Some midwives may have specific knowledge and skills to provide holistic sexual health care. However, findings from the author’s own research (Bogle 1996), and reflection seminars with midwives over the years, indicate that insufficient time is spent exploring the psychosexual aspect of sexual health.
A broader and more holistic philosophy of care at the micro-level is recommended, because effective functioning at this level is considered a prerequisite for macro-level activities. This philosophy should therefore support the view that an individual’s sexual thoughts, feelings, attitudes and behaviour can underpin their unique expressions of sexuality and sexual health care needs. These dynamic entities are constantly evolving and subject to change, and should be periodically reviewed with women, even within one maternity episode. A model of care underpinning this view is presented in Figure 10.2.
To work within this model midwives need knowledge and understanding of female and male sexual anatomy and physiology, human psychosexual development, and the influence that psychological, sociocultural and sociopolitical processes have on sexual health. They also need specific attitudes, skills and confidence to discuss sexual matters without embarrassment, within professional boundaries, and knowing when and to whom to refer for expert therapy (O’Driscoll 1998). The education and skills development process could begin with the following prerequisites.
Enhanced knowledge of potential physical and psychosexual health concerns of pregnant women
The sexual health concerns of women are presented in Table 10.1. The list is not definitive, but gives insight into the numerous concerns women may have about their sexual health during maternity care. As can be seen, their concerns are both physiosexual and psychosexual. Problems may range in complexity and clinical presentation, and several may continue beyond the maternity episode. However, most problems can be anticipated and satisfactorily resolved with empathetic listening and meaningful discussions.
Knowledge, attitudes and skills for sexual health promotion in midwifery practice 119
Enhanced knowledge of rationale and manner in which women disclose their most intimate concerns
This awareness provides useful insights into a woman’s psychological state. For most women, disclosure of a sexual problem is difficult, requiring courage and self-control.
Some women may voluntarily disclose their sexual health concerns to a midwife, when feeling isolated or at crisis point, because they trust the midwife’s professional knowledge and skills, and are respectful of the midwife’s judgements and clinical decisions. Others may disclose their immediate sexual health concerns in a round-about way, sometimes pretending that the problem is their friend’s, occurred in the past or is a possibility in the future. Disclosure may also be to vent feelings and emotions to anyone who will listen, to shock, seek sympathy or make social comparisons.
Activity – 2
Before reading Table 10.1 make a list of the sexual health concerns that women may wish to discuss with you in your role as a midwife or student. Then review the list in Table 10.1 and identify topics that you would find challenging. Reflect on how you could deal with them.
Sexuality
aehvioBur
Thoughts
Fe
eling
s
Sexual health Attitudes
The individual
FIGURE 10.2 Model of sexual health care. (From Bogle 1996.)
120 Sexual health promotion
The breadth, depth and truthfulness of sexual disclosures are influenced by the midwife–woman relationship. Age, gender, culture, religion, personality, social and professional status, of both woman and midwife, and the environment for disclosure all influence quality and reciprocity of information shared (Hargie et al. 1994). A woman may not feel that she knows or trusts the midwife to whom she is being asked to disclose. She may feel coerced if she has to divulge private and personal information to a stranger, fear judgemental unsympathetic treatment and have concerns that confidentiality will not be upheld. For some women, open, completely honest disclosures can take place in a short period of time, or slowly over several consultations, and be a relief when complete. Some women will use any opportunity to disclose and, if this happens in a public place, the midwife should respond to the here and now, without embarrassment. Reactions such as shock, disbelief, anger and repulsion, in the woman’s presence, should be avoided. According to O’Driscoll (1998), negative reactions to a sexual problem can have a lasting and harmful effect on a woman’s self-esteem and her intimate sexual relationship.
Enhanced self-awareness
This enables midwives to have positive regard and acceptance of women’s sexual diversity and caring needs. Burnard (1999) also suggests that self-awareness enables individuals to discriminate between their own problems and those of others.
