Human Reproduction Vol.22, No.8 pp. 2309–2317, 2007 doi:10.

1093/humrep/dem115
Advance Access publication on June 19, 2007

The relationship between perceived stigma, disclosure

patterns, support and distress in new attendees at an
infertility clinic

P. Slade1,3, C. O’Neill1, A.J. Simpson1 and H. Lashen2

1
Clinical Psychology Unit, Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 2UR, UK; 2Department
of Obstetrics and Gynaecology, Central Sheffield Hospitals University Trust, University of Sheffield, Jessop Wing, Tree Root Walk,
Sheffield S10 2SF, UK
3
Correspondence address. E-mail: p.slade@sheffield.ac.uk

BACKGROUND: A model suggesting that high perception of stigma is associated with reduced disclosure to others,

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leading to lower social support and higher distress in new attendees at an infertility clinic is tested. METHODS:
Questionnaires measuring stigmatization (Stigma consciousness questionnaire), disclosure of fertility difficulties
(Disclosure questionnaire), social support (Duke-UNC Functional Social Support Questionnaire) and fertility-
related [Fertility Problem Inventory (FPI)] and generic distress [Hospital Anxiety and Depression Scale (HADS)]
were completed by 87 women and 64 men. Data were analysed by gender comparisons, correlations and path analysis.
RESULTS: Women reported higher stigma and disclosure than men. For women, stigma and disclosure were unre-
lated but in men higher stigma was associated with lower disclosure. Perceptions of stigma were related to low social
support for both genders. Social support was negatively related to anxiety, depression and overall infertility distress
and showed greater predictive capacity than satisfaction with partner relationship. Testing the model showed that, for
men, stigma was linked to lower disclosure and support and higher fertility-related and generic distress. Disclosure
itself did not link to support. For women, greater disclosure linked only to higher generic distress. Stigma was directly
linked to fertility-related distress and to low perceived support which mediated a relationship with generic distress.
CONCLUSIONS: Stigma and the wider social context should be considered when supporting people with fertility pro-
blems. Greater disclosure may be associated with higher distress in women.

Keywords: disclosure; distress; infertility; stigma; support

Introduction
Infertility now affects a significant proportion of couples. Some
studies suggest that this can be associated with elevated levels
of distress, particularly in women whether or not treatment is
sought (Greil, 1997; Slade et al., 1997; King, 2003; McQuillian
et al., 2003) whereas others have emphasized the emotional
normality of samples (Downey et al., 1989; Downey and
McKinney, 1992). Psychosocial factors such as cognitive
appraisals, have been identified as influencing emotional
status and higher perceived social support is also associated
with greater global life quality for both men and women, and
lower emotional distress for women with fertility difficulties
(Connolly et al., 1992; Nachtigall et al., 1992; Abbey et al.,
1994). The role of social support as a buffer in the context of
stressors other than infertility is well documented (Taylor
and Seeman, 1999). However, people experiencing infertility
often report feelings of isolation (Imerson and McMurray,
1996). Indeed, Schmidt et al. (2005) reported that distress in
the social domain increased for both men and women who
had not achieved a pregnancy in 12 months of treatment.
The general literature on coping suggests that individuals
seek social support less in situations which threaten self-esteem
(Folkman et al., 1986). Infertility may threaten self-esteem due
to its potentially stigmatizing nature. A stigma is defined as a
negative sense of social difference from others, that is, so
outside the socially defined norm, it is both deeply discrediting
and devalues the individual (Goffman, 1963). Desire for chil-
dren is typically seen as the norm within societies (Rosenblatt
et al., 1973) and indeed may have a survival dimension. There-
fore, childlessness in couples could be seen as a form of
‘deviant behaviour’. If infertility is experienced as stigmatizing
(Whitford and Gonzalez, 1995), this may isolate people from
potential sources of support.
People who do not disclose their fertility difficulties to others
risk being assumed as voluntarily childless, itself identified as
stigmatizing (Lampman and Dowling, 1995). Whiteford and

