Childlessness in Midlife: Increasing Generativity Using a Narrative Approach Notes

Infertility: A Worldwide Problem

Infertility affects many individuals globally.
As people age, the chance of conceiving decreases, leading to increased infertility.
Infertility treatments mainly involve biological interventions.
Those still struggling with infertility might seek mental health treatment.

Midlife Struggle: Generativity vs. Stagnation

People in midlife (ages 40–65) may face a conflict between contributing to the next generation (generativity) and feeling stagnant.
This includes the struggle between having children and being childless.
Narrative therapy looks at the social and political stories that affect clients and challenges these ideas.
Therapeutic actions can bring out hidden stories to increase generativity.

Key Words

Infertility
Midlife
Childlessness
Generativity
Narrative therapy

Global Impact of Infertility

Infertility is a difficult issue for couples worldwide.
In 2010, about 48.5 million couples globally couldn't have children.
19.2 million couples (1.9% of women ages 19 to 44) couldn't have their first child.
29.3 million couples (10.5% of women ages 19 to 44) couldn't have more children.
Research is inconsistent about infertility rates in developing and developed countries.

Defining Infertility

Infertility has various definitions.
Traditionally, it's defined as not conceiving after 12 months of regular unprotected sex.
In clinical settings, infertility means the absence of conception.
In demographic research, it refers to the failure to give birth.
Clinical definitions vary, ranging from 12 to 24 months of trying to conceive.
The length of time is important because 12 months might be too short to determine infertility.
Research shows that about 50% of women get pregnant after 1 year of monitoring fertility.

Challenges in Studying Infertility

Gender and age are important factors when studying infertility.
Most studies focus on female infertility, showing a gender bias.
Research includes people from 18 to 89 years old, which is a wide age range.
Defining infertility is challenging because women in their mid-30s have a natural decrease in conception chances.
One study found that infertility decreased as women aged, but this was considered unlikely.
Younger women may overreport infertility, possibly because their bodies are still preparing for pregnancy.
Inconsistent definitions of infertility are due to natural bodily changes with age and gender bias.

Societal Expectations and Generativity

As people approach midlife, there are strong social expectations for childless individuals or couples to become parents.
Because of these expectations, people in midlife (ages 40–65) who are infertile and/or childless may find it harder to achieve Erikson's developmental stage of contributing to the next generation (generativity) compared to those with children.
Erikson notes that parenthood is only one way to achieve generativity.

Mental Health Effects of Infertility

Many cultures consider biological reproduction and childbearing as natural, creating pressure for those who can't have children.
Parenthood is seen as important for adult development and identity.
In some cultures, motherhood increases social status, making women feel responsible for infertility.
Women often worry about their ability to have children, while men focus on becoming fathers.
Men facing infertility may feel inadequate for not providing their partner with a child.

Psychological Effects of Infertility

Women experiencing infertility may have higher levels of depression and anger.
Women who were infertile had higher rates of depression and anxiety and lower self-esteem than men facing infertility, according to a literature review of infertility studies.
Men commonly experience grief from a loss of control over their genetic legacy.
Both men and women may feel disappointed and like they've failed due to involuntary childlessness from infertility.
Infertility-related distress affects both individuals and their relationships.
Couples may feel a loss of self-control and distress from not knowing how they will become parents.
Infertile childless couples may face social stigmas, isolation, lack of social support, and feelings of being flawed, leading to a lower quality of life.
Couples and/or individuals who experience childlessness involuntarily often view infertility as a long-term crisis rather than a temporary issue.
Women and men in mid to late life who become parents through stepchildren or adoption still report distress and regret about their infertility.
Ways to treat infertility are expensive, stressful, time-consuming, and life-changing.
Physical treatments for female and male infertility may include lifestyle changes, surgery, and assisted reproductive technologies.
Women in their late 30s and early 40s often use in vitro fertilization, but the chances of conceiving decrease with age.
Similar technologies, like using donor eggs, are common for middle-aged women trying to conceive.
Sperm extraction is possible for males in order to complete in vitro fertilization or intrauterine implantation.

Therapies for Psychological Distress

Several therapies have been studied to improve the psychological distress that comes with infertility.
Couples counseling is effective in improving marital and sexual satisfaction by providing education and skills training.
Group therapy for infertile couples that includes education about grief, marital satisfaction, and sexual satisfaction has a positive effect on feelings of grief related to infertility.
Acceptance and commitment therapy (ACT) helps couples accept negative experiences.
Once couples learned how to handle distress related to infertility through ACT mindfulness and experiential therapy, infertility distress decreased significantly for both partners after treatment.
A mindfulness-based program specifically for women decreased symptoms of depression, shame, and feeling trapped by teaching women to be more open to their thoughts and feelings about the difficulties of achieving motherhood.

