Relevant (Sexual) Aspects of Cultural Differences

Abstract

Culture is one of the most important elements influencing the sexual lives of people. Factors like traditionalism, religion, polygamy, machismo, and feminism influence sexuality and cultural ideas about motherhood and sex roles. This chapter focuses on those cultural aspects. Cultural differences exist not only by merit of geographical distance since cultures get intermingled through economic migration, political refugees, and global traffic. Even in midwifery, there are significant cultural differences between one country and another. In some countries, midwives independently guide childbirth at home, whereas, in other countries, the law prohibits such an approach. In some countries, the midwife provides postpartum contraception, whereas, in others, they don’t.

This book is written in English and focuses relatively strongly on Western maternity care. It certainly has a European touch since most authors work in Europe. An advantage of Western and Northwestern Europe is the more open and pragmatic approach to discussing sexuality. While sexuality is essential everywhere, some basic health and luxury seem needed before it becomes relevant to tackle the problematic aspects of sexuality. We believe this book to be precious to midwives in middle- and high-income countries (Atallah et al., J Sex Med 13:591–606, 2016). On the other hand, much of the information will also be handy for urban midwives in low-income countries.

This chapter is part of ‘Midwifery and Sexuality’, a Springer Nature open-access textbook for midwives and related healthcare professionals.

In all cultures, the midwife’s place is on the threshold of life, where intense human emotions, fear, hope, longing, triumph, and incredible physical power enable a new human being to emerge. Her vocation is unique. (Sheila Kitzinger)

1 Introduction

In order to have a comprehensive biopsychosocial approach to sexuality, it is essential to acknowledge that culture is an inherent part of the person as a unique holistic being. Furthermore, gender roles, male-centred societies, feminism, laws related to sexuality, religious beliefs, and behaviours considered appropriate or not are examples of culturally determined elements that significantly impact the development of a person’s sexuality. Therefore, in the midwife’s professional practice, the influence of someone’s historical and sociocultural context cannot be ignored when addressing this subject.

This chapter aims to clarify some relevant aspects of cultural differences in the field of midwifery and sexuality. This topic is especially important in an era in which multiculturalism, intergenerational differences, and diversity of values, religions, ideals, and traditions coexist throughout the globe.

To this end, we will offer an overview of several sexual elements that can generate controversy and difficulties in the midwife’s handling of sexuality, depending on their cultural perspective.

Furthermore, when talking about this topic, one cannot leave out the influence of the HCP’s own culture, which also plays a determining role in the midwife–woman relationship and how the midwife approaches the client’s sexual sphere. Therefore, this chapter also intends to reflect on factors such as the midwife’s type of education and training, sociocultural context and personal characteristics; in order to raise cultural awareness among HCPs and promote culturally sensitive, safe, and non-discriminatory care.

Nevertheless, we must consider culture as a dynamic and changing element that implies comprehensive individual and temporal diversity within each group. Thus, the existence of cultural identity does not override the importance of considering the personal identity and the woman’s autonomy. So, besides cultural scripts, women can make their own decisions and behave based on their own beliefs, values, knowledge, and experiences. Hence, we invite the reader to avoid understanding the contents of this chapter in a deterministic way. We precisely aim to prevent stereotypes, stigmas, and cultural generalisations. We will address structural, socio-economic, and educational aspects and language barriers and acculturation.

Last but not least, we have developed a series of recommendations with some theoretical and practical keys for midwives regarding a culturally sensitive approach to sexuality. These recommendations include a section dedicated to the organisational and structural aspects of the midwifery governing bodies and institutions in order to contribute to reducing barriers in this area. All this aims to promote adequate and non-discriminatory care for every woman in matters of sexuality.

2 Female Sexualities

Within the biopsychosocial model, sociocultural factors, psychological and biological factors mould our sexuality, influence how we perceive our sexual self, our sexual behaviours and practices, and even our sexual function [1]. It also influences the clinical practice with our clients. However, HCPs, including midwives, regularly neglect the effect of social and cultural components on sexual health and wellbeing. Considering sociocultural contributors in midwifery is critical as they shape the “dreaded” and embarrassing “sex talk”. Culture also partly predetermines if a woman is willing and able to discuss her sexuality with the midwife.