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Slade et al.
Gonzalez (1995) found that couples without children who had
not confided in others about their fertility difficulties suffered
joking questions and comments about their sexual behaviour
and potential or absent outcomes. Such experiences may
result in more fear around disclosure, feelings of isolation
and withdrawal from social situations, which could then
impact on emotional status. However, where the fertility
problem is known to others, it has been shown that people
are likely to receive comments that they perceive as unsuppor-
tive (Miall, 1985). The importance of others’ knowledge and
responses is further endorsed by Mindes et al. (2003) who
found that not only were unsupportive responses from others
associated with poorer adjustment at the time, but they also pre-
dicted depressive symptoms and psychological distress in those
who subsequently remained infertile.
It has been postulated that secrecy requires constant vigi-
lance in social interactions and therefore has significant
psychological costs (Smart and Wegner, 2000). Specifically,
‘the pre-occupation model’ suggests that the more one
attempts to suppress a particular idea the more it intrudes
into consciousness. Wegner (1994) has postulated the idea
of a duality of processing involving conscious suppression
and then unconscious ‘ironic monitoring’ of that process
which inevitably brings those thoughts into consciousness.
There are therefore grounds to suggest that higher stigma
may link with lower disclosure and greater distress. Van
Balen and Trimbos-Kemper (1994) suggested that the 10%
of men who kept their infertility as a secret were more dis-
tressed. Disclosure is also an important issue in a variety of
health conditions such as HIV status. Kelly and McKillop
(1996) provide a detailed discussion of psychological issues
related to patterns of disclosure.
The quality of the relationship (Newton et al., 1999) and
communication (Schmidt et al., 2005) with the partner
impact on the emotional status of subfertile couples. The
partner is potentially a crucial source of support for men and
women who are reluctant to discuss their fertility difficulties
with others (Hirsh and Hirsh, 1989). In the context of a stigma-
tizing stressor, the need for the partner for support and
emotional well-being may well increase.
Seeking treatment itself requires some level of confrontation
and disclosure. However, the possible influence that the
infertility-related perceived stigma and disclosure patterns
may have on physical, emotional and social well-being has
received little attention. A greater understanding of the
factors influencing the levels of distress and well-being at
this early stage in the process could prove valuable to counsel-
lors and other health professionals when identifying those in
greater need of input and also potentially inform the content
of therapeutic work. Most previous studies have tended to
focus on the emotional responses encountered later in the
process, after a specific diagnosis has been made or when the
treatment is initiated. There is evidence to suggest a relation-
ship between stress indicators and sperm quality (Fukuda
et al., 1996; Pook et al., 1999) and ovarian response to treat-
ment (Lancastle and Boivin, 2005), which highlights the
importance of identifying the factors that may influence
stress in the early stages of the process.
2310
Understanding the relationships between perceived stigma,
disclosure, social support and partner relationship may there-
fore assist in prediction of levels of distress. A potential
model for understanding how these variables may interact is
presented in Fig. 1. People experiencing infertility problems
may perceive infertility as being stigmatizing. This may
result in lower disclosure of their difficulties to others. Lower
disclosure may result in lower social support and as others
are unaware of the couples’ difficulties, the couple may face
insensitive comments in relation to their childlessness. Feelings
of isolation and perception of low social support may then
adversely affect distress levels. This may be influenced by
the quality of relationship with the partner.
Measures of distress may be generic or specifically infertility
related. Infertility-related distress can potentially lead to more
generalized distress where individuals begin to experience
anxiety or depression symptoms in relation to other areas of
their lives. Finally, as differential role expectations and socia-
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lizations exist for men and women (Becker, 1990; Greil, 1991),
the perception of stigma in relation to subfertility is likely to
differ. Consequently, gender differences must be considered
within this model.
The present study aims to
(i) describe and compare the levels of perceived stigmati-
zation, disclosure patterns and social support in men
and women embarking on infertility work-up and to
make gender comparisons;
(ii) test the model of proposed inter-relationships between
stigma, disclosure, social support, partner relationship
and fertility related and generic distress.
Specific hypotheses
(i) Stigma is inversely related to disclosure and social
support and positively associated with fertility related
and general distress;
(ii) disclosure is inversely related to social support;
(iii) social support is inversely related to fertility and
general distress;
(iv) the effect of perceived stigma on emotional distress
will be affected by disclosure, partner and generic
social support.
Figure 1: A predictive model for emotional distress in infertility
 Relationship between perceived stigma, disclosure patterns, support and distress

