Family Dynamics from a Cross-National Perspective: What are the Implications for Family Medicine?


Phua Kai Lit, PhD


Community Medicine Section, International Medical University, Sesama Centre, Plaza Komanwel, Bukit Jalil, 57000 Kuala Lumpur, Malaysia




Major issues, developments and transformations related to the contemporary family are identified. These include increasing numbers of singles, delayed childbearing, smaller completed family size, more female participation in the labour force, “multinational families”, cohabitation, homosexual domestic partnerships, rising divorce rates, single parent families, and assisted reproduction. Possible impacts of these changes on the health of family members are then discussed.




The “family” is undergoing a profound transformation in the Western world as well as in Asian countries such as Malaysia and Singapore. Some scholars in the West believe that the family is in a state of crisis. Others have even claimed that the family is a “crumbling edifice” and undergoing “breakdown” and raised alarms about the dire social consequences of such a development.1 Scholars who believe that the family is crisis-ridden point to widespread cohabitation in lieu of marriage; “serial monogamy” in the form of one unstable relationship after another; large numbers of out-of-wedlock births; high rates of divorce; and increasing numbers of single parent families.2 It has also been noted that rates of suicide, injuries, substance abuse and sexually-transmitted diseases among teenagers and young adults are significant in western countries such as Britain and the United States.3


Changes in the social institution called the “family” are related to major changes in society such as urbanization, industrialization, increased access to secondary and tertiary education for females, increased female participation in the labour force, and the appearance of new ideas concerning “appropriate” behaviour and “proper” social roles for women.

As societies change from agrarian-based economies to industrial and post-industrial economies, social institutions such as the family are also affected. For example, in rural, agricultural societies with low degrees of mechanization, it makes sense for a couple to have a lot of children (especially male children) in order to assist with farming and to provide economic resources and care when the couple is old. However, in an urban and industrial society, circumstances influence people to have fewer children while investing more in each of them with respect to education and so on.  This is because children in an urban, industrial economy are less likely to contribute to the economic resources of the family as a result of child labour laws, the need to spend a lot of time acquiring educational credentials in order to secure good jobs in the future, etc.


In an industrial economy, women are more likely to spend longer periods in school and to participate in the work force after leaving school. These have affected the age of marriage for females and changed the timing of their child-bearing also. Last but not least, new ideas of “appropriate” behaviour and “proper” roles for women originating from the feminist movement in the United States and other Western countries have also affected the dynamics of the family in the rest of the world. In this paper, I will begin with a description of changes in patterns of family formation, the appearance of alternatives to the traditional family, trends in family dissolution, and the introduction of new technology such as assisted reproduction. I will then discuss the implications of these changes with respect to family medicine and public health.




The number of singles (unmarried adults) is rising in the West as well as in Asian countries such as Singapore.4 It is becoming more common for people to defer marriage into their late 20s or even into their 30s for educational or occupational reasons. However, the state of being single can also be involuntary in nature. For example, in contemporary Singapore, it has been noted that the ranks of the singles include highly-educated women who have trouble finding “suitable” husbands and lowly-educated men who have trouble finding wives. Their predicament is due to the persistence of traditional ideas such as the desirability of women “marrying up” (i.e. the view that women should marry men who are of higher social standing than them such as being better educated, being better paid, etc.) and the reluctance of men to marry women who have achieved higher levels of socioeconomic attainment than themselves.5 Interestingly enough, although Singaporean government “match-making” agencies such as the Social Development Unit (SDU) and the Social Development Service (SDS) were ridiculed when they were first established, they have been relatively successful in getting more Singaporeans to tie the marriage knot. (However, reflecting former Prime Minister Lee Kuan Yew’s elitism and his belief in the genetic inheritance of intelligence, the SDU was originally established to raise the fertility of university-educated women by getting them to meet and marry university-educated men.6 To this day, SDU programmes are meant only for university graduates while SDS programmes are meant for non-graduates).7


As barriers against equal access of women to higher education and the more desirable occupations begin to fall, women spend more and more time in school and participate in greater numbers in the workforce. The result is that they are marrying later or are delaying child-bearing later into marriage. Also, completed family size is decreasing. In Malaysia, this process is most noticeable among the Chinese. Teenage marriage among Malaysian Chinese women is becoming less and less common and the total fertility rate has declined significantly in recent cohorts. The total fertility rate of the Chinese in West Malaysia has fallen from 4.6 births per woman in 1970 to 2.3 in 1990 – a decline of 50 per cent in twenty years.8 In the case of neighbouring Singapore, the fertility rate has fallen below replacement level and thus, the Government has been trying to encourage (unsuccessfully) its citizens to have more children.9


