Sexuality

The word sexuality is scattered liberally throughout contemporary sexual health literature, but the text frequently fails to explore what sexuality actually means. The word itself did not come into being until the modern era, and many authors are reluctant to confine it to a simple definition. This may well be because sexuality is fundamentally dynamic. It has different meanings culturally, its definition changes throughout history, and an individual’s feelings and values concerning their sexuality alter as they gain more life experience.

Lion (1982:8) embraces sexuality as a concept that is open to transmutation as ‘all those aspects of the human being that relate to being a boy or girl, woman or man, and is an entity subject to lifelong dynamic change. Sexuality reflects our human character not solely our genital nature.’ This definition alone demonstrates clearly that sexuality is more than overt sexual behaviour encompassing the complete range of human experience (Pratt 2000). A more recent definition, courtesy of the Royal College of Nursing (RCN 2000, cited on contents page), states that sexuality is: ‘an individual’s self concept, shaped by their personality and expressed through a heterosexual, homosexual, bisexual or transsexual orientation’. This definition may reflect a more contemporary view of sexuality.

The word ‘sex’ is usually employed to mean the act of having sex or to distinguish between the ‘sexes’ – that is, male or female. Gender is the name given to socially and culturally defined characteristics of the sexes – that is, masculinity and femininity.

Puberty and teenage pregnancy

Please see website and Chapters 19, 23 and 32 for more information.

Sex during pregnancy

Sex during pregnancy has historically been shrouded in myth, misconceptions and old wives’ tales. The advice offered during traditional British antenatal care has been one of abstention, without any evidence to substantiate this stance.

During pregnancy, many couples are fearful of continuing their sexual relationship. They may feel that they may somehow provoke miscarriage, premature labour or damage the fetus; some men have expressed fear of breaking the ‘bag of waters’ (Kitzinger 1985). Couples can be reassured that this is not the case.

The overriding message from most well-conducted studies is that sex during pregnancy for the vast majority of women is safe and does not lead to any increase in complications (Enkin et al 2000), though male superior position (Ekwo et al 1993) and a vagina colonized with specific micro-organisms, for example Trichomonas vaginalis (Read & Klebanoff 1993), have both been associated with preterm birth. More studies are required in this area to provide definitive results. The National Institute for Clinical Excellence (NICE) (2003) antenatal care guidelines stated that health professionals can inform healthy pregnant women that sexual intercourse during pregnancy is not known to be associated with any adverse outcomes.

There are a few definite or relative contraindications to different sexual practices or sexual intercourse during pregnancy. Forceful blowing of air into the vagina during oral sex is an absolute contraindication, as this may lead to fatal air embolism (Aston 2005, Lumley & Astbury 1989). The insertion of a foreign body into the vagina may cause damage to the internal structures and introduce infection (Walton 1994). Placenta praevia, vaginal bleeding, history of premature birth and rupture of membranes are often cited as clinical reasons to avoid sex during pregnancy (Aston 2005).

Whilst sex can be enjoyed by couples throughout the whole of pregnancy, other factors may play an important role. Change of body image (see website), tiredness, breast changes, backache and frequency of micturition are some of the things that can affect a pregnant woman’s sexuality (Aston 2005). There are many accounts that give a very negative view of sexuality and pregnancy. Kitzinger (1985) states that some women have a distorted view of their bodies during pregnancy, they feel bigger than they really are and think that their partners must find them ugly when in fact the partners often delight in pregnant women and find their physical changes exciting and beautiful.

Conversely, some women have a very positive ‘body image’ during pregnancy. They feel incredibly attractive and womanly. It is viewed as the ultimate expression of femininity and an eminently powerful symbol of potency and fertility.

Physiological hormonal changes during pregnancy mean that oestrogen and progesterone act together to procure marked pelvic vasocongestion, which occurs as a result of increased vascularity and venous stasis. The results can mean a heightened manifestation of all aspects of sexual intercourse, including orgasm (Aston 2005). For some, this may be the first time that they experience orgasm (Walton 1994). For others, however, vasocongestion may predispose the woman to discomfort during sexual intercourse (Aston 2005).

