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Introduction
Sexual disorders refer to ‘various ways in which an individual is unable to take part in a sexual relationship as he or she would wish’.1 Seksologia2 in 2001 divided sexual disorders into two: sexual dysfunctions in men and women and sexual disharmony. The latter is further classified into five groups: (1) social and psychological maladaptation; (2) sexual and psychological compatibility in the couple; (3) lack of knowledge and awareness; (4) sexual dysfunction which typically leads to problems with anorgasmia in women; and (5) sexual dysfunction in men like erection and length of intercourse in men.3 Sexual dysfunction is intensified with age and illness.4 Number of women entering post menopause estimated appfroximately 3.5 million in Iran.5 It is assumed to be approximately 5 million postmenopausal women in Iran by 2021.4 In this stereotyped beliefs, they are shown as lacking sexual interest or being sexually inactive. However, it has been demonstrated that most the elderly remain sexually active and require to spend some time with a partner of the opposite gender, or sustain a sexual relationship with an old partner to mitigate their frustrations.4 Aging affects sexual function but it does not disappear completely. The dimensions of sexual function which are adversely affected by menopause are lubrication, sexual pain and orgasm.6 According to Hess et al.7, women suffering vaginal dryness gained lower score on sexual enjoyment scale. Some accept the effects of menopause on their sexual relationships, and thus attempt to adjust the nature of their relationship with their partner from a sexual one to that of companionship. Others perceives the integral role of sexual relationships in their marital satisfaction and thus find strategies to adapt themselves to their modified bodies such as taking hormones, watching adult films, changing their approaches to sexual intercourse and enhancing their exercise regimen.8 Health experts should be trained about the effects of menopause on women's sexual life and the diverse reactions of women to such physiological changes.8 In spite of longer life expectancy and the increased population of the elderly in Iran, a paucity of studies on sexuality of older people is felt,9 and subjects related to sexuality are still considered as a taboo in Iranian society.101112 A lot of women are too embarrassed to ask questions about their sexual problems. It is largely due to entrenched traditional norms, values, cultural, and beliefs concerning sex and sexuality.13 There has been some quantitative studies141516 and a few qualitative studies171819 on the subject of sexuality in Iranian menopausal women. Moreover, sexual issues are rooted in specific cultures and contexts, and the discovery of their associated issues demands requires exploring and appreciating problems in sociocultural context specific to Iranian society. For this reason, a qualitative approach was adopted in this study. The goal of this study is to explore the perceptions and experiences of general practitioners (GP) and midwives during their sexual dialogue with menopausal women.
Materials and Methods
1. Design
To explore perceptions and experiences of GP and midwives during their discussion of sexual issues with menopausal women, a qualitative approach was adopted using content analysis. Since such a qualitative content analysis allows investigating people's experiences and attitudes, it is suitable for our study.20 The study was approved by the Ethics Committee of Mashhad University of Medical Sciences.
All participants were required to complete informed consent form. To this end, all participants were given a nickname to preserve their anonymity, and the whole study data was kept in a password protected computer and also in a locked cabinet at the university. Participants included of all GP/midwives who had at least two years of work experience before the interview and were willing to take part in the study to share their experiences.
The purposive sampling method was used to increase the multiplicity of participant's characteristics. In this context, Attempts were made that menopause participants included in the study. As such, 6 male and 7 female GPs (age range, 34–74 years) and 12 female midwives (age range, 25–60 years) were selected. They had 2 to 44 years of experience.
2. Data collection and analysis
One of the research team specialized in qualitative research conducted all interviews. In total, the majority of interviews (n = 23) were carried out at the workplace of participants and the rest were held in other places such as participant's home (n = 1), university office of the interviewer (n = 1) and a local coffee net (n = 1). The first round of interviews lasted between 32 and 66 minutes (mean, 47 min). Also, a second round of interviews was conducted for four participants, which lasted between 15 and 45 minutes (mean, 30 min). All semi-structured interviews were taped and transcribed word by word. Qualitative content analysis based on the definition of Graneheim and Lundman21 was used to explore the interview data. Interviews were reviewed several times to gain deeper insight about content areas. The text was broken into meaning units which included a few words to several sentences. Meaning units were abridged and labeled with a code, and then codes were combined and grouped into different categories in terms of meaning and content. The categories were further abstracted and formulated into themes and sub-themes.