Saying that there are as many female “sexualities” as they are women would not be an exaggeration. Every woman is unique in her sexuality. However, we can determine and be aware of several socio-cultural impacting elements. For example: in many regions of the world, religious beliefs, patriarchy, and family traditions drastically weigh on female sexuality. Conservative values and practices often limit access to sexuality education, restrict women’s knowledge of their own bodies, stigmatise female desire and pleasure, and further silence female sexuality because of taboo and shame. In nontraditional parts of the planet, mass media and social media play, in contrast, a major role in how women learn about and view their sexuality. However, we should be aware that access to information does not guarantee accurate sexuality education. Stereotypes and “norms”¹ can also distort women’s understanding of sexuality, sexual pleasure, and consent.

For instance, being Western or not, having a high educational level² or not, and so on, does not necessarily suggest that a person knows what a clitoris is and how to use it.

Understanding the impact of cultural differences on female sexuality gets even more complex when considering the variety in “acculturation” (the process of incorporating language, values, customs, et cetera after migrating into new surroundings) [2]. In this process, the two main movements are (1) embracing standards, morals, and practices of the destination culture and (2) keeping principles, dogmas, and attitudes of the native/original culture.³

Sexuality (just like contraception methods) is an essential aspect of someone’s level of acculturation. In other words, in our clinical setting, we cannot assume one’s understanding of sexuality and sexual practices, so we simply have to ask.

Despite the infinite diversity of sociocultural factors, several cultural aspects of female sexuality seem universal. Among those is the heteronormative view of women’s sexuality that considers penile-vaginal penetration as the only valid form of sex. In this regard, the woman from a conservative culture frequently wants, above all, to protect her “virginity” since her so-called intact hymen symbolises the honour of the family. On her wedding night, the same woman is supposed to surrender herself “completely” to her spouse. Vaginal sex is then not only validating her marriage and changing her social status into a “real” woman, but it is also the only way to “fulfil” and “keep” her husband. Nevertheless, in “liberal” cultures, intercourse is still portrayed as the most fulfilling type of sexual activity.

In both scenarios, guilt and anxiety can accompany failing, by which this topic is seldom discussed in the clinical setting. Even today, women worldwide are often silent about their sexual concerns, as they feel abnormal and too embarrassed to talk about it. Many midwives consider sexual pain, penetration difficulties, and lack of sexual pleasure shameful issues that they do not address. Besides, as exposed later in this chapter, midwives rarely ask about it because of their own discomfort and lack of training skills. And even when inquiring about the client’s sexuality and sexual concerns, the midwife might not get an answer because of having a different origin, culture, age, marital status, or gender.

Therefore, all cultures and subcultures influence how we perceive sexuality, its meaning or importance in our lives, what is considered normal and abnormal, and if or with whom we are ready to engage in a conversation about sexuality. Even if sexuality is viewed in a “positive” and empowering way, our view of its different dimensions⁴ is filtered by our cultural biases and sometimes tainted with shame and stigma.

In the next section, we will discuss examples illustrating some of the potential effects of sociocultural factors on female sexuality. Be aware that these illustrations cannot be generalised and should not be used to label or stigmatise people belonging to a particular cultural group.

This chapter does not address female genital mutilation since that topic will get ample attention in Chap. 25.

3 Attitudes and Practices

A great example of a sexual and socio-cultural problem is unconsummated marriage (UM), encountered especially among couples from conservative Middle Eastern cultures, accounting for up to 17% of visits to sexual health clinics in certain countries [4]. It is a condition where newly married couples cannot achieve penile-vaginal intercourse for variable periods, despite the desire and frequent attempts. Vaginismus (the involuntary vaginal muscle spasm as a reaction to the fear of some or all types of vaginal penetration) represents three-fourths of the female causes of UM [5]. Likewise, the high prevalence of UM in communities that strictly prohibit premarital sex is attributed to the social and cultural constraints that profoundly pressure the couple. In these conservative societies, the lack of sexuality education, sexual prohibition, misconceptions about sexuality, and unrealistic expectations, contribute to UM and vaginismus. In communities with ample opportunities for premarital coitus and where culture and society do not prohibit such contact, vaginismus is less prevalent. However, any practising midwife might meet women with UM or vaginismus without even knowing. For example, she might be following a pregnant woman who has never had vaginal sex and is afraid of a pelvic exam. One might think that these cases are sporadic and mostly anecdotal. The reality is that some women get pregnant either through outercourse (having sex with ejaculation but without penile-vaginal penetration) or with the help of assisted medical procreation. The same is true for women of different sociocultural origins living in the West and perfectly adapted to their environment, wanting to engage in vaginal sex but dealing with sexual difficulties related to penetration. Western HCPs should not dismiss UM or its distress as”a lack of socio-cultural skills”. That might be traumatising for the woman and severely aggravate UM’s impact on both partners.