Generativity and Childlessness in Midlife

When faced with infertility or childlessness in midlife (ages 40–65), it may be more difficult to stay resilient due to social expectations to become a parent, requiring more attention to mental health.
Erikson's theory of human development includes eight stages from infancy to late adulthood.
Erikson believes that humans develop by facing and overcoming psychological crises in each stage.
The psychological crisis of midlife is defined as generativity versus stagnation.
Generativity is defined as wanting to make a positive contribution or have an influence on future generations.
There is often a strong focus on the link between parenthood and psychological well-being for achieving generativity.
Erikson indicates that while parenthood is common, it is not essential or adequate for achieving generativity in midlife; parenting is just one way to achieve generativity.
Achieving generativity in midlife can happen through many different paths, including parenting, teaching, mentoring, caregiving, creating products to use in the future, helping institutions that support future generations well-being, volunteering, and/or civic involvement.
Cultural themes often focus on parenthood in terms of generativity through parent-child bonds, the gratification of parenthood, and leaving behind a genetic legacy.
Childless couples often do similar things, such as taking part in parental roles with other children, caring for family members, or mentoring younger generations in their field.
Childless parents often have pets, which maintains a sense of parental fulfillment.
Transcending personal adversity by sharing experiences of infertility with future generations to prevent similar adversities could also be related to generativity in midlife.
Research has found no significant differences between childless adults and parents in mid to late life regarding their generativity and psychological well-being, further supporting the idea that parenthood is not the only way to achieve generativity.

Overcoming Childlessness

While childlessness due to infertility can initially cause psychological distress, individuals or couples usually adapt to their child-free status over time.
Infertile childless individuals or couples must face and adapt to unique challenges as they enter midlife.
Due to the centrality of parenthood in midlife, childless adults are surrounded by reminders of their status.
New triggers for grief may arise throughout every developmental period and in their everyday lives.
Through all of society’s messages about the normality, ease, and gratification of parenthood, childless adults can overcome infertility and positively revise their meaning of life.
Just as there are many routes to reach generativity, there are many avenues that may be taken to overcome and adapt to biological childlessness.
King (2004) emphasizes the importance of withdrawing from the unrealistic goal of biological parenthood in order for adaptation to occur.
Without this withdrawal, a prolonged sense of failure may have an adverse impact on the future.
Setting new goals that are realistic and align with the revised meaning of life is imperative to overcoming the adversity of childlessness.
New goals may lead childless adults to focus on alternative roles, relationships, and support that allow them to create a satisfying and meaningful life.
A study with involuntarily childless married couples was conducted and found that resilience was a factor in their process of overcoming and adapting to infertility.
Resilient couples were found to lessen future negative influences by predicting and preparing themselves for situations that may trigger pain surrounding their childless status within the dominant narrative of parenthood.
Although infertility may be a difficult reality to adapt to in the beginning, there are many benefits to childlessness that have been recognized such as lower levels of stress, fewer financial concerns, less responsibility, and more freedom.
As the negative impact of infertility and childlessness lessens, there are endless positive adaptations that can be made to arrive at a gratifying and rewarding meaning of life.

Narratives of Midlife Generativity and Childlessness

Narrative theory suggests that the goal of therapy is to help clients see life events in a new, more positive way, or to "reauthor" the narrative of their lives.
Clinicians help clients reauthor their lives by recognizing the dominant discourses that the client uses to perceive past events.
These dominant discourses are what society and individuals around the client indicate is the "correct" and "normal" experience of events.
Dominant discourses are often problematic for clients because clients do not feel they can achieve what is considered the status quo.
Clinicians can guide clients to recognize unique outcomes or exceptions that help clients view the dominant discourse as problematic.
By identifying exceptions or unique outcomes in session, clinicians are able to help clients develop a subjugated story or a perspective outside of the dominant discourse that is preferred.
The subjugated story can also be "thickened" by asking questions that assist the client to further develop their preferred narrative.
Parenthood is often seen as paramount in the process of adult development and achievement of generativity
Individuals are led to believe that procreation and parenthood are involved in the normative processes of adult development.
These beliefs may arise from the value and necessity placed on this implicit obligation of continuity of humanity by families, communities, societies, and/or cultures.
Whether going against this societal obligation is involuntary due to infertility or by choice, childless adults in midlife face the pressures of having a lifestyle that counters the dominant discourse.
Due to social stigmas that commonly accompany infertility and childlessness, these labels could be pathologizing in nature and possibly hinder generativity achievement.
Recognizing that parenthood is not the only route to achieve generativity is imperative to arrival of fulfillment.
Narrative therapy places a strong focus on sociopolitical factors that may reinforce and influence the problem saturation within the dominant discourses that society has put in place.
Just as Erikson notes that there are many avenues in reaching generativity, narrative therapy also proposes that there are many ways in which people can story their lived experiences of infertility and childlessness.
Utilizing the concept of generativity and narrative practices, a different way to explore potential subjugated stories of infertility and childlessness in midlife within the dominant discourses of parenthood is presented.