Materials and Methods

Table 2: Fertility characteristics
Participants
Fertility characteristics Men (n ¼ 64) Women (n ¼ 87)
Participants were men and women attending a specialist infertility
centre for their first appointment between December 2002 and Mean duration of infertility 2.76 years (2.78) 3.44 years (3.38)
March 2003. One hundred and fifty-one people [87 women and 64 (SD)
men (62 couples)] completed the study. This constitutes 43% of a con- (Partner) Pregnant before (%) 19 (29.7) 32 (36.8)
(Partner) Outcome
secutive sample of attendees fulfilling the following inclusion criteria: Spontaneous abortion (%) 8 (42.1) 13 (40.6)
(i) new attendees for infertility treatment, (ii) have no children from Ectopic pregnancy (%) 1 (5.3) 3 (9.4)
their relationship and (iii) with sufficient English language to under- Termination (%) 5 (26.3) 8 (25.0)
stand and complete the measures. As the purpose was to investigate Live birth (%) 5 (26.3) 8 (25.0)
these factors as they relate to those embarking on infertility
work-up, it was appropriate to be as inclusive as possible.
Men in the sample were significantly older (mean ¼ 34.8 years, information sheet providing details of the study was also included as
SD ¼ 6.3) than the women (mean ¼ 31.8 years, SD ¼ 5.7), (t ¼ well as a reply slip, which the couples were asked to bring to their
3.06, d.f. 149, P , 0.01). The mean number of years participants initial appointment, detailing whether or not they were willing to be
had lived with their partner was 5.33 (SD ¼ 3.68) and 66.9% were approached to discuss participation in the study. Those in agreement
married. These demographic characteristics of the study sample are were then approached at the clinic by the researcher, prior to their
in harmony with those of the infertility first attenders population in appointment. Participants were provided with a questionnaire
terms of age with mean ages for men of 35.4 years (SD ¼ 6.3) and booklet to complete, separately and without consulting with one

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women of 31.8 years (SD ¼ 5.8). However, the study participants another, while waiting for their appointment or to post back if time
were slightly more likely to be married, 66% versus 60% for the poten- was insufficient.
tial population.
Table 1 shows the sample characteristics. For both men and women, Measures
the samples are slightly skewed towards the upper social class cat- The following measures were administered in the form of a question-
egories, based on the occupational status (Standard Occupational naire booklet.
Classification, 1991) and participants were predominantly of white
background. Ethnic minorities were less represented within the Adapted stigma consciousness questionnaire (Scale available
sample than within the clinic as a whole (5% versus 15%). from the authors)
Table 2 presents the fertility characteristics of the participants. The
The stigma consciousness questionnaire (SCQ) (Pinel, 1999) was
women reported experiencing fertility difficulties for slightly longer
developed to predict the extent to which individuals expect to be
than the men. Five women and nine men had had a biological child
stereotyped and discriminated against by others in general. This
from a previous relationship and one man and one woman had an
10-item scale was designed to be modified for different stigmatized
adopted child.
groups and therefore was adapted to measure stigma consciousness
relating to fertility difficulties. It included items such as ‘other
people have a lot more negative thoughts about people with fertility
Procedure
difficulties than they actually express’ and ‘Most people without fer-
The study was approved by the South Sheffield Ethics Committee.
tility difficulties have a problem viewing those with them as equals’.
A letter from the medical consultant inviting potential volunteers
One item from the 10-item scale (Number 9 relating to whether
was sent along with their initial appointment documents. An
those without fertility difficulties are perceived to discriminate
against those with) produced low internal consistency, and therefore,
was discarded from further analysis. A final score of stigma conscious-
Table 1: Sample characteristics
ness was determined by totalling the remaining nine items, scores
Men-frequencies Women-frequencies ranged from 0 to 54, with higher scores indicating greater stigma con-
(n ¼ 64) (%) (n ¼ 87) (%) sciousness. The final scale produced an acceptable internal consist-
ency, Cronbach’s alpha score, of 0.77.
Highest educational qualification
No exams 4 (6.3) 3 (3.4)
General Certificate Secondary 22 (34.4) 31 (35.6) The Disclosure Questionnaire (Scale available from the authors)
Education (GCSE)/Ordinary (O) A 17-item questionnaire was developed to assess disclosure beha-
level viour. The development of this questionnaire was informed by the
Advanced Level 6 (9.4) 8 (9.2)
patient profile questionnaire (Henderson et al., 2002), designed to
Vocational Qualification 11 (17.2) 16 (18.4)
Degree/Further Degree 21 (32.8) 29 (33.3) assess disclosure behaviour in cancer patients. The measure asks
Social class based on occupationa who ‘the participant has spoken to or asked another to tell about
I 9 (14.8) 9 (11.1) their fertility difficulties’ and yields three scores—disclosure to
II 23 (37.7) 26 (32.1) immediate family, disclosure to others and total disclosure.
III 18 (29.5) 36 (44.4)
IV 10 (16.4) 6 (7.4) Section 1 covers disclosure to immediate family. Responses relate
V 1 (1.6) 4 (4.9) to eight categories covering their own or partner’s mother, father,
Ethnicity brothers and sisters, respectively. A score of 1 was available for
White Background 61 (95.3) 82 (94.3) each of the four sections for own and partner’s family told. A score
Pakistani 1 (1.6) 1 (1.1)
of 21 was given to each parent/partner’s parent that was available
African 1 (1.6) 2 (2.3)
Not Specified 1 (1.6) 2 (2.3) to disclose to but who was not told. To score disclosure to own and
partner’s brothers and sisters, respectively, 21 was given if no sib-
a
Taken from the Standard Occupational Classification (1999). lings of a particular gender were told and a score of 21 was also