Another strongly culture-specific aspect of sexuality refers to “wet sex” versus “dry sex” [6]. In Western cultures, vaginal lubrication is a sign of arousal, an essential for pleasurable sex, and needed to prevent dyspareunia. However, in several Sub-Saharan African countries, people believe that dry sex is more enjoyable for the male partner who feels more friction. For the woman, it usually means pain. That, however, might for her be satisfactory because of pleasing her partner. In order to achieve dry sex, women use vaginal products to tighten the vagina, reduce its secretions, and even dry it up. Being confronted with such practices might be difficult for the midwife. However, for fulfilling our care mission, it is essential to listen in a non-judgmental way without imposing our own opinions. It can pave the way to sexuality education and enable to, afterwards, correct false beliefs.

Cultures also vary in the importance they attribute to sexual desire. For some, sexual desire is a sign of a loving and healthy relationship, while decreased desire is viewed as a distressing problem that needs treatment. At the same time, other women consider lack of desire as the norm and are not bothered by it [7]. Some people even consider female sexual desire sinful, with sexual practices a conjugal duty limited to vaginal penetration with procreation as the ultimate goal. By mentioning that, we underscore the importance of knowing our client’s beliefs before giving any sexual advice.

There are numerous examples of socio-cultural beliefs surrounding sexuality, and one cannot be proficient in all. However, it is crucial to be aware that, due to those beliefs, many women will wait for the midwife to ask about sexuality. Others might not be sexually active in a vaginal way or might not even know how vaginal intercourse is performed. Therefore, the end of this chapter will offer guidelines and recommendations on how the midwife or HCP could become aware of their own cultural blind spots to allow a culture-sensitive approach.

4 Cultural Differences among Midwives Concerning Sexuality Approach

We discussed the great cultural diversity in the world and its impact on women’s sexualities. But what do we mean when we talk about “midwives”? Do they constitute a homogeneous group of professionals with a neutral and biomedical perspective in all parts of the globe? Definitely not. Indeed, each reader will probably associate the word “midwife” with specific qualities, way of working, socio-economic status, and skills that may differ depending on the person’s cultural background.

Even though we expect that midwives accompany women throughout the different stages of their sexual and reproductive life in a respectful and empathetic manner, various factors make their experiences, beliefs, attitudes, and interventions very diverse worldwide. Some of the most significant disparities are the variety of practices they carry out, how they acquire their knowledge and the organisational differences of the profession in each country.

Overall, midwifery education can range from the generational transmission of knowledge among the community’s women to university programs in the most prestigious hospitals in large cities. Likewise, professional autonomy and competencies are heterogeneous. In some contexts, midwives accompany women during the first stage of labour. Still, the gynaecologist will be “in charge” of the last part of the second labour stage. In other places, midwives are responsible for the follow-up of healthy pregnancies, independently accompanying childbirth and postpartum, contraceptive advice, sexuality education, gynaecological cancer screening programs, menopause, and ultrasound scans. Another significant difference is the midwife’s autonomy to accompany home births. While in some countries, this practice is fully integrated into the system as one more option for women,⁵ in others, it is culturally unacceptable and even legally restrained. In the same way, while there are countries where midwives struggle to have their profession recognised and endorsed by legislation, most of them are part of a hierarchical healthcare system. All in all, midwives’ skills and knowledge of sexuality and their role in addressing it are highly diverse from one country to another.

At a global level, the International Confederation of Midwives considers knowing the socio-cultural aspects of human sexuality and acting accordingly as an Essential Competency for Midwifery Practice [8].

