Keywords

1 A History of Defining Sexuality

Over the last decades, sexuality has been constantly redefined. Sexual practices, sexual identities, sexual norms and sexual values all seem to be in flux.

When we want to define sexuality to make it a tangible and usable concept within midwifery practice, we have to start by adopting a broad perspective on sex itself. Over the past three decades, numerous studies have been looking into how people of all genders and sexual identities interpret ‘having sex’.

In 1999, Sanders and Reinisch published an early and influential study, giving insights into how young adults view having sex [1]. Since then, numerous studies have explored the same question in different cultural settings. In a recent survey, Horowitz and Bedford showed that the view of young adults on sex has changed over the past decades [2]. From this 2016 study, they stated that definitions of sex are better viewed as categorizations exhibiting a graded structure, in stead of fixed categories (moving beyond ‘yes it’s sex’, or ‘no it’s not sex’) This is illustrated by our own findings where 4% of young adults indicate that deep kissing can also qualify as ‘having sex’ and 3% do not necessarily feel they had sex, even when they experienced penile-vaginal penetration [3]. This clarifies that there is not one single definition covering all people’s views of having sex.

The majority of this research is geared towards sexual risk behaviour. However, we can use it also to better understand the complexities of sexual interaction, both pre- and post-natal, and during the period of trying to conceive. Overall it is safe to say that people’s ideas on having sex differ widely, which is relevant knowledge for practicing midwives.

For example, a couple consults the midwife because they have an active child wish but are still not pregnant after 12 months of trying. When you ask ‘if they have sex frequently’ and they answer: ‘We’re having loads of sex’, this does not necessarily mean that the woman is frequently experiencing intra-vaginal ejaculations.

Another example: At the exit consultation when going home after childbirth, the couple gets a well-intended message to ‘better refrain from having sex for a period of 6 weeks’. Such a strict, medically focussed recommendation might seem wise in light of minimising infection risk and giving the vulva and vagina enough time to heal. But, unintended, this advice often leads to couples not having the satisfying sexual experiences without vaginal penetration they can perfectly engage in, risk free, during this periode. Healthcare professionals (HCPs) need to be very clear in communicating what they mean, paying attention to the language they use. If the take-home message for couples is ‘Beware of vaginal infection when having intercourse before the vagina is fully recovered from childbirth!’, then the HCP should clearly state that the couple should refrain from any form of vaginal penetration. Preferably this is followed up by equally explicitly addressing which sexual behaviour will not cause problems: ‘All other forms of intimate and sexual behaviour, such as kissing, cuddling, stimulation of the breasts or the clitoris are perfectly safe!’ Those are important messages, as research points out that these intimate and sexual moments are a way of finding connection during the start of young parenthood, a period that can be very stressful for some couples.Footnote 1

A broader idea of what sex can be for a wide variety of couples can help the practicing midwife give more clear informational messages to clients, but it can also make it easier to think of possible solutions for the clients’ sexual distress. If you think back on the new parents who just left the maternity ward after having their baby, the couple that always viewed vaginal intercourse as a way to keep connected might struggle these first weeks after the advice not to do so for a while. When one’s idea of having sex also includes, for example, connected masturbation, in other words, both or one partner masturbating while in physical, intimate contact with each other, switching to connected masturbation for a while might be helpful advice for such a couple. Looking back at the research on definitions of sexuality, few people tend to view connected masturbation as ‘having sex’. A Canadian study [4] found that only 3.7% of individuals view masturbating in each other’s presence to orgasm as ‘having sex’. Imagine the couple looking for a way to be sexually active when their usual sexual script has become difficult to maintain, for instance, shortly after vaginal birth when experiencing painful penetration. Then being advised by a midwife, whose frame of reference on sex is broader than ‘just penetration’ and has an open view on numerous other forms of sexually stimulating activities, could be a huge advantage. Midwives with such a broader view on sex and sexuality will be more inclined to ask for clinically relevant details, and by doing so, they will more easily connect to the couple’s actual needs and practices instead of unknowingly making assumptions based on their own frame of reference. Think, for instance, of the woman divulging pain during intercourse, telling the midwife that they engage in foreplay before starting intercourse. Foreplay can mean many things, ranging from mood lighting, romantic music and back rubs to manual or oral stimulation of the genitals. With such a broad frame of reference, the midwife will ask what the woman means when she says ‘foreplay’, knowing that lack of physical arousal and lubrication might be causing her sexual pain. Although such mood lighting, romantic music and a back rub can be adequate ways to start up intimacy and sexuality in a couple, they will not automatically cause high physical arousal and lubrication in all women. Often more sexually focussed activities and even direct genital stimulation are needed.

