Abstract
This survey study uses responses from physicians and medical students to assess psychosocial burdens of family building in the physician workforce.
Female physicians are twice as likely as women of reproductive age in the general population to experience infertility.1 Physicians initiate childbearing later than nonphysicians, with a median age of first birth at 32 years vs 27 years among nonphysicians.2 One major reason is that medical training typically coincides with prime reproductive years.
For physicians who desire children, the family-building journey is often complicated by infertility, stress, childbearing delays, and professional pressures. We surveyed physicians and medical students to better understand the psychosocial burdens associated with family building.
Methods
We administered a questionnaire about family building to physicians and medical students from April to May 2021. Participants were recruited through social media and email listservs. We measured psychosocial burden from family building using regret from delayed childbearing, infertility diagnosis, assisted reproductive technology (ART) use, well-being outcomes, and relationship strain. Responses were dichotomized by combining “somewhat,” “moderately,” or “extremely” responses as agree. Race and ethnicity were self-identified based on survey instrument and were included as demographic characteristics. This survey study followed the AAPOR reporting guideline. The study protocol was reviewed and approved by the University of Miami institutional review board.
Statistics were calculated using SPSS version 28 (IBM Corp). Because fertility typically starts decreasing at approximately age 32, and more so after age 37,3 we compared the burdens among 3 age groups (age ≤31, age 32-36, and age ≥37 years) with χ2 tests.
Results
Of 3808 individuals who consented, 3310 completed the survey, including their ages. Most participants (n = 3068 [92.7%]) expressed a desire for biological children, identified as women (n = 2982 [90.1%]), and had completed training (n = 1738 [52.5%]) (Table 1).
Table 1. Sociodemographic Characteristics Stratified by Age Group Among 3310 Study Participantsa.
| Characteristic | Overall, No. (%)b | Age group, No. (%)b | ||
|---|---|---|---|---|
| Age ≤31 y | Age 32 to 36 y | Age ≥37 y | ||
| Sexc,d | ||||
| Female | 3014 (91.1) | 1165 (91.9) | 699 (92.5) | 1150 (89.4) |
| Male | 292 (8.8) | 100 (7.9) | 57 (7.5) | 135 (10.5) |
| Prefer to describe | <5 (<0.9) | 0 | 0 | <5 (<0.9) |
| Prefer not to answer | <5 (<0.9) | <5 (<0.9) | 0 | <5 (<0.9) |
| Genderd | ||||
| Woman | 2982 (90.1) | 1141 (90.1) | 693 (91.7) | 1148 (89.2) |
| Man | 289 (8.7) | 98 (7.7) | 57 (7.5) | 134 (10.4) |
| Nonbinary | 19 (0.6) | 15 (1.2) | <5 (<0.9) | <5 (<0.9) |
| Agender | 5 (0.2) | 5 (0.4) | 0 | 0 |
| Gender fluid | <5 (<0.9) | <5 (<0.9) | <5 (<0.9) | <5 (<0.9) |
| Gender queer | 8 (0.2) | 5 (0.4) | <5 (<0.9) | <5 (<0.9) |
| Prefer to describe | <5 (<0.9) | <5 (<0.9) | 0 | 0 |
| Prefer not to answer | <5 (<0.9) | 0 | 0 | <5 (<0.9) |
| Sexual orientationd | ||||
| Asexual | 24 (0.7) | 13 (1.0) | 6 (0.8) | 5 (0.4) |
| Bisexual | 221 (6.7) | 136 (10.8) | 33 (4.4) | 52 (4.1) |
| Demisexual | 15 (0.5) | 6 (0.5) | <5 (<0.9) | 6 (0.5) |