In Malaysia, residential patterns after marriage are also changing from patrilocal or matrilocal to neolocal, i.e., young couples increasingly prefer to live on their own rather than share a house or flat with their parents from the husband’s side (patrilocal residence) or the wife’s side (matrilocal residence). Rural to urban migration and rising incomes have contributed to this change. However, ties between the generations remain strong and adults tend to spend a lot of time visiting their parents on weekends and holidays. Even if parents and their grown children do live apart, they may live relatively close to each other in terms of physical distance and interact with and assist each other frequently. This has been called “quasi-coresidence”.10


In the past, polygamy was an acceptable practice among non-Muslim Malaysians. Today, polygamy is no longer permitted by law for non-Muslims. Also, it is no longer considered culturally acceptable for a non-Muslim man to have multiple wives.


In recent years, much attention has been paid to the phenomenon of “globalization”, i.e., the increasing social and economic integration of the countries and peoples of the world. As globalization ties different societies in the world together through trade and investment, labour migration, overseas education, mass tourism and so on, one outcome is larger numbers of cross-cultural and international marriages. In Malaysia, foreign-born wives are not unknown among males of Indian ancestry since the latter have often sought brides from the Indian sub-continent. The prevalence of foreign-born spouses is likely to increase among the Chinese and the Malays because of higher education or employment overseas and because of immigrant labour (skilled as well as unskilled) flows into Malaysia.


There is also the phenomenon of what I would call the “multinational family”, i.e., Malaysian families with family members scattered across different countries. An example would be a family where the husband works and resides in foreign countries for extended periods of time, the wife and younger children reside in Malaysia, while older children are studying or working overseas. Chances are that this family would also have relatives residing in Australia, New Zealand, Canada, Britain and the United States (not to mention Singapore). Chan and Tey’s calculations indicate that net outflow of Malaysian Chinese from the country over the last few decades has been quite significant.11


Married foreign workers in Malaysia (especially unskilled workers from Indonesia and Bangladesh) have also contributed to the phenomenon of “multinational families”, e.g., Indonesian maids with husbands and children back in Indonesia and male Bangladeshi workers with wives and families back home.




As mentioned earlier, cohabitation is common in Western countries such as the United States.12 Couples in such relationships may even choose to have children together since the stigma against out-of-wedlock births is gradually disappearing. Cohabitation has also appeared in Malaysia in heavily urbanized regions such as the Klang Valley. The Prime Minister Of Malaysia was quoted as saying in December 2000 that, “It is sad that marriage is no longer considered a sacred act as advocated by Islam. In some places, people no longer consider marriage sacred. Some just live together and if they feel they want children, they just have them.”13


In certain Western countries, another alternative to the traditional family is the homosexual couple. In countries like the Netherlands, homosexual “domestic partnerships” are legally recognized.14 In the American state of Vermont, homosexual relationships called “civil unions” are officially recognized by state law.15 Although homosexual marriage is taboo in Malaysia, chances are that homosexual couples living together in quasi-married relationships can be found in Bohemian areas such as Bangsar in Kuala Lumpur.




Family dissolution can occur through abandonment, divorce or death. Thus, a husband or wife may choose to abandon spouse and children; families may break up because of divorce; and one or both members of a couple may die prematurely and leave behind a widowed spouse with fatherless/motherless kids or totally orphaned children. Divorce rates have risen to significant levels in Western countries as compared to the 1950s and earlier. In the United States today, as much as one out of every two marriages end in divorce.16 When divorcees with children remarry, the interesting phenomenon called the “blended family” emerges. A blended family can consist of a husband and a wife who both have children from previous marriages. Thus, their children will have step-siblings and also more than four grandparents each!17


Abandonment and divorce have also contributed to rising numbers of single parent families in Western countries. Premature death of one parent is not a significant contributing factor in the developed countries. In the contemporary United States, unmarried teen pregnancy and childbirth is an important contributing factor to rising numbers of single parent families.18 Teenaged births can result in 30-year old grandmothers if both the mother and her daughter bear children when they are in their mid-teens! 


One important reason why single parent families are considered a social problem is that often, they consist of a woman living with children in poverty. Children who grow up in poverty are at greater risk of all sorts of ill effects such as poorer health, low educational attainment and so on.19 Female divorcees and widowed women are at a great disadvantage in terms of the chances of getting remarried as compared to male divorcees and widowed men. This is more so if they have already borne children and if they are middle aged. This is especially true in countries like Malaysia where social conventions permit men to marry much younger women but discourage women from marrying men who are significantly younger than them. Middle aged female divorcees and widows would find that most men of their age have already married and that younger men are unlikely to consider them to be “suitable marriage partners”. Middle aged male divorcees and widowers, on the other hand, have better chances of remarriage even if they are also disadvantaged to some extent. The children of male divorcees are more likely to be living with their mother. Also, prevailing social conventions allow them to marry much younger women. Thus, until attitudes change and people no longer consider it unusual or unacceptable for women to marry much younger men, middle aged female divorcees and widows will be at a much greater disadvantage with respect to prospects for remarriage.