Also, the WHO [9] includes “Addressing gender and cultural sensitivity” as one of the seven principles that guide the delivery of the “Packages of Interventions for Family Planning, Safe Abortion Care, Maternal, Newborn and Child Health”.

However, midwives consider approaching sexuality itself a complicated task, even more so when dealing with women not adapted to the mainstream culture. Frequently, without proper training regarding sexuality and cultural sensitivity, midwives have to rely on their own values, experience, and cultural scripts to address such topics. In this way, they can learn from their practice, successes, and mistakes and via their colleagues. In the long run, this has the potential to enrich professional practice by gaining on-the-ground experience. Nevertheless, without proper training, this relies on the interest and resources of each midwife and often causes avoiding these topics, fear of failure, a tendency to stereotype, a narrow view of sexuality, and uncertainty or rejection towards clients from different cultures.

Understanding fertility, pregnancy, childbirth, postpartum, and breastfeeding as cornerstones of women’s sexuality, the cultural elements inherent to each individual midwife, and their biases in this regard will impregnate the practice. So, whether they address this subject explicitly or not, being aware of one’s frame of reference and context becomes especially relevant.⁶

We recommend that the institutions that design midwifery curricula ensure appropriate training in these fields. On the one hand, it may provide confidence and skills to practitioners in approaching issues related to sexuality from a cross-cultural perspective. And on the other hand, an ethno-sensitive educational approach can also help blur the racial, ethnic, and status boundaries.⁷ Such development can contribute to upgrading the whole midwifery profession (from university-trained to traditional) towards a comprehensive midwifery care model that safeguards women’s rights regarding their bodies, their sexuality, and their motherhood.

Let’s focus now on the diversity among co-workers. Various studies show that 99% of US midwives and 99.7% of UK midwives are female. Of these, >88% in both countries are white. However, the population they serve is much more diverse and heterogeneous. This fact implies an impoverishment of the cultural competencies in Western midwifery care, related to disadvantages and discrimination for women with non-Western cultural backgrounds. Not only towards clients but also among colleagues [10, 11].

Regarding male midwives, some women prefer to be accompanied by a female practitioner, regardless of the HCP’s competencies and skills. Even more so when it comes to discussing sexuality-related issues [12]. This is about an intersection, among others, of the cultural clashes between conceptions of shame or decency, the principles of tradition and/or religion, the ego of the HCP, and the practicalities of the organization of modern medicine. Also, given that women and men are likely to integrate cultural norms differently, the lack of training, as mentioned above, will often mean that the HCP will approach sexuality from her/his personal frame of reference. An additional relevant cue to recommend adequate training in sexuality. Being aware that such cultural clashes can arise, and being taught how to manage them, might help to understand and deal with these issues in a more satisfactory way for both the professional and the woman or couple.

Furthermore, enhancing the cultural diversity of the midwifery workforce may facilitate the rise of cultural humility, remove barriers in this field, and enrich culturally sensitive practice [13,14,15].

Case Study

Ioana and the contraceptive advice

After the birth of her ninth child, Ioana went to the regular six-week postpartum consultation. In each of her deliveries, she had placental retention, and on several occasions, her life was in grave danger because of it. From the Western view of health care, the right thing for this woman was to make sure she accepted a long-term contraceptive, and so the midwife tried to convince her.

Ioana spoke a language that the midwife was unfamiliar with, but as the clinic was in a very multicultural area, there was a permanent interpreter whose presence was requested in advance. However, Ioana belonged to a cultural group that was not common in the city, and, in the end, they had to communicate through the help of Ioana’s friend and the online translator. Anticipating that this consultation would require more time than usual, the midwife had reserved a double timeslot in her schedule, but that was insufficient. By developing all her abilities and creativity, the midwife somehow succeeded in transferring part of the information to Ioana. Nevertheless, Ioana simply said “no” energetically with her head and finger while smiling embarrassingly.

After several “failed” attempts, the midwife referred this case to the hospital team as a last resort.

Despite all efforts, it didn’t work.

But how was this possible if she had used all the available material and human resources?

Question to the reader:

What was the midwife missing? Where, why, and how should you have reacted differently?

The following are some relevant aspects to consider when addressing these issues:

• Unawareness and non-research on what family, sex, fertility, abortion, and contraception mean to the woman and her community.

• Cultural, educational, and language barriers.

• Lack of time.

• Unfamiliarity with specific tools for the culturally appropriate translation of health issues.

• Ethnocentric⁸ and paternalistic approach.

With this, we believe that addressing sexuality as part of the midwife’s practice is essential, but it does not make sense at all if the cultural aspects, which strongly influence people’s sexual lives, are not considered.

5 Recommendations for a Culture-Sensitive Approach

Paasche-Orlow described the essential principles of culturally competent care [16]:

• Principle 1: Acknowledgement of the importance of culture in people’s lives.

• Principle 2: Respect for cultural differences.

• Principle 3: Minimisation of any adverse consequences of cultural differences.

Based on these principles, we will present some recommendations to provide theoretical and practical keys for midwives regarding a culturally sensitive approach to sexuality.

All this is conceived from a positive point of view, understanding differences in this field as a two-way learning opportunity in which cultural exchange enriches the client, the midwife, the midwifery profession, and the population in general. The reader might feel more at home with some recommendations than others, agreeing more or less with them as a professional. Then, we have succeeded with one of our objectives: to make the intersections between culture and sexuality a topic considered by midwives. From here, new ideas, greater awareness, and even the implementation of actions that promote a real and significant change in this regard may appear.

The recommendations aimed at the individual midwife are the following:

• 1. Recognise the impact of culture on one’s own psychosexual development and sexual life and, in that way, become aware of one’s own norms and values regarding sexuality.

• 2. Be aware that each individual, despite shared cultural backgrounds, is unique in sexuality.

• 3. Normalise and legitimise non-judgmental discussions concerning sexual health in all cultural contexts by systematically recording aspects of people’s sexuality in the clinical history.

• 4. Keep an open mind and a respectful, active listening stance.

• 5. Avoid determinism and overgeneralisation on cultural grounds.

• 6. Detect and manage cultural and communication barriers that may hinder the midwife–woman interaction related to sexuality.

• 7. Be aware of the influences of one’s subculture.

• 8. Recognise discriminatory situations on cultural grounds occurring in the midwife’s workplace.

• 9. Collaborate and establish alliances between sexual and reproductive health service providers and organisations or associations in various communities (outreach work).

However, to expect all midwives to be experts in cross-cultural sexual healthcare is unrealistic and perhaps unnecessary because of the wide individual diversity within groups with the same cultural background. But also because of barriers that depend on governing structures and institutions. For this reason, we have here below included some structural and organisational recommendations:

• 1. Improve organisational aspects and provide human and material resources to midwives to allocate time for culturally competent sexual health care to women.

• 2. Include cross-cultural and sexual health awareness in midwifery training.

• 3. Promote cultural exchanges within the midwifery training program, between midwives in rural areas and those in cities, traditional and professional midwives, and even performing a minor part of the training abroad.

• 4. Ensure the availability of adequately trained interpreters or suitable tools (such as specific translating software⁹) to accompany women and professionals in sexually related conversations.

• 5. Aspire to create culturally diverse staff in midwifery teams.

• 6. Create a specialised cross-cultural-care midwife or committee, guaranteeing the continuity and quality of care for immigrant women and a reference role for colleagues.

• 7. Create culturally appropriate materials and educational campaigns related to sexuality for immigrant women and make them in different formats available for midwives.¹⁰

• 8. Improve equitable access to sexual and reproductive health services for all women, eliminating discrimination based on cultural background, social class, ethnicity, etc.

6 Conclusions

In the practice of midwifery, we may consider cultural differences related to sexuality as an opportunity to face new challenges and discover different behaviours in this regard. Thus, certain situations in this field that at first may seem shocking or even incomprehensible can become a learning process for the midwife and even result in an unexpected approach to the users, being able to minimise cultural barriers.

Together we can gradually develop a more global, coherent, women-centred, individualised, and holistic midwifery care concerning sexuality. An approach responsive to all women’s needs and concerns, regardless of their cultural background. In other words, a truly biopsychosocial model that embraces cultural pluralism.¹¹