| Fluid | 11 (0.3) | 6 (0.5) | <5 (<0.9) | <5 (<0.9) |
| Gay | 52 (1.6) | 23 (1.8) | 10 (1.3) | 19 (1.5) |
| Heterosexual | 2796 (85.1) | 984 (78.0) | 667 (89.2) | 1145 (89.6) |
| Lesbian | 46 (1.4) | 22 (1.7) | 6 (0.8) | 18 (1.4) |
| Pansexual | 18 (0.5) | 8 (0.6) | 7 (0.9) | <5 (<0.9) |
| Queer | 37 (1.1) | 27 (2.1) | <5 (<0.9) | 6 (0.5) |
| Questioning | 26 (0.8) | 16 (1.3) | <5 (<0.9) | 7 (0.5) |
| Prefer to describe | 13 (0.4) | 8 (0.6) | <5 (<0.9) | <5 (<0.9) |
| Prefer not to answer | 28 (0.9) | 12 (1.0) | 5 (0.7) | 11 (0.9) |
| Age, mean (SD), y | 35.3 (8.9) | 27.0 (2.7) | 34.0 (1.4) | 44.2 (7.0) |
| Title | ||||
| Medical student | 899 (27.2) | 833 (65.7) | 54 (7.2) | 12 (0.9) |
| Resident | 441 (13.3) | 299 (23.6) | 120 (15.9) | 22 (1.7) |
| Fellow | 199 (6.0) | 51 (4.0) | 115 (15.2) | 33 (2.6) |
| Independent practitioner | 1738 (52.5) | 68 (5.4) | 461 (61.1) | 1209 (94.0) |
| Prefer to describe | 31 (0.9) | 16 (1.3) | 5 (0.7) | 10 (0.8) |
| Race and ethnicityd | ||||
| Asian | 531 (16.1) | 187 (14.8) | 133 (17.6) | 211 (16.4) |
| American Indian or Alaskan Native | <5 (<0.9) | <5 (<0.9) | <5 (<0.9) | <5 (<0.9) |
| Black or African American | 189 (5.7) | 61 (4.8) | 35 (4.6) | 93 (7.2) |
| Hispanic, Latinx, or Spanish origin | 40 (1.2) | 19 (1.5) | 13 (1.7) | 8 (0.6) |
| Middle Eastern or North African | 102 (3.1) | 42 (3.3) | 25 (3.3) | 35 (2.7) |
| Multiraciale | 236 (7.1) | 115 (9.1) | 46 (6.1) | 75 (5.8) |
| White | 2142 (64.8) | 821 (64.8) | 491 (65.0) | 830 (64.6) |
| Prefer to describe | 39 (1.2) | 11 (0.9) | 5 (0.7) | 23 (1.8) |
| Prefer not to answer | 23 (0.7) | 9 (0.7) | 6 (0.8) | 8 (0.6) |
| Specialtyf | ||||
| Anesthesiology | 57 (2.4) | 13 (3.0) | 12 (1.7) | 32 (2.6) |
| Dermatology | 21 (0.9) | 5 (1.1) | 9 (1.3) | 7 (0.6) |
| Emergency medicine | 175 (7.4) | 25 (5.7) | 56 (8.1) | 94 (7.5) |
| Family medicine | 224 (9.4) | 46 (10.6) | 67 (9.7) | 111 (8.9) |
| Internal medicine | 596 (25.1) | 78 (17.9) | 169 (24.4) | 349 (27.9) |
| Internal medicine–pediatrics | 37 (1.6) | 6 (1.4) | 9 (1.3) | 22 (1.8) |
| Neurology | 42 (1.8) | 19 (4.4) | 10 (1.4) | 13 (1.0) |
| Obstetrics and gynecology | 255 (10.7) | 50 (11.5) | 80 (11.5) | 125 (10.0) |
| Pathology | 32 (1.3) | 6 (1.4) | 6 (0.9) | 20 (1.6) |
| Pediatrics | 372 (15.6) | 66 (15.2) | 127 (18.3) | 179 (14.3) |
| Physical medicine and rehabilitation | 23 (1.0) | <5 (<0.9) | 6 (0.9) | 14 (1.1) |
| Psychiatry | 98 (4.1) | 25 (5.7) | 18 (2.6) | 55 (4.4) |
| Radiology | 59 (2.5) | 7 (1.6) | 14 (2.0) | 38 (3.0) |
| Radiation oncology | 14 (0.6) | <5 (<0.9) | 5 (0.7) | 5 (0.4) |
| Surgery | 325 (13.7) | 69 (15.9) | 93 (13.4) | 163 (13.0) |
| Prefer to describe | 49 (2.1) | 13 (3.0) | 13 (1.9) | 23 (1.8) |
Participants were recruited through social media (ie, Twitter, Instagram, LinkedIn, and Facebook groups) and email listservs (American College of Physicians and American Medical Women’s Association). The specific Facebook groups used to recruit participants were American Medical Association Medical Students, American Medical Women’s Association, Association of Women Surgeons, Gay Men Physicians Group, LGBTQ+ Premed and Medical Students, LGBTQIA+ Med Students, Medical Student Pride Alliance, Physician Moms Group, Physician Women Warriors, Women in Academic Medicine Leadership.