2 Why People Want ‘Sex’ and What They Actually Want in Practice

When addressing sexuality during consultation, we should use clear/explicit language.Footnote 2 Knowing that even ‘having sex’ can have so many different meanings in people’s minds, one can imagine that using even more abstract terms like ‘being intimate’ or ‘having relations’ are a sure way to create misunderstanding between the HCP and the woman or couple. So the clinical implications of the term ‘sex’ covering such a broad range of actual practices and behaviours that might or might not imply health risks are numerous. Besides, even within couples, people’s ideas on sex can vary regarding the emotional meaning and importance they attribute to their sexual practices. It can vary, for instance, because of the context. Where people might see a sexual one-night-stand as ‘just having fun’, having sex in a committed relationship will almost always carry additional meanings like expressing feelings of love, searching for comfort, etc. Research has shown that people have sex for various reasons ranging from ‘wanting to experiece the physical pleasure’ and ‘wanting to conceive’ to ‘wanting to relieve menstrual cramps’ and ‘wanting to be popular/boost my social status’ [5].

Concerning the importance of sex during pregnancy, a recent study indicated that partners do differ in the importance they attach to remaining sexually active [6]. In case of such differences between the partners, keeping a positive attitude towards sexuality as a couple seems to be the most relevant factor to address for the practicing midwife, who wants to help this couple remain sexually satisfied and happy during pregnancy.

3 Sexual Health and Its Place Within Midwifery Care

An excellent professional approach to sexuality within midwifery (and health care in general) thus needs to be a broad approach. An overarching framework for such a broad approach was provided by the World Health Organisation in 2006 when they proposed their definition of sexual health [7].

Sexual health is a state of physical, mental, and social wellbeing in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships and the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence [7].

So, the WHO globally recognises sexuality as an integral part of people’s overall health and wellbeing. Building on this theoretical framework, the WHO defines several necessary parameters to ensure people’s sexual health: Among them are:

The ability of men and women to achieve sexual health and wellbeing depends on:

  • Their access to comprehensive, good-quality information about sex and sexuality

  • Knowledge about the risks they may face and their vulnerability to adverse consequences of unprotected sexual activity

  • Ability to access sexual health care

  • Living in an environment that affirms and promotes sexual health

Sexual health-related issues cover a wide range, encompassing sexual orientation, gender identity, sexual expression, relationships, and pleasure. They also include negative consequences or conditions such as infections with human immunodeficiency virus (HIV), sexually transmitted infections (STIs), reproductive tract infections (RTIs), and their adverse outcomes (such as cancer and infertility); unintended pregnancy and abortion; sexual dysfunction; sexual violence; and harmful practices (such as female genital mutilation, FGM) [7].

When looking at this definition, one realises its far-reaching consequences if fully applied in practice. First, we need to realise that sexual health is more than maintaining a level of physical health that enables people to have sexual experiences. Sexual health is not just a physical affair, aimed at being free from infections, disabilities or dysfunctions that could harm one’s potential for sexual expression. Next to the physical aspect of sexual health, we recognise the psychological and social dimensions of sexual health as equally crucial for attaining sexually healthy people. The biopsychosocial model, one of today’s leading models for understanding health in general, clearly echoes that philosophy [8].