There is increasing awareness of the negative effects of family dysfunction on the well-being of its members. This is certainly true in Malaysia: for example, public awareness of spouse abuse and domestic violence has increased and it is no longer considered acceptable for one spouse to subject another to constant verbal, emotional or physical abuse.  There is also heightened awareness of other related issues such as child abuse and neglect.


The major issue, in my opinion, is whether the prevalence of dysfunctional families is increasing in Third World countries such as Malaysia that are undergoing great economic, social and cultural transformation. Is child abuse and neglect on the rise? Is the number of unwanted and abandoned babies on the rise? Are dual career couples neglecting their children to the detriment of the welfare of the latter?20 Is domestic violence occurring at higher rates or is the apparent increase due mainly to greater awareness of the extent of the problem? If family dysfunction is indeed increasing and this increase is due to rapid and profound socioeconomic transformation as well as changing values, what can be done to tackle the problem?




Advances in medical technology have led to techniques such as in vitro fertilization (IVF) and other forms of assisted reproduction. Surrogate motherhood, wittily called “rent-a-womb” by some people, can also be considered a form of assisted reproduction. The appearance of assisted reproduction technology has given rise to economic, ethical and legal questions.21 First of all is its cost. The high cost of IVF would limit its access only to infertile couples who are affluent unless there is a public subsidy for this medical procedure. Public subsidies for IVF would, in turn, give rise to the question of appropriate allocation of scarce healthcare resources.


“Surrogate motherhood” refers to the process whereby a contract is drawn between a couple (fertile husband and infertile wife) and a third party (the surrogate mother) and the latter agrees to bear a child for the couple in return for monetary payment. The surrogate mother is fertilized with sperm from the man using artificial insemination. She is supposed to hand over the baby to the couple at birth and to have absolutely no ties with the baby thereafter even though she is the biological mother. As the famous “Baby M” case of the late 1980s in America demonstrates, things can get really complicated if the surrogate mother changes her mind and decides to keep the baby.22


Other ethical issues can also arise from the phenomenon of surrogate motherhood, e.g., what if a couple who are both fertile decide that they do not want the wife to go through the process of pregnancy (possibly because of career reasons) and hires a surrogate mother to carry their child for them? Here, the biological parents are the couple and the surrogate mother serves purely as the “incubator” for the baby. Would this be ethical and should it be permitted?




So far, I have identified the following issues, developments and transformations related to the family:


Increasing number of single adults

Delayed childbearing

Smaller completed family sizes

Preference for neolocal residence on the part of young married couples

Rising rates of female participation in the labour force

Physically separated and “multinational families” as a consequence of migration

Alternatives to the traditional family such as cohabitation

Increase in the divorce rate

Greater number of single parent families

Assisted reproduction


I will now discuss possible impacts of such developments on the health of family members.


1.     Increasing Number of Single Adults


It is well known that social isolation can be detrimental to mental and physical health. Conversely, researchers like Linda Waite argue that marriage has positive effects on a person’s health.23 Thus, attention needs to be devoted to the emotional and physical health of people living alone, e.g., unmarried adults living alone, divorcees without an adult partner, and widowed people living in isolation. Adult men living alone may be at higher risk of acquiring sexually-transmitted diseases if they make use of commercial sex services or are promiscuous in their sexual behaviour.


2.     Delayed Childbearing


It is well known that children born to young, teenaged women or to women who delay childbearing into their mid 30s or later are at higher risk of suffering from birth defects and from other forms of ill health.24 Therefore, as more and more women postpone childbearing into their mid 30s or later, antenatal care and related services will need to be improved to protect the health of neonates. Also, rates of infertility may rise with later marriages and postponement of childbearing.


3.     Smaller Completed Family Sizes


Some couples may choose voluntary childlessness or decide to have only one child. One relevant question here is whether there is an “only child syndrome”, i.e., what are the long term effects on psychosocial development if a person grows up as an only child? Is the only child more likely to be “spoilt” by the parents? China’s “one child per couple” policy for the Han Chinese majority (increasingly violated especially in the rural areas) has been alleged to result in doting parents and grandparents spoiling their “Little Emperors” and even overfeeding/stuffing them to the point of obesity!25   Smaller completed family sizes would mean that the responsibility of caring for aged parents would fall on the shoulders of fewer adult children in the future. Childless couples would need to amass significant resources in order to be reasonably comfortable during retirement.


