BIOPSYCHOSOCIAL CONCEPTUALISATION OF INFERTILITY

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Social constructionism

Social constructionism is primarily concerned with epistemology (knowing) and not with ontology (being) (Gergen, 1985; Steier, 1991). According to Steier (1991) ontological reality does exist, but we cannot in any sense know a real world. We cannot even imagine what the word ‘to exist’ might mean in an ontological context, because we cannot conceive of’being’ without the notions of space and time. Thus, reality is the result of the social processes accepted as normal in a specific context, and knowledge claims are intelligible and debatable only within a particular context or community (Denzin & Lincoln, 1998; Gergen, 1985; Steier, 1991).
Contrary to the emphasis in constructivism, the focus of social constructionism is not on the meaning-making activity of the individual mind but on the collective generation of meaning as shaped by conventions oflanguage and other social processes (Denzin & Lincoln, 1998). Instead of focusing on the matter of individual minds and cognitive processes, Gergen (1985) and other social constructionists turn their attention outward to the world of inter-subjectivity, shared social constructions of meaning, and knowledge. The key features of social constructionism are as follows.
First, social constructionism posits that ‘facts’ are dependent upon the language communities that have created and sustained them. Thus, definitions and all forms of naming are socially constructed. The social constructionist perspective suggests a role for language in both reflecting and shaping the culture. Language is an important mechanism involved in describing and creating social constructions of infertility (Gergen & Davis, 1997).
Second, social constructionism contends that people generate their truth from language available to them. Thus, any ‘fact’ about the world depends upon the language within which it is expressed. Objects are known through their names. Words do not simply ‘map’ or ‘copy’ the world; they create how we perceive the world (Gergen & Davis, 1997). The implication of this view on a psychology of gender is that terms of understanding within the field are open to question and reconstruction.
Third, the social constructionist position implies that any type of description of the nature of reality is dependent upon the historical and cultural location of that description. The social constructionist position helps to overcome the conflicts that may occur when different versions of reality come into contention. From this position, it is possible to acknowledge the multiplicity ofworld-views, and to work towards creating conditions wherein the separate parties can find opportunities for mutuality, tolerance, and compromise (Efran, Lukens & Lukens, 1988; Gergen & Davis, 1997).
Fourth, social constructionists generally hold that there are no universal ethical principles, but that they are constructed. Thus, there is no single way to set ethical standards, but many. This implies moral principles cannot be hierarchically arranged to give preference to justice considerations over values of caring. The social constructionist approach contends that answers to moral dilemas are dependent on the communities. A concern with the nature of values is intrinsic to a social constructionist position, and when one evaluates a scientific explanation one can ask what are the ethical considerations that are embedded in the framing of the explanation, its origins, its classification system, and its consequences. One cannot ignore value considerations and claim that one is merely ‘reporting the facts’. Because facts are socially constructed, they are always subject to questioning for their ethical implications. This is considered consistent with the political goals offeminism (Gergen & Davis, 1997).
Fifth, social constructionists emphasise that any claim to reality can be viewed with scepticism. Unlike some scientific viewpoints that claim that we can know the facts about the world by merely looking, smelling, touching, and/or listening, the social constructionist position emphasises that our sensory experiences are mediated by our linguistic descriptions of our experiences. That is we know our sensory worlds via language, just as we know the abstract world. The social constructionist position does not allow exceptions to this skeptical stance, even when one’s private sensory experiences are at stake. We cannot know our selves, free of cultural constrains, any more than we can know other parts of the world. We must always recognise ourselves embedded in cultural communities. One can ask questions about the world, but cannot claim to have discovered the truth. The best one can expect is that a new interpretation, different perspective, or an interesting slant can be created. In this sense, social constructionism invites creativity, new interpretations, and openness to other fields of knowledge. Whether a new interpretation becomes acceptable depends importantly upon others in the linguistic community.
According to Guba and Licoln (1989) the constructionist, interpretive, naturalistic and hermeneutics approaches are all based on similar notions. However, interpretivist and constructionist persuasions are usually « somewhat artificially disentangled … to afford a closer look at salient aspects of each. Yet it should be apparent that current work in these methodologies reflects the synthetic impulse of the post-modern zeitgeist » (Denzin & Lincoln, 1998, p. 245). Therefore, an interpretive approach was also applied in this study. According to Terre Blanche and Durrheim ( 1999) the interpretive approach assumes that reality consists of peoples’ subjective experiences of the external world and that such subjective experiences can be understood by interacting with and listening to their stories. The assumption here is that reality can be understood and interpreted but not predicted or controlled (Ivey, 1999). It was necessary for me to use the interpretive paradigm because I wanted to go beyond the data, to account for certain gaps in the data, and to account for a totality ofthe infertility experience (Giorgi, 1992).

Sampling Strategies

The second step in the sampling process involved choosing the sampling procedure. A purposive sampling method was used, where the researcher’s judgement is used to select unique and information-rich cases for in-depth investigation (Barker et al., 1994; Grbich, 1999; Neuman, 1997; Terre Blanche & Durrheim, 1999) as described in the target population above. A convenience or opportunistic sampling method was used to identify infertile women, their partners, and their families for possible inclusion in the sample. I networked with friends who were general medical practitioners and psychologists, a gynaecologist, and a colleague at work to obtain the sample (see section 8.5.3 for ethical issues and informed consent).
The objectives of the study were discussed with these networking figures. These friends referred their patients with a history of infertility who consulted them for any other condition, and not necessarily infertility. The one gynaecologist was interested in collaborative research with me, hence his willingness to refer his infertile clients. The work colleague, who also helped me in the field, served as a networking figure in her community.
In addition to this, a snowball sampling or chain referral method was also used in that some infertile women identified similar others who were willing to participate in the study. Thus, at the conclusion of each interview, the participants were asked to suggest another person in a similar situation who was to participate in the study. The infertile women had to first talk to these participants before the researcher contacted them. Theoretical sampling or sampling to redundancy was also employed. This method guided the sample size as described below (Barker et al., 1994; Grbich, 1999; Terre Blanche & Durrheim, 1999).

CHAPTER 1 – INTRODUCTION
1. 1 The Context of Infertility
1.2 Delineation of Thesis
CHAPTER 2- BIOPSYCHOSOCIAL CONCEPTUALISATION OF INFERTILITY
2.1 Introduction
2.2 Biomedical Aspects oflnfertility
2.2.1 Aetiology
2.2.2 Risk Factors for Infertility
2.2.3 Diagnosis and Treatment
2.3 Psychological Aspects oflnfertility
2. 3. 1 Conceptual Understanding of Infertility
2.3.1.1 Psychogenic hypothesis
2.3 .1.2 Stress hypothesis
2.3.1.3 Crisis perspective
2.3.2 Psychological Intervention oflnfertility
2.3.3 Infertility: Ways of Coping and Social Support Factors
2.3.3.1 Coping strategies
2.3.3.2 Social support
2.4 Socio-cultural Aspects oflnfertility
2.4.1 Causal Beliefs about Infertility
2.4.2 Management Strategies
2.5 Conclusion
CHAPTER 3- INFERTILITY, THE FAMILY SYSTEM, GENDER AND
MOTHERHOOD
3 .1 Introduction
3 .2.Infertility and the Family System
3.3 Infertility and the Mrican Family
3.4 Infertility and the Conceptual Understanding of Gender
3. 5 Infertility and Motherhood
3. 6 Conclusion
CHAPTER 4 – RATIONALE AND FRAMEWORK OF STUDY
4.1 Introduction
4.2 Research Problem
4. 3 Rationale for the Study
4.4 Objectives ofthe Study
4.5 Theoretical Framework
4.5.1 Biopsychosocial Model
4.6 Research Questions
4. 7 Conclusion
CHAPTER 5- RESEARCH METHOD
5.1 Introduction
5.2 Research Paradigm
5.2.1 Feminist Social Constructionist Research Paradigm
5. 2.1.1 Feminist research
5 .2.1.2 Social constructionism
5.3 Sampling
5.3.1 Target Population
5.3.2 Sampling Strategies
5.3.3 Sample Size
5.3.4 Biographical Characteristics ofParticipants
5. 3. 4. 1 Women participants
5.3.4.2 Men participants
5.3.4.3 Family members participants
5.4 Data Collection
5. 4. 1 Interviews
5.5 Transcription and Translation ofData between Languages
5.6 Methods ofData Analysis
5.6.1 Steps in the Analysis
5. 7 Challenges in the Methodology
5. 7.1 Research Paradigm Shift
5. 7.2 Ethical Considerations
5.7.3 Anticipation and Interaction
5. 7. 4 Validity and Reliability
5. 7. 5 Generalisation of Findings
5. 8 Conclusion
CHAPTER 6- INFERTILITY AND THE AFRICAN WORLD-VIEW
6.1 Introduction
6.2 The Family Cultural Identity
6.2.1 The Importance ofBlood Ties
6.3 Marriage and Family Life
6.4 Explanatory Model oflnfertility
6. 4. 1 Revisiting the Definition of Infertility
6.4.2 Causal Explanations
6.4.2.1 Western Medical Model
6.4.2.2 Ethnomedical explanations
6.4.3 The Impact ofReligion on the Understanding of Infertility
6.4.4 The question ofWho Carries the Diagnosis
6. 5 Management of Infertility
6. 5. 1 Management Modalities
6.5.2 Family Involvement
6.6 Conclusion
CHAPTER 7- THE PSYCHOLOGICAL IMPACT OF INFERTILITY
7.1 Introduction
7.2 ‘This Process is Painful’: Struggling with Infertility
7.2.1 When does the Struggle with Infertility Begin?
7.2.2 In Search ofDiagnosis and Treatment
7.2.2.1 Uncertainty of diagnosis
7.2.2.2 Choice ofhealth care
7.2.2.3 Traumatic diagnostic and treatment procedures
7.2.2.4 Availability and access
7.2.2.5 Psychological intervention
7.2.3 Doctor Patient Relationship
7.3 The Emotional Tumult
7. 3. 1 Individual Experiences
7.3.2 Family Members’ Experiences
7. 4 Identity Crisis and Loss of Control
7.5 Impact on Interpersonal Relationships
7. 5.1 Couple Relationship
7. 5 .1.1 Communication
7. 5. 1.2 Affective response
7.5.1.3 Sexual relationship
7.5.2 Family Relations
7.5.2.1 Parental context
7.5.2.2 Sibling context
7.5.2.3 Extended family context
7. 5. 3 Extended Social Network
7.5.3.1 Occupational environment
7.5.3.2 Other social networks
7.6 Responding to the Impact of Infertility
7.6.1 Ways of Coping with Infertility
7. 6. 2 Gender Differences in Coping Mechanisms Used
7. 6. 3 Using Alternate Management Options
7.6.3.1 Alternate parenting
7.6.3.2 Adoption
7.6.3.2.1 Familial adoption
7.6.3.2.2 Formal adoption
7.6.4 ‘Life goes on’: Deciding to Let Go
7.6.5 The Struggle Continues
7. 7 Conclusion
CHAPTER 8- INTEGRATION AND DISSEMINATION OF FINDINGS
8. 1 Introduction
8.2 Integration
8.2.1 Implications ofFindings
8.2.2 Implications for Practice
8.2.3 Implications for Methodology
8.3 Dissemination ofFindings
8.3.1 Scientific Article
8.3.2 A Booklet on Infertility
8. 4 Conclusion
CHAPTER 9- CONCLUSION
9. 1 Introduction
9.2 Consolidation
9.3 Limitations ofFindings
9.4 The Need for Further Research
9. 5 Conclusion
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THE PSYCHOLOGICAL IMPACT OF INFERTILITY ON AFRICAN WOMEN AND THEIR FAMILIES