Dominant Discourses

Childlessness is often viewed as immature because those without children are seen as choosing to put themselves before a family.
These individuals are characterized as happier, having less responsibility, and being worth more financially.
Individuals without children are also viewed as having less well-being because they are not reaching the meaning of life—having children.
The lifestyle of marriage and parenthood is expressed to be morally correct.
Childlessness may lead to confusion.
Dominant discourses place pressures on humans, as they are expected to have children to fulfill their roles as men and women.
Not completing this task may lead to feelings of depression, guilt, and despair due to an inability to conform to societal expectations.
At the same time, these individuals are told they are supposed to be more carefree and happy, which they cannot necessarily experience because they are also not meeting the expectations of parenthood.
In order to reach a compromise between these two dichotomous positions, those without children may experience difficulty due to the conflicting messages held by society.
Couples also face the discourse of time.
There are six family life stages that are considered normative developmental transitions that individuals go through including unattached young adults, newly married couples, families with young children, families with adolescents, launching children, and aging families.
Trends such as age when married, age when first having children, and roles of mother and father are being delayed as couples put themselves or their careers first and postpone starting a family.
These individuals are confronted with the discourse that they are abnormal because they did not abide by the normative timeline and transitions that couples are supposed to follow when creating a family.
This discourse may result in couples feeling old and selfish because they did not respect the dominant discourse or family life stage of time.
There may also be increased distress in the couple relationship as women may feel pressured to be a mother and make a family while men may become increasingly detached from the couple system as a coping mechanism for not meeting the dominant discourse of males.

Dominant Discourses of Women

Many women take on a narrative that motherhood and parenting are normal and expected.
The delay of having children and/or the experience of being infertile results in a missed opportunity.
Women without children are thought of as failures because they have not fulfilled the duty biologically devised for women.
Due to the dominant discourse of motherhood, even women who are able to have children may feel like there is a necessity to choose between motherhood and a career or risk being grouped into the "others".
Whether or not childlessness is involuntary or by choice, women may be automatically grouped into the "others" and are often viewed as self-centered because society assumes they chose to focus on their own careers or relationships.
Under these societal assumptions, women may adopt guilt and despair because they are considered more egotistical and willing to put themselves before being a mother.
Significant stigma comes along with infertility and attempting to become pregnant in middle adulthood.
Women are taught that they have a biological clock and by around the age of 43, they have lost their chance to fulfill the discourse of being a mother.
Women struggling with infertility in middle adulthood describe being placed in the category of "old" because of the reduced potential for fertility due to "old eggs".
Women may compete against the discourse of risk that indicates that women older than 43 are incapable of having children without the risk of potential harm toward themselves or the child.
The discourse of selfishness may also be continued if women choose to attempt to have a child because they are putting themselves and their child’s lives at risk.

Dominant Discourses of Men

The discourse of a man during infertility can differ greatly from that of a woman.
The role in assisting a woman in becoming pregnant is often viewed by men as unimportant, thus placing most of the difficulties on women for not meeting the expectations of motherhood.
Men may expect feeling detached from an inability for the woman to become pregnant because it is considered the woman’s job.
Men may also experience another discourse more similar to women in that they do not equal up to their manhood.
The inability to impregnate their wife or partner may lead men to feel that their manhood is compromised because they are not virile.
There may be difficulty in men’s abilities to balance feeling detached from the infertility while also feeling that they are no longer a man because they cannot produce a child.
This may result in depression and despair in the man.
Men may emphasize their male identity by following stereotypical male gender roles such as heteronormativity and hypermasculinity to disguise their discomfort with not feeling like a man when the woman cannot conceive.
Since women are working and developing their careers more than in the past, men are anticipated to have more of a role in parenting than before.
Men are expected to take on more responsibility with the children and being a father who is involved with his children may be more of a social ideal than in the past.
Waiting to conceive, as well as difficulties with conception, may result in men supporting a more traditional gender role due to their inability to meet societal discourse of being a father.
Instead, there may be a drive to provide financially for their partner while feeling more detached from the idea of family because they are unable to achieve the discourse of being a father.