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Slade et al.

given if partner’s siblings of that gender were not told. If some broth- consistency, assessed by Cronbach’s alpha, being 0.90 for the
ers or sisters were told a score for disclosing to that grouping was depression scale and 0.93 for the anxiety scale. A total of the two
derived by calculating how many were told divided by the number dimensions are used as a measure of general distress.
available to tell. A score of 0 was given to any category where there
was no one available to tell. Total scores for immediate family had Analyses and statistics
a possible range of 28 to 8. Negative scores indicate non-disclosure
Analyses were conducted using SPSS11.0 with parametric and non-
despite the family member being available to tell whereas higher
parametric statistics being applied dependent on the nature of the dis-
scores indicate more people told.
tributions. Data are presented as means (standard deviation) and a
Section 2 covers disclosure to others and assesses the number of
P-value ,0.05 was considered significant. To test the proposed
other people told in the categories of: own and partner’s other
model, a path analysis was completed using the approach outlined
family members, close and distant friends, co-workers, people
by Kenny (2004). The value of a path analysis in this context is that
having similar difficulties and others in general. Respondents indi-
it provides an integrated understanding of how factors may inter-relate
cated which frequency rating was appropriate for each category with
to lead to the critical outcomes of high distress and therefore identifies
five possible options (0, 1, 2 –4, 5– 10 and more than 10). Scores
potential underlying psychological processes. In this approach to path
from each category were totalled using the lower end of the frequency
analysis, direct and indirect paths between variables are tested by
range. Higher scores indicated more people told.
regression analysis and the significant paths retained. P-values
An overall total disclosure score was calculated which was the total
,0.05 were taken as significant.
number of people disclosed to, based on the total number of family
members told and the ‘others’ scores. Spearman correlations identified
high consistency between these measures of disclosure with no coeffi-

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cients falling below 0.7. As a result for the path analysis, to test the Results
proposed model, total number of people disclosed to was the chosen Gender comparisons
variable. However, the separate dimensions are shown for the individ- Gender differences were analysed using the independent t-test
ual analyses. or Mann – Whitney test. Table 3 shows women had disclosed to
significantly more people than men despite reporting higher
The Duke-UNC functional social support questionnaire
stigma. Women also scored significantly higher than men on
(Broadhead et al., 1988)
all three measures of distress (infertility-related strain,
This eight-item, functional, social support questionnaire yields a
anxiety and depression symptoms). Women were found to
single total support score, with higher scores indicating greater percep-
score significantly higher than men on all subscales of the
tions of support, was used. The scale showed high internal consistency
(Cronbach’s alpha ¼ 0.88). An example of an item (reverse scored) is FPI with the exception of childfree/status quo acceptance.
‘I get invitations to go out and do things with other people’ with visual
analogue ratings being from ‘as much as I would like’ to ‘much less Child status and duration of infertility
than I would like’. The few participants who had had a biological child showed no
significant differences in stigma and duration of infertility was
Dyadic Adjustment Scale-7 (Spanier, 1976) uncorrelated with any outcome measure except anxiety in men
A seven-item short form of the dyadic adjustment scale (DAS) (rS ¼ 0.33, P , 0.05).
(Spanier, 1976) was used to assess levels of adjustment and distress
in the couple relationship. This measure contains seven items, six
measured on a six choice-scale and one on a seven-choice scale, Table 3: Gender comparisonsa
with higher scores indicating more relationship adjustment. The Variable Men Women t/z scores
short form has well-established validity (Sharpley and Rogers, 1984; (n ¼ 64) (n ¼ 87) (t-tests/
Hunsley et al., 2001). The present study identified high internal con- Mean (SD) Mean (SD) Mann–
sistency (Cronbach’s alpha ¼ 0.80). Whitney)