The biopsychosocial approach to health emphasises that we should see health as a constant search for balance between the physical, psychological and social dimensions of someone’s being. Only when these three equally important aspects of a person’s self are in harmony, the person is ‘healthy’. This approach also highlights that these three dimensions are overlapping and intertwined. This means that when one of these dimensions, e.g. the physical, gets out of balance, for instance, by hyperemesis, this could sooner or later affect both the psychological and the social dimensions. As a result, people will become unbalanced, e.g. depressed mood, unable to contribute to household chores, experiencing less or no sexual desire, possibly impacting the partner relationship, etc. The same applies to sexual health: the physical, psychological and social dimensions need to be in balance, both individually and mutually, to enable them to have pleasurable sexual experiences. Only then can we genuinely say people are in a state of optimal sexual health.Footnote 3 That reality also implies that any sexual problem can have root causes in these three dimensions or even in all three simultaneously. When left unchecked for too long, sexual problems will evolve. Even when the original cause has already abided (e.g. an old episiotomy scar that used to induce pain during penetration), maintaining factors (e.g. a fear-response causing high pelvic floor tension) can arise because the original problem was not addressed in due time. When given time, problems stemming from one dimension of our health can begin to impact possibly all three dimensions of our being. Sadly, due to social stigma, people tend to wait very long before consulting a health care professional about sexual problems. For example, in Flanders, researchers found 7 years as the mean time between the first experience of a sexual problem and consulting a health professional [9].

Next to the realisation that sexual health requires a balance between people’s physical, mental and social wellbeing, the WHO’s definition of sexual health declares that sexual health can only be attained if people have safe and pleasurable sexual experiences. In short: if we want our patients to be sexually healthy, it is our responsibility to ensure that they can enjoy their sexuality. For midwives, this means actively stimulating couples to keep sexuality pleasurable when trying to conceive (no matter how long this might take) and during pregnancy and young parenthood. If we take a broader approach, we have to make sure that when patients, even those admitted to health care institutions, wish to have pleasurable sexual experiences, we need to enable them to do so, despite their current physical or mental state and their limited social environment.

Think, for instance, about the women admitted at 10 weeks of pregnancy because of hyperemesis. An extended stay in a hospital environment makes it challenging for the couple to retain a certain level of intimacy, let alone sexuality. Still, the same view on sexual health applies. They should be able to eg. lay together, cuddle, kiss, ... during the hospital stay. This is even more so for this couple, as we know that keeping intimacy and sexuality alive during pregnancy is a critical factor in preventing possible sexual problems post-partum and in young parenthood. Within this broad approach, one quickly realises that we still have a long way to go to bring the WHO’s vision on sexual health into practice.

Picking up the WHO’s message, in 2019, the World Association for Sexual Health (WAS) published its Declaration on Sexual Pleasure [10].

Sexual pleasure is the physical and psychological satisfaction and enjoyment derived from shared or solitary erotic experiences, including thoughts, fantasies, dreams, emotions, and feelings. Self-determination, consent, safety, privacy, confidence, and the ability to communicate and negotiate sexual relations are key enabling factors for pleasure to contribute to sexual health and wellbeing. Sexual pleasure should be exercised within sexual rights, particularly the rights to equality and non-discrimination, autonomy and bodily integrity, the right to the highest attainable standard of health, and freedom of expression. The experiences of human sexual pleasure are diverse and sexual rights ensure that pleasure is a positive experience for all concerned and not obtained by violating other people’s human rights and wellbeing. WAS [10].

The WAS tried to bridge the gap between theory and practice. To implement their vision of sexual pleasure, WAS stated: ‘The programmatic inclusion of sexual pleasure to meet individuals’ needs, aspirations, and realities ultimately contributes to global health and sustainable development, and it should require comprehensive, immediate, and sustainable action’.

For example, practicing midwives might scan the general information leaflets they use. Do they include sexuality? For the midwifery tutor, that could mean reviewing their course material. Does it link to sexuality (e.g. when teaching about breastfeeding, do we also address the effects of breastfeeding on sexuality)? Etc.

Following these frameworks, one can summarise the following key elements for sexual-health-sensitive midwifery practice:

  1. 1.

    Sexual health is an integral part of general health and wellbeing and requires a biopsychosocial approach.

  2. 2.

    Sexual satisfaction is a necessary component of healthy sex life.

  3. 3.

    Midwives have a professional and moral obligation to promote the sexual health of their patients by both disseminating accurate information and if needed, guidance on sexuality-related issues.

  4. 4.

    Midwives’ responsibilities to address sexuality issues apply to all levels: on a micro-level (in relationship with the client/couple), meso-level (within their broader scope of practice, among colleagues and within professional organisations) and macro-level (diminishing the taboo around sexuality in the society, thus further deconstructing the myths surrounding sexuality and influencing local and global policies).

In conclusion, the only good midwifery practice is sexual health-sensitive midwifery practice.