3. Trustworthiness
In this study, a special attention was paid to the issue of trustworthiness as discussed by Lincoln and Guba.22 It was composed of three factors of credibility, dependability, and transferability. As for the first factor, credibility, the subjects were selected from a wide range of gender, work experience, and menopause status to gain access to multiple experiences. The analysis and discussion of the emerging findings was conducted in the presence of all members of the research team. To increase the dependability of results, an interview guide was used and a single researcher conducted all inter views. Transferability refers to ‘the degree to which the results can be generalized to other contexts or groups’. It is the reader who decides the transferability of findings to other settings, but authors are required to provide sufficient documents regarding the transferability of their results.23 As such, this paper provides detailed information about the context, enrollment, and demographics of subjects, as well as data collection and of analysis.
Results
Through data analysis “sexual disharmonies” was emerged as a central theme which included two categories: (1) reasons for sexual disharmonies (ageing and health related-problems, marital problem, stereotyped beliefs regarding menopause and sexuality, different upbringing by parent, daily concerns); (2) strategies used by couples (changing role and values, pretend to reach orgasm, suppress their sexual desire, to meet sexual needs of husband in accordance with religious rules, seek help peers, friends or traditional medicine and health providers, Seek help charmer, sex with other women to fulfill sexual need, pretend to be in a bad mood to excepts from sex).
1. Reasons for sexual disharmonies
(1) Ageing and health related-problems
1) The effect of menopausal symptoms and health problems on sexual function
Menopausal symptoms such as lessened sexual desire and vaginal dryness as well as health problems such as vaginal fistula or health problems of the spouse (such as diabetics, hypertension and heart dieses) or side effects of drugs taken for diseases caused sexual disharmony.
I ask her how many times she has sex with her husband. She says, “Once a month. I don't ever want to, unless he comes and forces me into it , my vagina is too dry and sensitive.” (Midwife, 40 years old, 12 years of work experience)
“One postmenopausal expatriate women with vaginal fistula said that she avoided sex, because she was ashamed of expelling gas from her vagina during intercourse.” (Female GP, 50 years old, 3 years of work experience)
“I had a few postmenopausal patients who said they had sexual desires but their husbands were very old or disabled with problems such as prostatitis, hypertension, diabetes or in some cases the intake of sleeping pills.” (Female midwife, 50 years old, 3 years of work experience)
2) Change in body image
One of the reasons why postmenopausal women do not have sex is the terrible body image they have of themselves after menopause. In the experience of informants, some menopausal women were reluctant to get naked in front of their husband because they had a negative image of their body.
(2) Marital problem
1) Big age gap in the marriage
According to informants, a big age gap between couples, especially when a woman is older than her partner, leads to disharmony is, with menopausal women being unable to fulfill the sexual desires of their young partner. A very small number of menopausal women tried to imitate pornographic movies and satellite program to satisfy their husband, but they deeply regretted doing so as such films were against their culture and religious values. Oftentimes, women refer to cosmetic skin clinic, cosmetic clinic surgery and health providers.
“A 30-year-old man had married a 50-year-old woman. This woman could not meet her husband's sexual needs and thus followed the teachings of pornographic movies to satisfy their husband... the postmenopausal woman is unable to keep up and suffers a lot.” (GP fe male, 70 years old, 44 years of work experience)
2) Changing sexual expectations of men
Influenced by satellite programs and young couple romantic behaviors, the sexual expectations of most men have changed, leading to aggravated sexual disharmony. Some men expect their wife to act flirtatiously like young couples, or to imitate acts shown in satellite programs, but women usually refuse to do so and thus inflict great pain on their husband.