Disclosure to immediate own 21.54 20.00 t ¼ 21.71

The Fertility Problem Inventory (Newton et al., 1999) and partners’ family (5.63) (5.06)
This standardized measure was selected as a means of measuring fer- Disclosure to others 4.45 (8.29) 5.36 (8.54) z ¼ 21.55
Total number of people 7.16 (10.48) 8.80 (10.23) z ¼ 21.969*
tility specific distress. It consists of 46 items, rated on a six-choice disclosed to.
scale, with higher scores indicating more psychological strain or dis- Stigma 16.81 (8.05) 22.30 (9.93) t ¼ 23.63***
tress. It assesses fertility related distress falling under five domains, Perceived social support 34.22 (5.35) 32.87 (6.86) z ¼ 20.91
social, sexual, relationship, future concern and role identification, Infertility-related strain (FPI) 119.30 143.69 t ¼ 24.79***
separate subscales: (28.25) (33.8)
with a final score indicating overall infertility-related strain. High
Social concern 20.86 (7.46) 30.47 (9.69) t ¼ 26.86***
internal consistency for the whole scale was found for the present Sexual concern 17.09 (6.82) 21.20 (8.19) t ¼ 23.34**
study (Cronbach’s alpha ¼ 0.93). Relationship concern 20.73 (7.74) 23.59 (9.27) t ¼ 22.00*
Role identification 32.56 38.50 (9.66) t ¼ 23.59***
(10.49)
The Hospital Anxiety and Depression Scale (Zigmond and Childfree/status quo 28.05 (7.58) 29.97 (7.82) t ¼ 21.51
Snaith, 1983) acceptance
This standardized measure, designed for use with a medical popu- Anxiety symptoms (HADS) 6.20 (3.56) 8.91 (3.93) t ¼ 24.35***
Depressive symptoms (HADS) 2.34 (2.1) 3.93 (3.19) t ¼ 23.68***
lation, was selected as a general measure of distress, assessing
anxiety and depression symptoms. It consists of seven depression *P , 0.05, **P , 0.01, ***P , 0.001 (all two-tailed).
items and seven anxiety items, which are rated on a scale of 0 to a
Non-parametric analyses are provided where there is deviation from
3. This scale has shown good reliability and validity, with internal normality.

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 Relationship between perceived stigma, disclosure patterns, support and distress

Relationships between stigma, disclosure and social support
The associations between stigma, disclosure and perceived
social support were measured using Spearman’s correlations.
For men, stigma consciousness was significantly, negatively
correlated with the total number of people disclosed to
(rS ¼ 20.26, P , 0.05). For women, there were no associ-
ations between stigma and disclosure. No significant associ-
ations were found between disclosure patterns and perceived
available social support for men or women. However, negative
relationships between stigma consciousness and perceived
social support were identified for both genders (rS ¼ 20.42,
P , 0.01 for men and rS ¼ 20.28, P , 0.01 for women).
The relationship between measures of perceived support
and distress
The relationships between perceived availability of social
support, relationship satisfaction and the measures of distress
were assessed using Spearman’s correlations (separately for
both men and women in relation to depression symptoms,
over and above that predicted by partner relationship satisfac-
tion. Therefore, social support only was selected for further
analysis.
Testing the model using path analysis
In order to ensure that a specific hypothesis-driven testing
was followed using the key variables, the analysis focused
only on stigma, total disclosure, social support, global
infertility-related distress and total distress (HADS total).
The analyses were conducted separately for men and women.
Several of the variables were first transformed to produce dis-
tributions that conformed more closely to normal prior to
analysis. These were: disclosure (which was log-transformed),
support (which was reflected and log-transformed, thereby
becoming a measure of lack of support) and total HADS
(which was square-root transformed). Since the model pro-
poses a single causal chain of one independent and four depen-