Subjugated Stories

Individuals or couples experiencing infertility may hold narratives of their lives that prevent them from finding happiness and generativity in their lives.
Those ascribing to unhelpful dominant discourses about parenthood equating to generativity may struggle if the individual or both partners have experienced infertility challenges.
To replace the dominant discourses from clients’ lives, clinicians may need to thicken subjugated stories surrounding ideas of generativity, such as creating a legacy, making an impact, or leaving something behind.
Although parenthood is a dominant discourse on how to achieve these potential subjugated stories, clients experiencing infertility have likely engaged in other behaviors that produce generativity.
To thicken subjugated stories, the clinician may aid clients in externalizing the infertility by helping create metaphors that oppose stagnation and promote generativity.
Some possible metaphors that may be beneficial for externalization are educating the stagnation about generativity, employing their personal agency against the stagnation, removing themselves as the puppet masters of infertility, liberating themselves from the stagnation, or possibly resisting the influence of the infertility.
These metaphors may help individuals or couples separate the problem from themselves and open the door to further develop the subjugated stories of generativity.
Clinicians may also need to identify what other activities or individuals are important in the clients’ lives to thicken the subjugated story.
Possible subjugated stories surround leaving something behind or creating something for future generations.
This creation may not include building relationships with other people, but instead creation through the arts.
Clients may enjoy creating two-dimensional art, such as drawing or painting, and three-dimensional art, such as pottery, carpentry, or jewelry design.
Clients involved in creative writing, music, dance, or performance arts may also relate to this subjugated story of creation.
Clients may engage in these behaviors individually, as a couple, or with a larger group of individuals.
These creative behaviors may previously have gone unnoticed by the clients as producing something to leave to others, especially if these behaviors are part of a client’s career or a hobby.
Identifying these unique outcomes in which clients have felt a sense of productivity while creating art can begin to thicken their subjugated story and help increase their ability to identify happiness and a sense of meaning in their lives.
Additionally, making an impact is another subjugated story that clients may connect with.
This may include more intimate interactions, such as mentoring a child, adopting an animal, or befriending an elderly neighbor.
Making an impact can also include more distant interactions, such as donating money or other items to charities, or can fall somewhere in between, such as volunteering at various institutions.
When examining the concept of making an impact, clients may focus on impacting other humans; however, making an impact can include working for the fair treatment of animals, helping in the environmental movement, or other social movements.
Those who make more distant impacts may not recognize their behaviors as making an impact on others.
This may be particularly true if the clients are being impacted by those whom they are interacting with or the movement they are associated with.
Couples could make an impact together by volunteering, adopting a pet, or joining a movement together.
Getting clients to remember interactions with others may also thicken the subjugated story by helping them not only recognize how others have impacted them but also how the client has impacted others.
If working with a couple, the clinician may also examine how each partner has impacted the other.
Identifying how individuals may impact others through their day-to-day interactions, such as friends, relatives, or colleagues, may be useful.
By remembering these interactions, clients may begin to understand that impact making is frequently occurring, thus unique outcomes may be discovered for the clients.
Another possible subjugated story could be leaving a legacy.
Although making an impact and creating something to leave behind are related to creating a legacy, creating a legacy may connect better to a client’s narrative.
Creating a legacy may include stories of artwork, awards, sports success, or even career success.
Although these legacies may be from the distant past for clients, the clinician can thicken the subjugated stories by identifying these unique outcomes to stagnation.
Clinicians can also identify other people that may carry on the legacy of clients, such as nieces or nephews.
By remembering the influence of these individuals and exploring how the client’s impact on others may lead to a legacy being created may help thicken the clients’ subjugated stories.
Narrative therapy allows for client lead discussion with an emphasis on the language and meanings specific to his or her unique dominant discourse.
It is suggested for individuals or couples who display signs of grief in regard to their inability to have biological children and/or the ineffectiveness of assisted reproductive technologies, to seek grief counseling.
Once the individual and/or the couple has reached a state of acceptance, subjugated stories about his or her infertility and childlessness can begin to be explored.
The suggested subjugated stories should be considered as examples that depict new possible ways for individuals and couples to view their child-free status.
These examples do not even begin to encompass the vast array of possible stories that may be brought out in the therapeutic process.
Due to the uniqueness of each individual’s experiences with infertility and childlessness, it is imperative for clinicians to follow the client’s lead as subjugated stories are brought to surface.

Conclusion

The reality of infertility can create psychological distress in individuals and couples.
Those who reach midlife and still remain childless have often accepted their child-free status.
Due to the common assumption of parenthood as the way of generativity achievement, arriving at this acceptance is a process that must happen gradually over time.
With the combination of generativity theory and narrative therapy practices, the dominant discourses of parenthood can begin to be debunked and acceptance of subjugated stories connected with infertility and childlessness can occur.