“A veiled woman came into my office, saying that her husband had asked her to sleep naked at night. These women blamed satellite programs for their husband's demands.” (Midwife, 50 years old, 25 years of work experience)
“Women came to me complaining that her husband had developed a tendency to watch satellite programs at old age. As a result, he often asked her to do hair coloring or wear dress like them [women in satellite programs]. He husband, ashamed to state his wishes directly to me, had written them on a piece of paper, saying that he wished his wife put on makeup like young girls or be more flirtatious”. (Midwife, 58 years old, 3 years of work experience)
3) Negative effects of prior marital dissatisfaction on sexual satisfaction
The quality of pervious marital and sexual relationship has a significant effect on current sexual relationship. Women, who suffered from unfulfilled emotional and sexual needs of their husbands or their husband remarried in past, attempt to revenge their husband by avoiding sexual relationship when they are old and weak. Seeing young couples with close emotional bonds around or on TV recall their unfulfilled wishes, which arouse angry anger and frustration.
She said, “I'm so vengeful toward him right now. When he was young, he wouldn't have sex with me for even six months or a year. My pride did not let me express that I had sexual needs. (Female GP, 38 years old, 10 years of work experience)
When I see young couples the satellite programs and TV these days, I say, God damn you man.” (Female GP, 36 years old, 8 years of work experience)
Participants also belief that marital problem has different effect on sexual function women and men. According to a GP 32-year informant with 5 years of work experience, men tend to satisfy their sexual desires no matter have mad they are at their wife, but it is not the case for women. For instance, when arguing with their in-laws or being scolded by their husband, women cannot perform well sex-wise.
4) Misconceptions about sexual needs
One underlying reasons for sexual disharmonies between couples is unfamiliarity with sexual expectations of each other. Informants stated that, some menopausal women were reluctant to sleep with their husband because they had a negative image of their body, thinking that the shape of their body and appearance was important to their husbands. However, in the experience of informants, what was of utmost importance to men was the quality of sexual relationship not the shape of their partner's body and appearance. Informants cited many stories about men who have sexual satisfaction despite the obesity and agley of their wife.
These women don't know that what matters is the quality of sex. I have an exceptionally pretty and handsome coworker in spite of her age; yet her husband went and took a temporary bride who was so fat, short and ugly. She would say, “I ask my husband why on earth he didn't marry a beautiful woman instead, and he answers, because you did not satisfy my needs very well.” (Midwife, 58 years old, 3 years of work experience)
(3) Stereotyped beliefs regarding menopause and sexuality
1) Avoiding belief “sex as a means of blackmailing husband”
According to a 52-year informant with 3 years of work experience, women use sex as a means for blackmailing their husband and to prevent his betrayal when they are young. On the verge of menopause, a 40-year-old women are keener on beauty tips and treating their sexual problems so that they can compete with younger women, but postmenopausal women stop to follow these strategies because there are less likely to do act of betrayal for an old men.
2) Sexual myths and beliefs
Stereotyped beliefs such as “sexual pleasure is not for women”, “impropriety of sexual relationships at old age”, “sexual relationship is exclusive to youths” which are internalized by menopausal women. Stereotyped beliefs have a lifelong effect on their perception of sexual relationships. These caused menopausal women are shamed to raise or speaking wrappers for sexual needs with their husband. Lack of training about how to fulfill the sexual needs of their husband is another reason underlying the inability of menopausal women to fulfill the sexual desires of their partner.
“Being of a relatively older generation, postmenopausal women have learnt from their mothers and grandmothers that sex is not for women, that women are just a means to satisfying their husband's sexual desires, getting pregnant and bearing children.” (Midwife, 40 years old, 12 years of work experience)
(4) Daily concerns
Great responsibility inhibits the freedom of menopausal women from thinking about sex. According to informants, some menopausal women said they missed sex because they were overwhelmed by responsibilities such as taking care of grandchildren, purchasing the dowry of their daughter and so forth. Moreover, menopausal woman's concerns about separation and divorce of their children inhibited them from pondering on sexual issues.