4.     Increasing Preference for Neolocal Residence by Young Married Couples


Aged parents have traditionally lived with their adult children in Malaysia. However, this situation is changing as young couples increasingly prefer to reside separately from their parents after marriage (neolocal residence). Thus, as this practice spreads, the number of elderly couples living by themselves or elderly widows living alone (since women have a longer life expectancy than men and they also tend to marry older men) will increase.

How would this affect the physical, mental and socioeconomic well-being of the elderly?


5.     Higher Female Labour Force Participation


In Malaysia and Singapore, working women with children often employ live-in maids from Indonesia, the Philippines and other surrounding countries to take care of their children when they are at work. They may also have a live-in mother or mother-in-law to supervise the maid in their absence. Whatever the case may be, these maids have therefore become de facto child-minders for many Malaysian couples. Maids from Indonesia are often poorly educated and may be lacking in knowledge of hygiene and proper child nutrition. The potential for abuse and neglect of children in the absence of the parents or other relatives also exists. Thus, all these factors may be detrimental to the well-being of children under the care of maids. Kids with mothers who work outside the home may be poorly supervised and thus be heavily influenced by the mass media and their peers. The mass media and peer groups may encourage them to indulge in risk-taking behaviour such as cigarette smoking, drinking of alcohol, experimentation with drugs and other harmful substances, dangerous driving, early sexual activity and so on.26 Early sexual activity immediately brings into mind issues such as sexually-transmitted diseases, contraception, unwanted pregnancies, illegal and legal (in Singapore) abortions, abandoned babies and so on. 





6.     Physically Separated and “Multinational Families”


Family members may be physically separated as a result of the husband and wife working or residing in different cities (and children studying away from home). “Multinational families” are similar except that family members are scattered across different countries. Economic globalisation has increased the number of multinational families. Here, the relevant issues would be whether strains on the relationship between husband and wife may arise, and the impact of lengthy periods of separation on the psychosocial well-being of family members.


Migrant workers in Malaysia are also members of  “multinational families” in the sense that Indonesian maids may have left husbands and children behind in Indonesia while male Bangladeshi workers may have wives and children back home in Bangladesh. Male migrant workers may seek commercial sex services and thus expose themselves to the risk of contracting a sexually-transmitted disease. Female migrant workers may be at some risk of experiencing sexual harassment from male employers or co-workers.27 Migrant workers in Malaysia may engage in sexual relations or cohabitation with locals or other migrant workers although they may already have spouses back home. Similarly, their husbands and wives back home may also develop such relationships with others.   


7.     Cohabitation and Other Alternatives to the Traditional Family


Popenoe and Whitehead believe that cohabitation has negative effects on the couple involved in such a relationship. Specifically, they say that it increases the risk of breaking up after marriage, that unmarried couples are less happy than married couples, and even that living together “increases the risk of domestic violence for women, and the risk of physical and sexual abuse for children.”28 The number of unplanned pregnancies and births may also rise if couples in such relationships (including immigrant workers in Malaysia) do not practice contraception carefully. As for homosexual marriages, such relationships are not legally permitted in both Malaysia and Singapore.


8.     More Divorces Leading to Single Parent Families


In the United States, there is debate over the question of whether divorce can exert lasting negative effects on children. Some researchers believe that the negative effects of divorce on children are significant and widespread and may even reveal themselves only after many years into the future. The latter is the so-called “sleeper effect”.29 Others argue that these views are exaggerated.30 For example, Andrew Cherlin’s view is that


What divorce does to children is to raise the risk of serious long-term problems, such as severe anxiety or depression, having a child as a teenager or failing to graduate from high school. But the risk is still low enough that most children in divorced families don’t have these problems.31 


Whatever the case may be, if the number of divorces is large enough, the minority of kids who are severely affected into the long term may still add up to a significant number.32 These kids will require help from relevant health and social services providers.  Besides this, divorce often results in a single parent family with lowered living standards. The single parent family is likely to consist of a mother and her children since the divorce court may be more inclined toward awarding custody of the children to the mother than to the father. The single parent and her kids may even end up living in poverty if she is a housewife with little or no working experience and who will therefore experience great difficulty in obtaining a well-paying job after the divorce. Her problems will be compounded if the ex-husband does not contribute his child support payments regularly. Thus, rising divorce rates may result in growing numbers of single parent families living in poverty. Growing up in poverty would definitely be detrimental to the well-being of these children.