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men and women). Table 4 shows that for men, negative associ-
ations were found between perceived available social support
and all three measures of distress, whereas partner relationship
satisfaction was only found to have a significant negative
association with depressive symptoms. A similar pattern of
associations is shown for women, although partner relationship
satisfaction was also found to have a significant negative
association with anxiety symptoms. As the social support
measure potentially encompasses support from the partner,
further hierarchical regression analysis (Table 5) was com-
pleted to check whether it contributes to prediction of distress
above and beyond relationship satisfaction. The two variables
accounted for 40% and 46% of the variance in depression
symptoms for men and women, respectively. They also
accounted for 12% of the variance in anxiety symptoms for
women. Table 5 shows that for women, perceived available
social support plays a significant individual role in predicting
anxiety symptoms, over and above that accounted for by
partner relationship satisfaction. This was also the case for
dent variables, a sequence of multiple regression analyses was
conducted regressing each dependent variable on all prior vari-
ables. Following the procedure outlined by Kenny (2004), the
regressions were conducted first with all paths present,
second with all predicted paths and significant non-predicted
paths present and finally retaining only significant paths (all
alphas were set at 0.05).
The outcomes of these path analyses for men and women are
shown in Figs 2 and 3. The final model was tested in the Mx
Structural Equation Modeling package (Neale et al., 2003) to
obtain an index to assess the goodness of fit of each of the
proposed models to the data. The root mean square error of
approximation (RMSEA) index gave the very acceptable low
values of 0.00 for the model for men and 0.056 for the model
for women. Values less than 0.06 indicate a close fit (Hu and
Bentler, 1999).
Essentially for men, as predicted by the model, stigma is
inversely related to disclosure, but this does not form a
pathway through to low support and distress. Instead, there is

Table 4: Correlations for the variables with results for women bottom left quadrant and men upper right sections of the table are shown (Spearman’s are
presented for consistency as typically one variable of the pair was non-normally distributed)

Stigma Total Perceived social Partner Global strain (FPI) Anxiety (HADS) Depression
disclosure support relationship (HADS)
satisfaction

Stigma 20.26* 20.42*** 20.03 0.43*** (0.40***) 0.44*** 0.08

Total 20.22 0.02 20.14 0.10 (0.12) 20.08 0.08
disclosure
Perceived 20.28** 0.01 0.47*** 20.53*** (20.31**) 20.39** 20.54***
social
support
Partner 20.23* 20.10 0.40*** 20.17 (20.15) 20.18 20.48***
relationship
satisfaction
Global 0.67*** (0.64***) 0.13 (0.10) 20.25* (20.23*) 20.16 0.43*** (0.31**) 0.38** (0.29*)
strain (FPI)
Anxiety 0.41*** 0.21 20.24* 20.28** 0.48*** (0.45***) 0.55***
HADS
Depression 0.40*** 0.15 20.55*** 20.43*** 0.55*** (0.52***) 0.67***
HADS

Global strain (FPI) excluding social concern is presented in brackets following results for full score.
*P , 0.05, **P , 0.01, ***P , 0.001 (all two-tailed).

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Slade et al.

Table 5: The effect of social support on distress while controlling for partner relationship satisfaction using hierarchical regressions

Dependent variable Predictor variables R square change F Change Significance Overall R square for both
(df1, df2) predictor variables

Anxiety symptoms (HADS) Partner relationship 0.07 6.58 (1,85) 0.012 0.12
in women satisfaction
Perceived social support 0.05 4.28 (1,84) 0.042
Depressive symptoms Partner relationship 0.16 16.51 (1,85) ,0.001 0.46
(HADS) in women satisfaction
Perceived social support 0.29 45.08 (1,84) ,0.001
Depressive symptoms Partner relationship 0.17 12.35 (1,62) 0.001 0.40
(HADS) in men satisfaction
Perceived social support 0.23 22.89 (1,61) ,0.001

a strong pathway to perceptions of low support and through this
to both infertility specific and general distress. There are also
additional direct pathways to both measures of distress. Inter-
estingly, the infertility-related distress is not directly linked
to more generalized distress for men.
The analysis of gender differences
Women reported higher levels of fertility-related stigma than
men. This could indicate that women are more sensitive to per-
ceptions of stigma in general. However, Pinel (1999) found, in

