and their partnership and other social relations ([Table 2]). Hungarian women reported more “expressive” attitudes than German women. Gender
differences in the German group were detected only on Emotional and Mind/Body scales.
Hungarian women scored lower than men on all FertiQoL subscales except Relational
scale. Gender differences were detected on PAQ scales as expected: women showed more
“expressive” attitudes, and men showed more “instrumental” attitudes.
Table 2 Cross-country and gender differences in FertiQoL-, PAQ-scores.
|
FertiQoL Emotional
|
FertiQoL Mind/Body
|
FertiQoL Relational
|
FertiQoL Social
|
PAQ Instrumental
|
PAQ Expressive
|
|
Women
|
Men
|
Women
|
Men
|
Women
|
Men
|
Women
|
Men
|
Women
|
Men
|
Women
|
Men
|
|
Country
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
M ± SD
|
|
M: mean, SD: standard deviation
* p < 0.05
** p < 0.01
*** p < 0.001
a differed from German women
b differed from German men
c differed from Hungarian women
|
|
Germany
n = 246
|
60.5 ± 17.6
|
74.4 ± 16.1 ***a
|
72.2 ± 16.2
|
81.5 ± 13.8 ***a
|
80.2 ± 11.6
|
77.8 ± 13.4
|
73.0 ± 17.2
|
74.2 ± 13.9
|
19.3 ± 4.3
|
21.2 ± 3.9 ***a
|
22.8 ± 3.2
|
21.6 ± 3.5 **a
|
|
Hungary
n = 252
|
69.0 ± 16.3 ***a
|
81.4 ± 12.8 ***b,c
|
76.5 ± 16.7 *a
|
89.7 ± 10.9 ***b,c
|
83.3 ± 13.4 *a
|
85.4 ± 12.8 ***b
|
80.3 ± 13.8 ***a
|
86.9 ± 9.4 ***b,c
|
19.8 ± 4.4
|
22.0 ± 4.6 ***c
|
25.1 ± 4.0 ***a
|
22.3 ± 4.3 ***c
|
We did not find any differences in quality of life in connection with education level
in the total study population, but with regard to women, the level of education had
some effect on quality of life. Women in the higher secondary education group reported
better QoL-scores in each domain than did women with primary or lower secondary education
(regarding emotional, social and global domains, female participants with university
degree also scored higher than female members of the primary or lower secondary education
group) (Data not shown).
Differences in gender role attitudes: Having incorporated both “expressive” and “instrumental”
attitudes has a strong correlation with good quality of life
We performed correlations between the dimensions of the two questionnaires to filter
possible tendencies for high scoring in every scale. PAQ scales correlated with FertiQoL
scales only in certain cases significantly (Data not shown) so we excluded the high
intercorrelation between the scales and we created four distinct PAQ-categories: “combined”,
“instrumental”, “expressive” and “neutral”. As stated before, the category “combined”
comprises high scores on both scales (instrumental and expressive), category “instrumental”
means high scores on the instrumental scale only, category “expressive” means high
scores on the expressive scale only and the category “neutral” comprises low scores
on both scales (instrumental and expressive).
Participants in the “neutral” and “expressive” group tended to show poorer quality
of life than subjects with “combined” attitudes in the German group ([Fig. 1]). These differences were especially accentuated on the FertiQoL Emotional, Mind-Body
and Social scales. Individuals with “neutral” attitudes reported additionally a lower
level of mind/body quality of life than members of the “instrumental” group. In relational
domain, participants with “neutral” scored lower than individuals in all three other
groups.
Fig. 1 FertiQoL scores (corrected by gender and education) and gender role attitude categories
in the German group. a significantly differed from expressive group at level p < 0.05, b significantly differed from neutral group at level p < 0.05.
It was remarkable that Hungarian individuals in the “expressive” category seemed to
be on the lowest level of quality of life compared with the “combined” group ([Fig. 2]). On all four QoL scales, belonging to the “combined” group was associated with
the highest scores concerning the Hungarian sample. Even participants with “instrumental”
and “neutral” attitudes reported about lower relational and social quality of life
than members of the “combined” cluster.
Fig. 2 FertiQoL scores (corrected by gender and education) and gender role attitude categories
in the Hungarian group. a significantly differed from expressive group at level p < 0.05, b significantly differed from instrumental group at level p < 0.05, c significantly differed from neutral group at level p < 0.05.
Discussion
The most important finding of the present study is the connection between gender role
attitudes and infertility specific quality of life. Our second hypothesis that “expressive”
attitudes are associated with poorer quality of life and “instrumental” attitudes
correlate with better quality of life was not confirmed. We conducted the analysis
with gender role attitude groups in a more complex way using a four-fold classification
of gender role attitudes.
“Combined” attitudes (that means having incorporated both “expressive” and “instrumental”
attitudes) tend to have a strong correlation with good quality of life in all areas
affected by infertility in both Germany and Hungary. The central finding of our study
is that flexibility in the gender role attitudes (“combined” attitudes) might act
as a buffer against infertility-related stress for both members of the couple. Similar
results have not been found yet in infertile subjects [12], [14], but higher level in mental health was proven to be supported by “combined” role
attitudes in general populations [35], [36], [37], [38].