Total numbers may vary due to item nonresponse. Counts in cells with fewer than 5 individuals are suppressed to protect anonymity.
Another response option, which no participants in this sample selected, was Intersex.
The categories for sex, gender, sexual orientation, and race and ethnicity were from participant self-report from specific categories for selection available in the survey instrument.
Participants who selected more than one option are considered multiracial for the purpose of this study.
Only residents, fellows, practicing physicians, and prefer to describe were asked this question.
Almost two-thirds of participants (n = 1985 [60.1%]) delayed childbearing due to training, and most regretted doing so (n = 1110 [55.8%]) (Table 2). Regret rates were highest among ages 32 to 36 years (n = 325 [64.2%]), followed by age 37 years or older (n = 457 [57.0%]), and age less than 32 years (n = 328 [48.4%]). The most common primary reason cited (n = 975 [42.0%]) for delaying having children until after training was “residency requires too many hours at work, which makes parenting difficult.” Approximately one-fifth (n = 698 [21.1%]) of participants reported an infertility diagnosis, and 19.2% (n = 589) used ART; these proportions were higher with increasing age. Twenty-eight percent (n = 903) of participants reported that “fertility issues” affected their well-being. Thirty-eight percent (n = 200) of those who used ART (n = 527) and 9.2% (n = 187) of those who did not use ART (n = 2024) and were partnered sought therapy for family-building stress. Some participants (n = 381, 14.1%) reported that “fertility issues” negatively affected their relationship with their partner. Almost half of participants who used ART (n = 229 [43.5%]) reported relationship stress compared with few who did not use ART (n = 145 [7.2%]).
Table 2. Psychosocial Burden Associated With Family Building Among Study Participants.
| Characteristic | Overall, No. (%)a | Age group, No. (%)a | χ2 (df) | P value | ||
|---|---|---|---|---|---|---|
| Age ≤31 y | Age 32 to 36 y | Age ≥37 y | ||||
| Have you delayed childbearing due to training? (n = 3303)a | ||||||
| Yes | 1985 (60.1) | 680 (53.8) | 506 (66.9) | 799 (62.2) | 37.951 (2) | <.001 |
| No | 1320 (39.9) | 584 (46.2) | 250 (33.1) | 486 (37.8) | ||
| Do you regret delaying childbearing due to training? (n = 1985)a,b | ||||||
| Not at all | 451 (22.7) | 172 (25.4) | 96 (19.0) | 183 (22.8) | 68.802 (8) | <.001 |
| A little bit | 424 (21.4) | 178 (26.3) | 85 (16.8) | 161 (20.1) | ||
| Somewhat | 491 (24.7) | 178 (26.3) | 135 (26.7) | 178 (22.2) | ||
| Moderately so | 394 (19.8) | 112 (16.5) | 130 (25.7) | 152 (19.0) | ||
| Extremely so | 225 (11.3) | 38 (5.6) | 60 (11.9) | 127 (15.9) | ||
| Have you or a partner sought therapy to cope with the stress of family building? (n = 2716)a,c,d | ||||||
| Yes | 393 (14.5) | 82 (8.9) | 110 (16.2) | 201 (18.0) | 35.713 (2) | <.001 |
| No | 2323 (85.5) | 837 (91.1) | 571 (83.8) | 915 (82.0) | ||
| Do you currently or have you in the past met the criteria to be diagnosed with infertility? (n = 3310)a,e | ||||||
| Yes | 698 (21.1) | 55 (4.3) | 187 (24.7) | 456 (35.4) | 411.284 (4) | <.001 |
| No | 2248 (67.9) | 994 (78.5) | 507 (67.1) | 747 (58.0) | ||
| Not applicable | 364 (11.0) | 218 (17.2) | 62 (8.2) | 84 (6.5) | ||