Without conscious awareness midwives may identify too closely with women’s sexual problems, imagining that they are similar to or the same as their own, or similar to other significant people in their lives. They may even project their TABLE 10.1 Examples of sexual health concerns of women during the period of midwifery care During antenatal care During intrapartum care During postpartum care
Body image Vaginal examinations Body image
Eating disorders Vaginismus Tiredness/fatigue
Subfertility treatment Pain Adjustment to motherhood
Unplanned/unwanted pregnancy Body exposure Variations in sexual desire and resuming sexual intercourse
Marital status, age, parity Body fluids breastfeeding
Miscarriage/abortion Nipple stimulation Milk ejection during orgasm Variations in sexual desire and sexual Instrumental vaginal delivery Orgasmic pain
activities in pregnancy
Sexual myths and values Perineal trauma Perineal discomfort
Lifestyle Caesarean section Vaginal size, discharge and
dryness Relationship discord/infidelity Partner witnessing birth Dyspareunia
Lesbian relationship Family involvement Contraception
Domestic violence Female genital mutilation Stress incontinence
Sexual abuse Male attendants Relationship discord
Antenatal screening for sexually Paternity STIs
transmitted infections (STIs)
Female genital mutilation Sex of baby Condom use
Accommodation – space and privacy Fear of death/stillbirth Occupation, e.g. sex industry STIs
Knowledge, attitudes and skills for sexual health promotion in midwifery practice 121
own problems on to a woman, failing in their professional duty to focus on the woman’s identified needs. Midwives should think carefully about what and how much of their own personal sexual life they share with a woman, in an effort to open up conversations, to express concerns for the woman’s situation or to present a humane face.
Possessing sex-positive attitudes
Midwives need to consider their attitudes towards sex and sexual activities, in order to avoid judgemental and discriminatory practice. Respect and acceptance of the sexual values and beliefs that a woman holds are paramount to ensuring that sexual health promotion activities planned are congruent and acceptable. Sex should be viewed as a key element to a happy life, seen as a pleasurable experience and an effective form of communication between partners. Efforts should be made to encourage positive expressions of sexuality and sexual desire, and to raise women’s sexual self-esteem. A midwife’s sex-negative attitudes may manifest in stereotyping, stigma, prejudice and discrimination (Hayter 1996). Despite this, midwives also need to know that no one is free of judgemental thoughts and feelings, although some people may be more judgemental than others. As judgements about sexuality and sexual activities are particularly strong, some midwives may have difficulty repressing their own thoughts and feelings, and judgemental attitudes may be expressed. Inappropriate interpersonal communication can cause physical and psychological harm. Midwives can begin by acknowledging, accepting and respecting the strength of their personal judgements and regularly undertake self-review.
Ability to demonstrate genuine interest in a woman and her sexual problems By demonstrating an empathetic approach, a midwife is able to put herself in the woman’s shoes, genuinely feeling the way the woman is feeling about her problems.
Although a certain amount of sympathy is required, Egan (2002) believes its usefulness is limited in helping. One of the dangers of being over-sympathetic is that the midwife can become immersed in the woman’s self-pity, becoming her accomplice, and then begins to take sides with the woman without knowing the complete story. As guilt, blame and resentment often accompany sexual ill-health, midwives should be careful not to collude with a woman in apportioning blame, especially when directed at her sexual partner.
Ability to convey understanding in a language that the woman understands Sexual language should be agreed, because vocabulary needs to be unambiguous.
Medical and technical language should be avoided, as should language that may be perceived as judgemental. Bor and Watts (1993) suggest that health professionals should use clients’ words and language to identify and acknowledge their sexual problems. The words women use to describe their sexual organs and sexual behaviours may be influenced by the context, the nature of the problem, maturity, sexual knowledge, cultural attitudes and interpersonal communication skills. Words used can be colloquial or technical, depending on with whom the individual is communicating. Sometimes a woman may use colloquial language inappropriately when communicating with a midwife, causing embarrassment. Midwives may need
122 Sexual health promotion
to explore colloquial words used by women primarily to identify words that are unfamiliar, uncomfortable to use and incomprehensible.
Ability to discuss a woman’s feelings in a sensitive manner
Discussing a woman’s feelings gives valuable insights into her emotional state.