It is often assumed that there is a linear decrease in sexual activity as pregnancy progresses, but for some women sexual activity may well increase during the second trimester. This may be due to the disorders of pregnancy subsiding and the woman developing a sense of wellbeing. However, it is also well recognized that sex diminishes during the third trimester (Frohlich et al 1990), most probably due to the discomfort and mechanics of having sex with a greatly enlarged abdomen. Alternative positions to the missionary position, such as the man behind the woman or ‘spooning’, or the woman sitting or kneeling on top of the man, could be explored.. Other non-penetrative options such as self or mutual masturbation, oral sex, fondling or massage or purely kissing and cuddling may also be adopted (Walton 1994).

It is suggested that having sexual intercourse may be an alternative to other methods of induction, the theory being that sperm is rich in prostaglandins, thereby providing a stimulus for ripening the cervix. However, to date, this has been poorly evaluated, and more research is required in this area (Kavanagh et al 2001).

Overall, keeping clear channels of communication open is the most important aspect of maintaining an intimate sexual or non-sexual relationship.

Sexuality and labour

Labour is usually synonymous with anxiety, discomfort and pain. It is not often viewed as being a ‘sexual’ experience. It is clear when reading literature in this area that for some women and their partners it can be an intensely pleasurable and sexual experience. The sounds a woman makes during contractions, the organs that are used in the process of childbirth, the overwhelming energies and powers that are at work during labour, are all intimately related to sex and sexuality (Aston 2005, Gaskin 2002, Kitzinger 1985, Williams 1996). Kitzinger (1985:210) describes it thus: ‘the most intensely sexual feeling a woman ever experiences, as strong as orgasm, even more compelling than orgasm’. In her book Spiritual midwifery, Gaskin (2002) quotes a number of experiences of the sexual nature of childbirth. One woman recounts her birth experience with her husband: ‘My rushes (contractions) hardly felt heavy at all, but I knew they must be because I was opening up. We just kept making out and rubbing each other. We got to places that we had forgotten we could get to… going through the birthing I felt his love very strong. It was like getting married all over again’ (Gaskin 2002:53). Rabuzzi (1994) cites examples of other couples’ erotic experiences of labour. One husband of a woman having a home birth said: ‘The birth was not only painless, but very pleasurable. We had never read about this aspect.’ He goes on to describe the noises his wife made whilst the baby’s head was crowning as being ‘orgasmic’ and ends with: “what a long way from the pain and agony of conventional myth’ (Rabuzzi 1994:120).

If labour can be such a sensual and gratifying experience, it may be a cultural or contextual aspect that makes it generally viewed negatively. It is suggested by some that the scientific and technological procedures have taken childbirth out of the hands of women and set it in the context of the powerful male-dominated institution of the hospital (Cosslett 1994, Williams 1996), where everything is controlled, the medical model’s ultimate goal being ‘safety’ whatever the cost. In contrast, the natural childbirth discourse is focused on the power of the woman, which is more in evidence in home births (Cosslett 1994; Williams 1996). Midwives argue that ‘safety’ and ‘satisfaction’ are both achievable.

Nipple stimulation is known to produce oxytocin, and therefore can be performed by the woman or her partner to attempt to initiate or augment labour naturally. Privacy will of course be required if she wishes to try this activity.

Women requiring specialized care

There are some groups of women who may need specialized care and attention during pregnancy, labour, childbirth and afterwards. Some are discussed below.

What are the issues concerning sexuality for each of these woman?

It is important not to stereotype these women. All will quite probably have similar issues, but in addition: Anne may have to deal with reactivated memories of the abuse; Lydia may have to deal with homophobia and sometimes hostile behaviour; Saadah may be terrified of labour and birth; Katie may face stigma and labelling of being promiscuous; Bernie may have conflict between being a nursing mother and a sexual being.

Survivors of sexual abuse

The prevalence rate for reported cases of childhood sexual abuse is around 21% for females in the UK. A similar or higher rate is reported in Canada and North America (NSPCC 2007). It is clear, given the high prevalence of childhood sexual abuse, that midwives will, at some point, care for women who have survived sexual abuse. These women may or may not disclose such abuse to their carers.

Memories of abuse, even those that have been partially or wholly repressed, may be triggered by pregnancy and childbirth (Courtois & Riley 1992, Kitzinger 1990). The change in body image, submission to physical contact, and feelings of powerlessness are all factors that are likely to make the survivor regress back to times when she encountered similar susceptibilities.