9.      Assisted Reproduction


As discussed previously, advances in the technology of assisted reproduction has raised many economic, ethical and legal issues. Government subsidies for assisted reproduction (especially for more expensive procedures such as IVF) would improve access but raise questions about whether this would be a reasonable allocation of limited healthcare resources. If public subsidies for assisted reproduction are not available, this would mean that only infertile couples who have the financial means would be able to have access to this technology. 




As the social institution called the family changes in Malaysia, the psychosocial and physical well-being of its members may be negatively affected. There is a need to study the impact of the various changes on the well-being of its constituent members such as the father, the mother, the children, ageing grandparents, other dependent relatives and so on. Strategies can then be introduced to prevent or limit the negative effects of such changes.    





1.     Utting D. Family and Parenthood: Supporting Families, Preventing Breakdown. York: Joseph Rowntree Foundation, 1995.


2.     Utting D. Ibid.


3.     Bennett DL, Bauman A. Adolescent Mental Health and Risky Sexual Behaviour. British Medical Journal 2000; 321: 251-252.


4.     Yap MT. Population Policy. In: Low L, Toh MH, eds. Public Policies in Singapore: Changes in the 1980s and Future Signposts. Singapore: Times Academic Press, 1992: 127-143.


5.     Yap MT. Ibid.


6.     Selvan TS. Singapore: The Ultimate Island. Melbourne: Freeway Books, 1990.


7.     Social Development Unit website. Government of Singapore.


8.     Chan KE, Tey NP. Demographic Processes and Changes. In: Lee KH, Tan CB, eds. The Chinese in Malaysia. Shah Alam: Oxford University Press, 2000: 71-93.


9.     Mitton R. Endangered Species. Asiaweek 2000; December 1: 46-47.



10.  Johnson RW, Da Vanzo J. Mother-Child Coresidence and Quasi-Coresidence in Peninsular Malaysia. Journal of Population 1996, 2:21-42.


11. Chan KE, Tey NP. Ibid.


12. Smock PJ. Cohabitation in the United States: An Appraisal of Research Themes, Findings, and Implications. Annual Review of Sociology 2000; 26:1-20.


13. Mahathir Laments Cohabitation. The Star 2000; December 13.


14. Hallsall P. Lesbian and Gay Marriage Through History and Culture. 1996; June 1.


15. Other States Looking to Follow Vermont’s Civil Unions Lead. 2000; July 24.


16. Cherlin AJ. Generation Ex-. The Nation 2000; December 11.


17. Cherlin AJ. Marriage, Divorce, and Remarriage. Revised and enlarged edition. Cambridge, Massachusetts: Harvard University Press, 1992.


18. Bianchi SM. Feminization and Juvenilization of Poverty: Trends, Relative Risks, Causes, and Consequences. Annual Review of Sociology 1999; 25: 307- 333.


19. Montgomery LE, Kiely JL, Pappas G. The Effects of Poverty, Race, and Family Structure on US Children’s Health: Data from the NHIS, 1978 through 1980 and 1989 through 1991. American Journal of Public Health 1996; 86:1401-1405.


20. The Lost Children of Rockdale County. Frontline 1999; October 19.


21. Giving Nature a Hand. Online Newshour 1997; January 27.


22. Chesler P. Sacred Bond: The Legacy of Baby M. New York: Vintage, 1989.

23. Waite L. Does Marriage Matter? Demography 1995; 32:483-507.


24. Basch PF. A Textbook of International Health. New York and Oxford: Oxford University Press, 1990.


25. Jing J. ed. Feeding China’s Little Emperors: Food, Children, and Social Change. Palo Alto: Stanford University Press, 2000.


26. The Lost Children of Rockdale County. Ibid.


27. Jones S. Making Money Off Migrants: The Indonesian Exodus to Malaysia. Hong Kong: Asia 2000 Ltd and Australia: University of Wollongong, 2000.


28. Popenoe D, Whitehead BD. Should We Live Together? What Young Adults Need to Know about Cohabitation Before Marriage. A Comprehensive Review of Recent Research. No date.


29. Wallerstein J, Blakeslee S. Second Chances: Men, Women, and Children a Decade After Divorce. Revised edition. New York: Houghton Mifflin, 1996.


30. Cherlin AJ. Going to Extremes: Family Structure, Children’s Wellbeing, and Social Science. Demography 1999, 36:421-428.


31. Cherlin AJ. Generation Ex-. The Nation 2000; December 11.


32. Whitehead BD. The Divorce Culture: Rethinking Our Commitments to Marriage andFamily.  New York: Alfred A. Knopf, 1997.