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For women, there are many similarities but important
differences. Step 1 of the model is not supported in that
stigma does not predict disclosure. As for men, there is a sig-
nificant pathway from stigma to perception of low support
and through this to general distress but not to infertility-
specific distress. However, there is a strong direct pathway
not mediated by support from stigma to infertility-specific
distress. Additional paths indicate that for women high infer-
tility distress is associated with high general distress and the
greater the disclosure to others the greater the general
distress.
Discussion
This study investigated whether stigma affects disclosure
which in turn was hypothesized to influence perceived social
support availability and consequently distress in new patient
attenders at an infertility clinic. To maximize the generic appli-
cability of the study findings, the aim was to be as inclusive as
possible. The data therefore were derived from a heterogeneous
sample in which specific location of cause was not yet
identified.
a study of stigma consciousness in the general population, that
men were more stigma conscious than women, on stigma
related to gender. Another explanation could be that women
are more at risk of being stigmatized for fertility difficulties
than men. Previous research has suggested that the socializa-
tion process promotes different meanings around procreation
for men and women, reflecting the virility of the man,
whereas motherhood is more central to the female identity
(Mahlstedt, 1985).
Despite greater stigma, women also reported greater disclos-
ure. Other studies have suggested that women are more likely
to communicate to others about their fertility difficulties than
men (Berg and Wilson, 1991; Beutel et al., 1999; Schmidt
et al., 2005), although the degree of communication does not,
in this study, correspond absolutely to the measure of disclos-
ure that represents the number of people rather than the
frequency of discussion. The tendency for women to disclose
more than men about stressors in other contexts is well docu-
mented (Tamres et al., 2002).
Similar to other studies no gender differences were found
between men and women on perceived availability of social
support (Tilden et al., 1990). Mean levels of support were at
the higher end of the range for community samples indicated