Subjects with “expressive” role attitudes tend to be the sensitive for psychosocial
consequences of infertility. This type of gender role categories is connected with
low QoL in Hungarian couples in all domains. In the Hungarian group, our hypothesis
was supported completely in that “expressive” attitudes were associated with expression
of negative emotions and other burdens evoked by involuntary childlessness. This result
is notable because at this point we can find a complex and strong link between burdens
of infertility and sensitivity of subjects with “expressive” attitudes that may be
determined through strong cultural values of expressivity of emotions and handling
problems regarding transition to parenthood.
However, German participants with “neutral” gender role attitudes report also lower
levels of quality of life than members of “instrumental” and “combined” cluster. Regarding
German individuals who attribute themselves neither “expressive” nor “instrumental”
role attitudes may have more problems to create a confident identity. “Neutral” gender
role attitudes correlate with greater anxiety and distress in such a gender role specific
topic like infertility [14], [39].
Several couples with higher levels of education were found in the study (41.3 % in
Hungarian, 34.2 % in German group). However, our results do not correspond to the
representation of persons with university degree in the general population of both
countries [40], [41]. This share is in line with recent results that high education is positively associated
with lifetime fertility intentions in women in Europe [26], [42]. However, the increasing number of women and men with non-academic educational level
in our study – compared with reports of recent studies in German and Hungarian samples
of involuntary childless couples [16], [43], [44], [45] – is indeed impressive because it suggests that information about fertility treatments
is more widely available and more individuals with lower education, supposedly with
less financial sources, can afford to start an assisted reproduction treatment (ART).
Our hypothesis that Hungarian couples had a poorer quality of life because of a stronger
identification with traditional gender roles did not tend to be proven. However, Hungarian
women had more self-reported “expressive” attitudes than German ones. Although this
difference was significant for women our hypothesis that a more traditional gender
role model is more present in Hungarians was only partly confirmed. Surprisingly,
Hungarian couples rated quality of life regarding infertility-related domains higher
than did their German counterparts. In interpretation of these results, we consider
that factors from other parts of life and/or medical treatment could enhance the quality
of life that was not accurately considered in our study design. Generally, the presence
of an appreciative social environment, including supportive medical staff leads to
better psychological well-being [4], [46]. Moreover, perceived social support decreases the infertility-specific stress in
personal and relational level [47]. On the other hand, the importance of social expectations may play a role in higher
quality
of life than expected in the case of Hungarian respondents [16]. Another interpretation could be that the high educational status of Hungarian women
(compared to German women) could indirectly increase QoL of the couple because a potential
satisfying work situation might offer an alternative life goal if ART should fail.
In addition, gender role expectations may have changed even recently [26].
To the best of our knowledge, this is the first study measuring self-reported gender
role attributes in the field of infertility conducted in two different countries.
This study adds new information to the literature focusing on the close relations
between gender roles and infertility.
A main strength of the study is that it broadens the literature of infertility with
psychosocial approach in Central and Eastern Europe. Only a few recent studies investigated
relevant topics, for instance couplesʼ general experiences of infertility in a traditional
milieu, infertile womenʼs gender role attitudes, sexual adjustment and feelings of
stigmatization in this region [17], [48], [49], [50]. In addition, there is an expressed need in the literature for investigating infertility-specific
psychosocial aspects in different sociocultural contexts [51].
We used a disease-specific questionnaire in order to get a picture of the infertile
couplesʼ experiences covering all substantive problems. As the FertiQoL was developed
internationally, it is a proper measurement to detect cross-country differences.
Our focus was mainly on gender related attributes, so other, perhaps important variables
such as personality traits, general well-being, or self-coherence were not taken into
account. We also did not calculate with medical diagnosis because the rate of unexplained
infertility and no data about the cause was too high in the sample what could have
resulted in biased differences.
The number of participants is satisfactory (n = 540), but a relatively low response
rate in the Hungarian group (43 %) may have influenced the results through selection
bias. This fact means that a significant part in that group did not want to participate
in research or is not open to speak about their infertile status. We may only suppose
that non-responding individuals have more problems to cope with infertility, but seclusion
and secrecy to distant relationships could make them adjust easier to involuntary
childlessness [47]. On the other hand, the data of German couples were collected only in one fertility
centre which can lead to contraselected results. In order to get more representative
results, it would be desirable to expand the study and involve additional fertility
clinics.
Conclusions for Practice
Medical staff should give patients more information about links between gender associated
attitudes and experiencing difficulties when trying to become a parent. In psychosocial
infertility counselling for individuals or for couples, professionals could accentuate
the topic of gender roles and encourage flexibility in living them, developing a kind
of “combined” strategy to cope with the burden of infertility. This strategy of combined
“expressive” and “instrumental” attitudes proved to act as a buffer against infertility-related
stress for both members of the couple in two European countries and therefore it can
be recommended to infertile couples in infertility counselling.
Acknowledgements
We are grateful to the German and Hungarian women and men who agreed to participate
in this study.
We would like to thank the staff in all participating fertility clinics for their
help in collecting data.
Funding
This publication was based on RECʼs research, which was supported by the European
Union and the State of Hungary, co-financed by the European Social Fund in the framework
of TÁMOP-4.2.4.A/2-11/1-2012-0001 “National Excellence Program”.