2. Strategy to alleviate sexual disharmonies
(1) Adaptive strategy
1) Change in roles and values
Some of these women who believe that menopause is the same as ageing adopt an adoptive strategy and change their values and roles.
“When they hit 45, women experience vaginal dryness because of menopause, and they feel as if they' ve en tered old age. It changes their role from that of a pretty and sexy wife to a devoted mother and a good chef assuming that they are unable to compete with young girls.” (Midwife 58 years old, 3 years of work experience)
2) Bite the bullet and put up with sexual problems
According to participants, some menopausal women who believed in “untreatable nature of sexual problems”, considered menopause as a normal physiological change or were ashamed of discussing their sexual problems, adopted “Bite the bullet and put up with sexual problems” strategy.
3) Endeavor to protect the relationship with partner by means of fake sexual pleasure
Some menopausal women use fake orgasm as a strategy to conceal their reduced sexual desire because they are afraid that decrease in sexual desire influence on marital relationship. Participants related stories about menopausal women who pretended to reach orgasm.
4) Try to engage in substitute activities
Some men suppress their sexual desire when their wife had no regard for their sexual needs. One informant related the story of an old man who anonymously called to talk with a midwife, saying that he was trying to suppress his sexual instincts through gardening.
I even know a gentleman who said he wanted to talk with the midwife on the phone. He said, “Since I'm religious, I can't fulfill my sexual needs with other women. I do gardening to make myself busy ever since I retired from my job. I try to gradually kill my sexual instincts. My wife is so frigid; she has no sexual desires and won't ask for it if I don't initiate it even for a month.” (Midwife Rahmati, 52 years old, 3 years of work experience)
5) Obligatory involvement in sex in compliance with religious rules
A number of menopausal women felt obliged to fulfill the sexual needs of their husband despite their reluctance to do so. It was mainly due to the fact that Islamic rules urged Muslim women to fulfill the sexual needs of their husband.
(2) Adopting treatment strategies
1) Seeking help from peers, friends or traditional medicine and healthcare providers
According to informants, women preferred to seek help from their peers, friends or traditional medicine practitioner such as apothecaries rather than health providers. In fact, they referred to health providers only when other treatment methods suggested by apothecaries proved ineffective.
2) Seeking help charm
A small number of menopausal women, who were struggling with emotional and sexual gap with their husband, visited charm-writers to give them a charm, spell or something to make their husbands closer to them.
3) Sex with other women to fulfill sexual needs
Sex with other women is a strategy used by men to cater unfulfilled emotional or sexual needs.
4) Pretend to be in a bad mood to get rid of sexual tension
Some menopausal women with intolerable vaginal burning can't bear resort to strategies like pretending to be in a bad mood to get rid of sexual tension.
A 53-year-old woman said, “When I remember he's going to ask for sex tonight, my body starts to shiver. I do not lose my temper right then and there, but I pretend to be in a bad mood the day before so he won't ask me for sex that night, cause my vagina burns so much when he does it. I just can't bear sex anymore.” (Midwife, 50 years old, 22 years of work experience)
“I now have postmenopausal women who've contracted human immunodeficiency virus (HIV), genital warts, etc., because their husbanded have a sexual relation with prostitutes into this stuff.” (Midwife, 50 years old, 22 years of work experience)
Discussion
The qualitative findings of this study provide a number of reasons that lead to sexual disharmony, strategies taken by menopausal couples to handle these issues and also ramifications of overlooking sexual needs of spouse. Some women adopt an adaptive strategy by resorting to techniques such as faking orgasm or throwing a fit of temper, others are in an attempt to improve the situation and seek help from peers or friends, traditional medicine practitioners, charmwriters and healthcare providers. Men seek a different strategy to manage sexual disharmony like remarriage or suppressing sexual instincts. However, the results should be interpreted with caution for we only interviewed healthcare providers, and they may have failed to mention some other strategies. Our study identified a number of reasons for sexual disharmony such as effects of menopausal symptom and health problem on disharmony, negative body image, big age gap in the marriage, being unaware of sexual expectations of one's partner, stereotyped beliefs regarding menopause and sexuality, prior marital dissatisfaction on sexual satisfaction. Yang et al.8 reported that Chinese menopausal women sought strategies such as taking hormones, watching adult films, taking more exercise or changing relationship with their spouse from that of a sexual partner to a companion in the face of sexual problems. We also added other strategies such faking orgasm, throwing a fit of temper, seeking assistance from peers, friends or traditional medicine practitioners, charm-writers and health providers. Based on the experience of our informants, some men and women made anonymous phone calls while other menopausal women preferred to seek help from peers and friends. This confirms the potential need to form peer support groups for older women or providing telehealth cares which can offer anonymous counselling services to these women.