Figure 2: Path analysis for men

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 Relationship between perceived stigma, disclosure patterns, support and distress
Figure 3: Path analysis for women
by Broadhead et al., (1988). However, the study results suggest
that as women disclose more and are more stigma conscious,
they may be more vulnerable to negative social experiences
related to their infertility than men.
Considering the psychological status, women were found
to report significantly higher distress, in terms of infertility-
related strain (FPI), anxiety (HADS) and depression (HADS),
than men. This has also been found in other infertility popu-
lations (Abbey et al., 1991; Berg and Wilson, 1991). Overall,
means for global strain on the FPI in the current sample were
equivalent to those in other infertility samples for men (119.3
versus 117.0) but substantially higher for women (143.7
versus 134.4) (Newton et al., 1999).
The model
The model predicts that stigma would be associated with
reduced disclosure and although this was supported for men,
no association was found for women. Findings within the
coping literature may help to explain why feelings of stigma
were not found to affect disclosure patterns in women.
Women have been found to seek others’ support as a coping
mechanism more frequently than men (Wright et al., 1991;
Lee et al., 2000). It may be difficult for women to inhibit a
coping response, they typically use even though it may create
further difficulties for them. Interestingly, the path analysis
suggested for women greater disclosure was associated with
high-generalized distress. Restriction of potentially stigmatiz-
ing information may allow for improved sense of control and
containment of the impact of fertility difficulties. Once a wide
variety of others in different contexts such as work, friends are
aware, it may be that this allows no respite from the possibility
of others raising this issue, thereby limiting predictability in
social situations. These results also contrast with the view that
‘holding a secret’ inevitably intensifies the stressful impact of
an adverse event. Alternatively, it may be that it is the degree
of distress that drives women to discuss with others as a way
of attempting to manage this impact. However, consistent
with the present findings, McEwan et al., (1987) found that
people experiencing fertility difficulties, who shared their diffi-
culties only with a partner rather than seeking social support
outside the partnership show less emotional distress.
In the present study, it was not disclosure that was found to
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affect perceptions of availability of social support as predicted
but stigma consciousness. Higher stigma was related to lower
perceptions of available social support for both men and
women. Individuals are known to seek social support less in
situations that threaten self-esteem (Folkman et al., 1986).
Therefore, the relationship found between stigma conscious-
ness and social support may be connected through self-esteem,
which requires further investigation.
The lack of association between disclosure and social
support suggests that perceptions of support from others may
not require people to disclose their fertility difficulties.
However, the measure of support in the present study did not
assess how supported people felt in relation to their fertility dif-
ficulties but their perceptions of support in general. The former
may have produced different results. The measure of disclosure
also assessed the number of people disclosed to rather than fre-
quency of communication with others. Social support may be
associated with regular communication with a small number
of people rather than telling many people but discussing this
only once. The work by Schmidt et al. (2005) addressing the
different dimensions of communication about infertility indi-
cates the need for further investigations into both actual and
perceived support as well as frequency of communication
and number of people disclosed to provide a clearer picture.
The results of the present study suggest that the original pro-
posed model over emphasized the role of disclosure. Stigma
consciousness may influence the extent to which people inter-
pret ambiguous responses from others as being stigmatizing
and as a consequence lead to less perceived support and
more feelings of stigma. We, therefore, propose that future
studies should use longitudinal designs to identify whether
stigma leads to lower perceptions of support or visa versa.
As predicted, higher perceptions of social support avail-
ability were associated with lower distress, in terms of both
infertility specific and general distress in both men and
women. Perceived social support was found to be predictive
of such distress even when the effects of partner relationship
had been accounted for. This suggests that degree of support
from outside the partner relationship has an important influence
on distress levels, in people experiencing fertility difficulties.
2315
Slade et al.
The initial model (Fig. 1) did not predict that stigma con-
sciousness would have a direct effect on distress. However,
for both men and women, a direct pathway from stigma to
infertility-specific distress was found. In addition, for men
only, stigma also linked directly to generic distress. Of particu-
lar interest is that for women, there was a significant pathway
from infertility-related distress to generalized distress,
whereas for men these were not directly related. This suggests
again that whereas for men fertility related distress may be
relatively well contained and does not influence more generic
functioning, this is not the case for women.
The value of this study is that, although limited in sample
size, it provides an innovative analysis of relationships
between stigma, disclosure, support and distress. Clearly,
only a proportion of the potential sample participated. Partici-
pants appeared to reasonably reflect the potential sample in age
and marital status but showed less ethnic diversity. However,
there is a possibility that those actually choosing to participate
may find disclosure easier, although the minimization of
face-to-face contact by the use of questionnaires may have
limited this impact. In addition, although individuals were
asked to complete the forms without consultation in order to
maintain the independence of the data, it was not possible to
supervise every individual therefore it is difficult to ascertain
if this was adhered to in every case. It could also be considered
that stigma and the social concern aspect of the FPI might
overlap in their measurement. However, the former relates to
generic beliefs and expectations whereas the latter relates
more to feelings of individuals in contexts specific to them.
Reductions in correlations with stigma and support when
social concern was excluded from the FPI were marginal.
From a statistical perspective, it must also be noted that although
correlations between variables were statistically significant, the
magnitude of association was often small. In addition, path
analysis is a complex statistical procedure, using multiple vari-
ables and a larger sample would have enhanced the power.
However, the study clearly illustrates that the concept of
stigma and the relevance of disclosure patterns are potentially
important factors in responses to infertility, and it is to be
hoped that aspects relating to social context can now receive
greater research attention.
Clinical implications
This study suggests that taking into account patients’ percep-
tions of stigma may help to identify those at greater risk of dis-
tress. In preparation for infertility treatment, some discussion
around the issues of stigma and disclosure may be helpful
together with consideration of gender differences. For those
requiring counselling, it may be that specific cognitions about
stigma are common and could be targeted in therapeutic
input. Disclosure was not associated with increased perceptions
of support, and for women, more disclosure was predictive of
higher generalized distress. In other conditions where individ-
uals perceive themselves as stigmatized, such as social anxiety,
cognitive behavioural interventions invite sufferers to confront
and test out their fears of negative evaluation from others. In
such cases, exposure to the feared situation typically leads to
reduction of anxiety. However, for infertility where it is one
2316
aspect of life that may be causing distress, it may be that
containment is more effective particularly in the early stages.
Certainly, this study suggests therapeutic work should not
automatically encourage people to seek support through
widely disclosing their fertility difficulties. However, disclos-
ing to others in similar situations may reduce the stigma and
the level of anxiety which argues further consideration of the
value of support groups.
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Submitted on October 19, 2006; resubmitted on March 28, 2007; accepted on
April 2, 2007
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