As seen in Psychology Today.

The COVID Era has been challenging for people from all walks of life. Beyond the enormous death toll, the lingering symptoms affecting long haulers, and reports that upwards of 30% of patients who develop severe COVID-19 infections subsequently meet criteria for post-traumatic stress disorder (PTSD), there has also been a tremendous psychological toll even among individuals who were never infected with the SARS-CoV-2 virus. This has already affected fertility rates, as more people express anxieties about having children and mental health practitioners will need to be prepared to support patients who are agonizing over matters of family planning without imparting their own prejudices.

A Natural Response

Since April 2020, the National Center for Health Statistics and the Census Bureau have been conducting a survey to monitor how the pandemic has impacted mental health in the U.S. From the start of the survey through March 2021, the average share of adults reporting symptoms of anxiety or depression fluctuated between 33.9% and 42.6% before starting to steadily decline in April 2021. The last reported figure was 29% taken between June 23 and July 5, 2021. While this is certainly an improvement from earlier in the year, it is still more than three times that of the estimates for July 2019, when 9.5% of adults were experiencing these symptoms, according to the National Center for Health Statistics’ 2019 National Health Interview Survey.

Feeling anxious is, of course, a normal response to stress, and it should come as no surprise that reports of anxiety have gone through the roof. This is to be expected during an unprecedented global cataclysm. The same is true for those who feel despondent because of the pandemic.

It’s important to remember that, as unpleasant as these feelings are, they are natural. Everyone has days when they are not feeling their best or when they have a sense of nervousness without fully understanding why. It only becomes problematic when we experience these feelings incessantly and without stimuli to warrant them and their occurrence as pathological—i.e. abnormal. This pathology reaches clinical significance when it begins to interfere with social, academic, or professional obligations, thereby making it impossible to live a normal life. At this point, a clinician may diagnose an individual as having an anxiety or mood disorder.

Therefore, the fact that 29% of people are still feeling anxious and/or depressed should not strike anyone as odd. The pandemic is far from over and it would be wrong to assume that everyone who reported feeling anxious or depressed has a clinical disorder. Moreover, it would be truly shocking if there were no differences in the reported levels of anxiety or depression throughout 2020 and early 2021. To put it lightly, this has been a very tumultuous and unnerving time.

If anything, we should be hopeful because the number has already begun to decline. It shows that the majority of people tend to be resilient even during the most catastrophic events. In sum, it is entirely natural to respond to extremely stressful events with clinically significant levels of anxiety and depression, but it is also natural to bounce back relatively quickly.

A Cautious Response

One metric that does not seem likely to quickly return to normal is the fertility rate, which is the average number of children born to women during their reproductive years. The rate has been in steady decline for years and fell precipitously in 2020—especially in countries like South Korea, Japan, Wales and England, and the U.S., where record lows have all been reported.

There are logistical reasons for the sudden drop in fertility rates over the last year: Social distancing guidelines made it difficult for individuals to form new relationships, maintain nascent romantic relationships, or even have sex. Church & Dwight Co., the parent company of Trojan brand condoms, reported a 13% decline in sales in the second quarter of 2020, and yet another 6% dip in the third.

There are also psychosocial reasons for the decline. Some people lost their jobs or didn’t have a stable living situation, which made the idea of having a child (if such a proposition was even on the table) far less appealing. For individuals who have been subjected to living in tiny apartments (with or without children) or for those who have struggled with the lingering psychiatric effects of a severe COVID infection, long COVID, or severe anxiety and depression that arose due to extended quarantine, the idea of having children must seem incompatible with their current circumstances. Even relatively well-off young families who were dead set on having children at the start of 2020 may feel some hesitancies now that their decision to wait until the chaos has passed has led them to a delay of over a year.

This is not to say that family planning involves decisions that reside solely in the domain of logic or a staid assessment of one’s finances. The issue is charged with emotion, assumptions about one’s future ability to care for and love the child, and presumptions about what kind of world the next generation will inherit.

Given how difficult the past year has been, as well as the growing belief that the 21st century may be marked by far more global crises than the second half of the 20th century, I believe that many people have fundamentally altered how they approach this decision. Having a child has always required something of a leap of faith and there have always been reasons for anxiety, but I believe the pandemic has significantly changed the calculus. I also believe that its effects will be felt for years, if not decades because this increased level of circumspection is not a kneejerk response or an emotional one. Rather, this is something that most people have thought about a lot.

The pandemic has forced us all to take into account possibilities that were once considered to be the stuff of nightmares, and that it is unreasonable to just assume that everything will work itself out. In other words, it is reasonable to be anxious about the future, given the chaos unleashed by the pandemic, as well as the belief that the future will only become more chaotic due to the possibility that there will be more pandemics or because of events related to climate change.

A Conflicted Response

In addition to affecting the fertility rate, I believe this will also become a mental health issue as personal decisions about family planning begin to run up against conflicting personal convictions or pressures from family and community. For example, a deeply religious person may feel compelled by members of their congregation to add another member to the flock, but they may also have anxieties about the kinds of hardships that their children may face or the stresses of raising a young child should we have to enter lockdown once again. Given the likelihood that more pandemics are on the horizon and that this was not a singular event significantly changes one’s personal calculus. Similarly, a person’s convictions about the dangers that overpopulation poses to the environment and humanity’s future may have been galvanized due to the pandemic. If this individual simultaneously has a strong compulsion to have children, they may agonize over the decision to have a child or not.

These positions will likely become more sensationalized by forces within the media that seek to capitalize on these kinds of issues with overly simplistic answers to how one should behave. Some will likely argue that deciding not to have a child is selfish, while others will maintain that deciding to have a child is actually the selfish option. This is a false dichotomy in which we should never allow ourselves to be trapped because neither is necessarily selfish, and mental health practitioners will need to remain impartial and above this skirmish in the culture wars to offer our patients the best level of care. We need to acknowledge that many people feel an inner need to have children, others may feel socially obligated to do so, and still others may not experience either internal or external pressure to have children. To assume a universal biological or cultural imperative with respect to the decision to become a parent is misguided. It is ultimately one that each person or family must make on their own.

While the vast majority of Americans have shown themselves to be resilient to anxiety, depression, and trauma– and stressor-related disorders in the wake of the COVID-19 pandemic, this does not mean that everyone will return to normal once the virus has been reined in. Nor does it mean that they will approach major life decisions the same way they once did. Even if they do not have an anxiety disorder or feel nervous about returning to many types of pre-pandemic activities, many people will have far more anxieties about family planning now than they did prior to the pandemic. We will need to help our patients address these anxieties and, most importantly, we will need to do so without judgment and without letting our biases speak through us.