Women who have been previously sexually abused may display a range of behaviours as follows:

Some of the styles exhibited by sexual abuse survivors may also be enacted by women who have not been abused; however, in the former group, the behaviour may appear extreme.

Control has been identified as being of grave importance to women who have been sexually abused (Parratt 1994). Therefore, keeping women well informed, ensuring that they are made part of the decision-making process and obtaining informed consent for all procedures are absolute requirements.

Paternal presence at the birth

In western societies, there has been a cultural shift from men being virtually excluded from the birthing room, to men being actively encouraged to attend the birth of their child. It is not known what effect paternal presence at birth has on the process of labour or on the subsequent relationship of the couple. It does appear, however, in some studies that the presence of a female companion such as a doula can have numerous positive effects on the outcome of labour (Kennell & Klaus 1991).

One dimension of paternal presence at birth that is rarely discussed is the possible adverse effects on subsequent sexual relationships. Sex therapists working with sexually dysfunctional couples have discovered that the man’s experience of what was for him a traumatic labour and delivery has stifled any sexual feelings for his wife/partner (O’Driscoll 1998).

It is the midwife’s responsibility to ensure that the couple realize the importance and enormity of the decision for the man ‘to be there or not to be there’. They should be encouraged to discuss the issue openly (ideally antenatally) with the pros and cons clearly defined so that they can make an informed choice.

Perineal care

See website and Chapter 40 for further information on care of women with perineal problems.

Sex after childbirth

As with sex during pregnancy, many social and cultural taboos surround the issue of sex after childbirth. The main issues appear to be fear of infection and trauma, but there is no evidence to support these possible complications provided that the sexual activity is considerate and gentle (Walton 1994). The woman herself is therefore the best person to regulate when she is ready to resume sexual intercourse. In the past, there appeared to be an unwritten rule that women should abstain from sex until after the 6-week postnatal check, when the GP could give her the ‘all clear’ to resume sexual relations. It was assumed that all would be well sexually after this period of time. The reality, however, is quite contrary. Limited research in this field demonstrates that childbirth causes high levels of sexual morbidity and states that this is not adequately addressed by health professionals (Barrett et al 2000, Glazener 1997, National Childbirth Trust et al 1994).

There are also a number of areas related to sexuality and childbirth that appear to raise important issues for midwives and the women for whom they care. It is important that family planning is discussed with the woman soon after the birth; one of the reasons for this is that a woman’s fertility can return quite soon after giving birth. In addition to this, fear of becoming pregnant can diminish desire for sex.

A reduced libido postnatally may be an indication of underlying problems within the relationship, or could be a symptom of postnatal depression. If this is the case, other professionals will need to be involved in giving specialized care and attention.

However, in the majority of cases, sexual problems following childbirth are directly linked to the pregnancy, the labour and birth, or the baby. This being the case, midwives and other health professionals involved in childbirth are in a prime position to counsel, guide and support parents with sexual anxieties. Some of the more common reasons for breakdown in sexual relations may be related to negative body image, or confusion over adopting the dual roles of mother and lover (see website).

Breastfeeding and sexuality

The literature surrounding the effect of breastfeeding (Chapter 43) on sexuality and sexual activity is confusing and largely conflicting. Some found a positive effect on sexual activity (Masters & Johnson 1966); some found a negative impact (Alder & Bancroft 1983); and yet others found that there was no effect on sexual interest (Reamy & White 1987).

More up-to-date research further supports the hypothesis that breastfeeding reduces interest in sex (Barrett et al 2000, Glazener 1997). There are two assertions that may be derived from the conflicting evidence: firstly, that further well-conducted, comprehensive research is required in this field; and secondly, that no definitive conclusions can be drawn. Therefore, women’s sexuality may be affected in any of the ways described and each woman must be cared for, advised and counselled accordingly.

The menopause

This is a time of immense change when a woman’s fertility reduces, though she may continue to be fertile. A reduction in the fertility hormones, in particular oestrogen and progesterone, may cause bodily changes that may also affect a woman’s sense of sexuality. Some find this a period of liberation whilst others may experience a sense a loss of opportunities for fertility.