However, the midwife needs to be mindful that, in some cultures, people are brought up to believe that open display of emotions is unacceptable – talking about their feelings is considered to be a sign of weakness or self-indulgence. A tight upper lip is kept, fearing exposure to ridicule or loss of control. Burnard (1997) suggests that unexpressed emotions can distort thinking, and stop an individual from functioning fully or communicating feelings in words. By asking a woman how she feels about her sexual concerns a midwife can help her to express pent-up emotions. The midwife should pay particular attention to how the woman presents for the consultation, note and acknowledge the verbal and non-verbal feelings expressed, and sensitively confirm these with the woman.
Ability to discuss women’s sexual relationships in a sensitive manner
Midwives routinely ask women about their relationships at the booking interview.
The quality and honesty of responses will depend on how questions are asked.
As relationships are value laden and particular types are deemed acceptable or unacceptable, the messages that a woman receives about her relationships from friends, family, health professionals and society are important to her. Some women may be concerned about the midwife’s response if their sexual relationships fall below expectation. Midwives can sensitively ask a woman what she thinks as well as how she feels about her relationship. If the woman views her relationship as unsatisfactory, discussion can ensue on what actions she would like to take. This client-centred approach avoids giving information and advice prematurely, without knowing the bigger picture. However, when a child-protection issue is identified, the midwife should follow the guidelines for dealing with it (DoH 2003).
Ability to create an environment for open and effective communication The importance of effective communication cannot be over-emphasized. This process begins at the initial antenatal booking interview when a comprehensive sexual health assessment is undertaken (Zawid 1994). Although there is no single approach or format, and personal style develops with experience, there are many guiding principles. NICE (2003) advises midwives to undertake sexual histories in an environment that is suitable for discussing sensitive issues. Sensitivity, privacy and confidentiality should be shown at all times, so a woman’s sexual health concerns should never be discussed in the presence of anyone without the woman’s express permission. The relationship between midwife and woman should be built on equality, trust and respect. Active and effective listening should be demonstrated because this leaves the woman feeling valued, acknowledged and validated (Porritt 1990, Stein-Parbury 2000).
Before assessment starts, the woman should be informed of the necessity of discussing personal and sensitive questions, and why complete and honest responses are necessary, e.g. to plan appropriate care. Reassurance of autonomy and control of pace and amount of information disclosed are important and the process should be unhurried. A prepared list of sexual health issues for discussion, proceeding from less
Summary of key points 123
sensitive (medical and family history) to more sensitive questions, is recommended.
Flexibility is essential, because questions may need to be adjusted according to responses. Questions should be universally phrased assuming everyone does everything, e.g. ‘Many women are concerned about sexual activity in pregnancy, what might be your concerns?’. As already mentioned sexual language needs to be unambiguous, e.g. replace ‘husband’ or ‘boyfriend’ with ‘sexual partner’ and replace sexual intercourse with ‘having sex’. Open-ended questions provide the opportunity for expressing thoughts and feelings. Questions beginning with ‘how’, ‘when’, ‘what’
and ‘who’ are appropriate, e.g. ‘How has your pregnancy interfered with you being a sexual partner?’. Questions beginning with ‘why’ should be avoided, e.g. ‘Why did you not go for counselling following your termination of pregnancy?’. Closed questions limit the range of responses, may be considered judgemental, and cause defensiveness, refusal to answer and return for consultation, or to be seen by that midwife again. At the end of assessment, the woman’s priorities for sexual health care should be agreed and care planned accordingly.
Midwives may also wish to use a recognized framework to guide sexual health assessment. The PLISSIT model (Annon 1974) is highly recommended (Table 10.2).
By using this systematic framework, midwives can develop their skills in opening up discussions with women and progressing a conversation in a meaningful and sensitive way. They soon become aware of the boundaries and limitations of their role and know when to refer women for intensive therapy (Ingram-Fogel and Lauver 1990, Zawid 1994, Alteneder and Hartzell 1997). Finally they could become adept in assisting women to identify, understand, accept and, where practical, overcome sexual problems. Ultimately this health-promoting process will help women to maintain some independence and control of their lives.
TABLE 10.2 The PLISSIT model of sexual health intervention
Give PERMISSION: convey willingness to discuss sexual thoughts and feelings. Provide assurance that concerns or practices are normal. Permission is often sufficient to resolve what may become a major problem Offer LIMITED INFORMATION: provide information directly relevant to woman’s concerns. