The Suffering of Sterility Among Men : from Objectal to Identitaire Suffering

Journée SALF Mai 2013

The suffering of sterility among men: from objectal to identitaire suffering , how

to give support.

Monique Jaoul*

I. Introduction

Most studies on the psychological experience of infertility stress the depressive suffering common to men and women [1]. Very often, the revelation of an infertility causes the same reactions as that of mourning a death or a serious illness: that is revolt, jealousy, culpability, desperate search for a cause. The path to a kind of acceptation will take more or less time and that acceptation will depend on the way the course of ART will be experienced.

The suffering of infertility brings back past suffering: “the hope, the project of an individual filiation always induces a subjective dream which mobilizes the unconscious memory” says

Bydlowski [2]. The suffering associated with the AMP course reinforces the suffering of infertility itself: it is a circular dynamic. The number of couples who give up AMP after 3 cycles for psychological reasons is not negligible even when the medical prognosis is encouraging [3] [4].

2. Suffer from infertility

Literature tells us that women are more psychologically affected than men by their infertility.

They score higher on the questionnaire that evaluates stress and depression. But it seems that it is a difference of expression when facing the question of the failure of procreation: more

1 often men have more inhibited and controlled reactions, their emotional difficulty is more often shown through a social and professional hyper activity rather than a frank depressive state [5]. Other studies , more specifically conducted on male sterility, show that the feeling of infertility is anxiety provoking and can be responsible for sexual dysfunction because of the link made between fertility and sexuality [6]. Half of the men told of a sperm anomaly report transient erectile difficulties when infertility is announced [7] [8]. Furthermore, it often happens that the entourage of the subject is not informed , which happens rarely in the case of feminine infertility, indicating a difficulty for a man to assume his infertility as fertility is confounded with sexuality. The medicalization of procreation is often experienced as the putting aside of the man who feels only solicited to “provide” his spermatozoids and who feels guilt about what his partner must undergo, and that reinforces the loss of his self-esteem

[9]. Even when the announcement of their infertility causes profound and lasting depressive reactions in some men, they will have difficulties to seek consultation.

Some studies[10][11][12] have dealt with psychic processes put in place to cope with the trauma. They show an abraded psychic functions in 2/3 of the subjects involved from which conflicts and emotions are excluded, signaling the traumatic dimension of the procreative dead end and the medicalization of procreation. This defensive functioning prevents the awareness and the expression of the emotional life, reducing the fantasmatic life, resulting in a mode of thinking focusing on the concrete dimension of experiences at the expense of the affective life. This defensive attitude can fool the observer and mimic a good acceptation of

2 the situation or even indifference to it. This is not without consequence on the couple’s relationship, the female partner feeling that she is “the only one to suffer”. It can also affect, the medical management as if everything “went well” for him.

We will now present the psychodynamic perspective in which the impact of infertility and the suffering resulting from it must be viewed, in men and women, from the perspective of the

Oedipus conflict

3. The suffering caused by infertility in a man: from objectal suffering to identity

suffering

The suffering caused by infertility in a man can have several aspects. It can display a narcissistic dimension when it challenges his virility as fertility and virility are so intertwined in people’s mind as mentioned before [13] [14]. It can display an objectal dimension , that is turned toward others, be it a spouse “presenting a partner with a child” or a parent

“presenting his parents with a grandchild”, as a token of eternity or a gift to repair the odds of life[15] [16] : here it is the suffering of infertility from a generational point of view that has to be accounted for, both for men and women. It is, according to Bydlowsky, linked with the non settlement of the debt of life toward their parents, the impossibility to repay a transgenerational debt.

Up to the development of MAP sterility was generally attributed to women and the notification of a masculine sterility is still difficult to confess, especially to the father of the sterile man : indeed ,when seen through unconscious Oedipus lenses, the impossibility for a

3 man to become a father can mean the realization of the threat of castration that was feared during childhood as a result of incestuous desires of the little boy for his mother : getting rid of the father to take his place with his mother

But it can also have an identity dimension [17] which the too early proposal of a gamete donation, when the sterility is definitive , cannot soothe. This proposal can even paradoxically block the mourning of the fertility.

Two clinical cases will illustrate these aspects of the suffering of sterility. The choice of presenting different situations, partial and total infertility is voluntary; the aim is to show that the pain caused by a partial primary infertility is not lower that the one linked to definitive sterility. Undeniably the reactivated phantasms and anxieties are similar, ensuing from the vicissitudes of the psycho affective development of the child these men once were.

Bertrand: a pending debt

For Bertrand the revelation of his infertility came as a catastrophe he compared to a fatal disease , cancer , even though the possibility to turn to a IFV was offered to the couple.

He felt very depressed and is recovering slowly “I don’t know how I can get over all that. I am still, how can I say it, I am still digesting and I don’t know if this digestion is proceeding slowly, so I cannot think about tomorrow, I must cope with what I am doing (accepting his infertility) from day to day.

Bertrand is the adopted son of a couple who turned to adoption because of the husband’s infertility. The latter relationship with his own father had been completely severed since the

4 divorce of the parental couple when Bertrand’s father was a child; neither does he see his mother. On Bertrand’s father side, the filiation rupture is total.

Abandoned by his own father, Bertrand’s father struggled with is role as a father, he acted more like a buddy, father and son had a fusional relationship avoiding all conflicts : “we were close with my father whose education was that of father and son but not in a classic meaning …a relationship in which we stuck together and we were attentive to one another … a very very tender relationship because his own father had disappeared so soon, well he had left and euh…a relationship to an only son so much desired, the ninth wonder in the world.

He had no authority whatsoever and I am afraid to develop the same attitude toward my children, meaning to have a very complacent attitude so as to avoid any conflict, which is not the best way to act with children”. When Bertrand ran away when he was a teenager, his father did not scold him, did not say anything when the young man disappeared for months, he did not try to contact him “he did not worry really” when as a matter of fact Bertrand was living close to his parents. Bertrand did suffer from the situation “it would have been easy to locate me” says this former child who had already been abandoned before his adoption.

Comment:

Because of the weakening of the filiation symbolic link, the one that provides ties but also differentiates (one is son of, brother of, but one is not his father or brother), for Bertrand it is the narcissistic, imaginary dimension of this link, the repetition of the same that takes

5 precedence. In an imaginary unconscious identification (and not a symbolic one) to his father, a “body to body” relationship, he will be sterile as his father is.

Like other infertile men, by means of his sterility he avoids to pay back is life debt to this adoptive father, and that is what makes him suffer : not being able to give him a grandchild, not being able to mend the generational thread that has been damaged by filiation rupture at his and at his father’s level.

Bertrand carries the narcissistic wound of this adoptive father (having been abandoned by his father, being sterile) and can only work at protecting him avoiding “the murder of the father task” implied through fatherhood: symbolically killing one’s father when one becomes in turn a father. He props up his father and accumulates names without being able to take ownership of any of them.

The identity dimension can be stressed in the questioning of generations “who am I, I who have so much difficulty with my genealogy” he can ask.

He will have to be given time to accept and follow through the proposal made to the couple to search for spermatozoids through a testicular biopsy. If the result is positive, he will have to cope with the possibility to become a father and symbolically kill his own father, if it is negative he won’t be able to pay back his “life debt” toward him.

George: identity flickering

At the consultation we meet a man struck down by the revelation of his sterility. He is the youngest of the family. The parents are idealized, especially the father, a genuine Pater

6 Familias , whom he has always been eager to be like. Under this idealization an oedipial rivalry and an opposition to the family model are hidden, they show through a rather chaotic school trajectory, an unfinished college curriculum whereas his brothers have had a

“fautless” route and completed higher education. He has chosen a profession that is not up to the family expectations. He usually uses avoiding strategies toward father’s authority conflicts Eternal adolescent he does not feel quite like a man, he has always fantasized that he would become a man when he becomes a father.

The revelation of his sterility came as a terrible shock that has not been softened by the many months passed since and the perspective of a gamete donation. His very identity markers have been shaken: being a man/a woman, belonging to the community of fathers, being a father.

If he does not become a father, can he be a man? He will never belong to the community of fathers like his father and brothers, to the community of men; he will be in an unacceptable in between “the childless uncle” forever a teenager.

He can’t accept becoming a father through a gamete donation because this child will always remind his sterility to himself and to others. He fears he won’t be able to love that child, won’t be able to get involved as a father, to take the father role while this child will remind him of his exclusion from the Men/Fathers world. At the same time he can’t refuse because he is persuaded that he would lose his wife and with her this other identity support: being “the husband of”. He does not have the time he would need to perhaps resolve his grief because of the age of his wife which requires that the donation process be sped up.

7 His suffering is extreme, he can’t talk about it to anyone, he can’t find support from his close relations as if he talked about it the reality of his sterility would become actual and palpable.

For the moment, he lets time fly, without revealing his doubts, letting things go on, waiting for an appeasement that does not come, clinging to the very weak (1/1000) hope that he can become a father naturally.

Comment:

In G, beside the narcissistic castrating wound (sterility being equivalent to the actual performance in his body of the anguish of imaginary castration of the Oedipus complex) it is the identity dimension for the sterility suffering that is expressed: “who am I a man or a woman, a grown-up or forever a teenager? What is my place in my parentage?” Here are the questions he sadly asks.

It seems that for the moment the donation project freezes the process of elaboration and sublimation of the loss of his procreative capacity through a response that comes too soon.

Even if he wishes to start a family, an important identity support for him, he is afraid of not being able to consider the child who would be born from a donation as his own, to reject him as he would remind him of the trauma of his sterility that he thinks can’t be mended.

However, he has been able to resume a dialogue with his wife, a dialogue that had been interrupted and he has come out of his withdrawal from his family.

3. What support to be proposed ?

8 These two cases in which the psychic suffering of men confronted to the incapacity to procreate whether totally or partially is openly expressed are rather exceptional when considering the expression of this suffering. Most of the time, psychological consultations are asked for by women; if men suffer, they don’t talk about it and rarely seek a consultation.

However they more often come with their partner (1/6 consultation) and that will show a search for help they cannot express directly for themselves.

We have mentioned the particular type of defense that men very often set up to fight the profound helplessness they experience and the anxieties reactivated by psychological wounds, be they of a narcissistic, castratic or identity nature. They consist in a repression of the affects, a denial or a trivialization of this suffering for the benefit of the consideration of their partner’s. Very often one can notice a refusal to speak to their wife, their relatives or their friends. We have seen that that mode of defense, close to the psychosomatic functioning, even if it protects them partially, tends to freeze the infertility wound elaboration task and sometimes the mourning of the procreative capacity task that would allow a real clearing, a genuine sublimation.

In those instances providing care is difficult because it questions the possibility to encourage those men to open the wounds they so carefully protect. When they accept the risk a genuine elaboration task can take place. Sometimes they will only accept to work on the problem as a couple, situation which limits the possibility of an individual elaboration of reactivated

9 ancient conflicts but nevertheless allows the dialogue within the couple to be resumed and a re-narcissisation through the affective balance reinstated within the couple [18].

4. Conclusion

We can say that it is crucial that assisted procreation actors allow themselves to be touched and made aware by the unique stakes brought through each procreation project and its dead ends. Not being fooled by the apparent absence of difficulty, trying to put words on what empathy can detect notwithstanding the screen of silence, giving a listening time that the sterile man does not allow to himself can open a space for words and sometimes start the mourning of his fertility: this mourning time being necessary for a creative elaboration of new sublimatory pathways to be opened and to prevent the child-to-be from carrying the weight of an unelaborated mourning.

*Monique Jaoul,

Docteur en psychopathologie, service d’AMP CHI Poissy St-Germain

Bibliography

1Granet Ph. Aspects psychologiques de l’infertilité conjugale et sa prise en charge dans le cadre des procréations assistées, Devenir, 1995,7,(2), 7-29. 2 Bydlowski M., « Les enfants du désir » Odile Jacob, 2008 3 Coëffin-Driol C., Giami A., l’impact de l’infertilité et de ses traitemebnts sur la vie sexuelle et la relation de couple : revue de littérature Gyn Obstet Fertil 2004 ; 32 : 624-37. 4 Goëb J.L. et al. Vécu psychologique des démarches d’assistance à la procréation, Annales Médico- psychologiques 164 (2006) 781-88 5Lachkar P. L’homme infertile : un homme en souffrance. Contr Fer St., 1992;20. 6Mimoun S., « Psychologie masculine et AMP », in Traité de Gynécologie Obstétrique Psychosomatique, op. cité, p. 153-157. 7 Daniluk JC. Infertility: intrapersonal and interpersonal impact. Fertil Steril 1988;49. 8 Salama S. et al., sexe et infertilité La lettre du gynécologue 2012, 368-369.

10 9Epelboin S. suivi des femmes après AMP, J. Gyn. Obst. Et biologie de la reproduction, 2008,37 38-40 10 Bourdet-Loubère S. « le vécu psychologique d’hommes infertiles, apport et repérage de l’aménagement défensif », l’information psychiatrique vol 88, n°9, 721-6, 2012 11Jaoul M., Albert M, Bailly M., D. Molina Gomes D, Selva J., « Blessures dans la filiation et infertilité masculine :étude comparative et psychodynamique », Androl. (2010) 20:131-143 12Mazzone J.C Le deuil de la ,fertilité dans l’insémination avec sperme de donneur (IAD). .androl 2010, 20 :216- 82 13 Bydlowski M. la dette de vie, itinéraire psychanalytique de la maternité, Paris, PUF, 1997. 14 Meija Quijano C., Germond M., Ansermet F., « Parentalité stérile et procréation médicalement assistée, le dégel du devenir », Erès, 2006, p. 211 15Squires C., Jouannet P., Wolf JP, Cabrol D., Kuntsmann JM., Psychopathologie et procréation médicalement assistée : comment les couples infertiles élaborent-ils leur demande d’enfant, Devenir, vol 20 (2008), pp 135- 149 16 Mimoun S. psychologie masculine et AMP in traité de gynécologie obstétrique psychosomatique 1999 Flammarion 17 Delaisi de Parseval G. la part du père 1981 Le Seuil 18 Fonty, Bydlowski M., aspect psychologique des stérilités masculines, Revue de médecine psychosomatique 1985, n° 1, p.97-101 19 Bydlowski M. La dette de vie, itinéraire psychanalytique de la maternité, PUF, 1997 20 Aubert Godard A., Devenir père d’un enfant : un risque narcissique, in Dugnat : Devenir père, devenir mère, Eres 2004, p129-142 21 Jaoul M. et al Prise en charge des échecs de procréation, au masculin : une blessure peut en cacher une autre, gynobst et fertil 37 (2009)