Our study showed that menopausal women tended to avoid sexual relationship to alleviate burning during intercourse. The results of this study are consistent with previous studies in which the feeling of vaginal dryness reduced likelihood of women's engagement in sexual intercourses or their interest and enjoyment of having a passionate sexual relationship with their partners.7824 Our study suggested that women with fistula avoided sexual relationship because they were worried about the gas release from vagina during intercourse. Several studies have shown that marital and sexual desires are affected with by fistula. According to the results of a qualitative study, Tanzania women with a fistula were forced to sleep in another bedroom or separated from their husbands due to the bad smell released from their vagina.25 In Uganda, some women with fistful reported to have lost their appetite and mood for sex.26 According to the experiences of our informants, menopausal women's negative attitude towards their body and the way that their husband judged their body prevented them from engaging in sexual relationships.25 Our study is in agreement with the findings of Pascoal et al.27 and Quinn-Nilas et al.28. According to which women's perception of their partner's attitude about their body was a strong predictor of body appearance cognitive distraction during sexual activities in a sample of portages women.27 In another study, dissatisfaction with one's body and concerns about the negative judgment of others predicted reduced sexual desire and arousal.28 The results of this study are in keeping with the findings of Ling et al.29, according to which menopausal women believed that their spouse's health problem such as hypertension and renal failure had affected their spousal sexual performance. In China, menopausal women were worried that their husbands would tend to seek their unfulfilled sexual needs using sex workers or resorting to extramarital sex.29 Iranian women are less concerned in this relation, because there is usually a large age gap between couples so that men are too older and less likely to betray their wife. Our findings revealed that some menopausal women developed HIV, vaginitis bacteria and genital warts as a result of their husband's sexual relation with a new younger partner. This is consistent with Trottier and Franco30 study in which finding a new sexual partner had led to a second peak of human papillomavirus in peri-or postmenopause period30 and also Pearline et al.31 study in which using commercial sex workers increased sexually transmitted infection prevalence in the elderly. Concerns about financial problems inhibit women from reflecting on sexual issues. This is in line with the findings of many studies in which greater income was found to be associated with sexual satisfaction,32 frequency of sexual activity33 and lower sexual dysfunction.34 However, Tomic et al.24 in their study in the US did not report any association between sexual satisfaction and annual income. According to the results of literature review, the greatest sexual satisfaction was reported by women, who had 5 to 6 year age difference with their husband.35 A study in Iranian context demonstrated that lower age difference was associated with greater sexual satisfaction.36 Our findings showed that big gap ages were an important factor in sexual disharmony.
The primary limitation of this study is that data were only obtained from healthcare providers. It can affect the reliability of the data. Thus, to gain deeper insights, the perspective of both menopausal couples and healthcare providers should be taken into account.
Conclusion
Healthcare providers must be aware of various sexual behaviors of menopausal women and their husbands when they see sexual disharmony in their patients. Menopausal women should be cautious about the consequences of disregarding the sexual needs of their husbands. The results of this study can help to develop restricted guidelines for sexual discussion with menopausal women.
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