| Have you used assisted reproductive technology? (n = 3063)a | ||||||
| Yes | 589 (19.2) | 40 (3.5) | 149 (21.0) | 400 (33.4) | 340.904 (2) | <.001 |
| No | 2474 (80.8) | 1115 (96.5) | 561 (79.0) | 798 (66.6) | ||
| To what degree have fertility issues affected your well-being? (n = 3238)a | ||||||
| Not at all | 1858 (57.4) | 894 (73.3) | 357 (47.9) | 607 (47.6) | 265.290 (8) | <.001 |
| Slightly | 477 (14.7) | 170 (13.9) | 129 (17.3) | 178 (14.0) | ||
| Somewhat | 332 (10.3) | 75 (6.2) | 94 (12.6) | 163 (12.8) | ||
| Moderately so | 304 (9.4) | 46 (3.8) | 94 (12.6) | 164 (12.9) | ||
| Extremely so | 267 (8.2) | 34 (2.8) | 71 (9.5) | 162 (12.7) | ||
| To what degree have fertility issues negatively affected your relationship with your partner? (n = 2697)a,c | ||||||
| Not at all | 1826 (67.7) | 715 (79.4) | 432 (63.7) | 679 (60.7) | 118.688 (8) | <.001 |
| Slightly | 490 (18.2) | 125 (13.9) | 153 (22.6) | 212 (19.0) | ||
| Somewhat | 232 (8.6) | 43 (4.8) | 62 (9.1) | 127 (11.4) | ||
| Moderately so | 116 (4.3) | 14 (1.6) | 28 (4.1) | 74 (6.6) | ||
| Extremely so | 33 (1.2) | <5 (<0.9) | <5 (<0.9) | 26 (2.3) | ||
Total numbers may vary due to item nonresponse. Only participants who reported their age were included.
Only asked of participants who delayed childbearing.
Only asked of participants who were partnered.
Of the 393 participants who have sought therapy to cope with the stress of family building, 6 did not indicate whether they had used assisted reproductive technology.
A diagnosis of infertility was defined as not getting pregnant under age 35 after a year of trying or over age 35 after 6 months of trying. A total of 380 participants replied “not applicable” to this question; these individuals had not tried to conceive (n = 270), did not want biological children (n = 73), are men who only partner with men (n = 60), or are women who only partner with women (n = 21).
Discussion
Our survey study on psychosocial burdens of family building in the physician workforce found (1) high rates of regretting delaying childbearing, (2) worse well-being associated with fertility challenges, and (3) 6 times greater likelihood of reporting relationship strain and 4 times greater use of therapy to cope with the stress of family building among those who used ART. The often inadequate insurance coverage for ART paired with the high cost may be factors in these difficulties.4 Notably, almost half of those who delayed childbearing cited medical training or practice as the reason for the delay. Our data extend other research5,6 by outlining the psychosocial burdens experienced by physicians and trainees building their families.
Our study limitations include a nonrepresentative sample and inability to estimate the response rate or degree to which response bias may affect generalizability due to our recruitment strategy.
The high rates of regret of delaying family building, subsequent infertility and use of ART, and relationship strain, including therapy needs, make family building arduous for many physicians and medical students, especially ART users. Our data highlight the need to change how we support family building for the entire physician workforce.
Data Sharing Statement
References
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Supplementary Materials
Data Sharing Statement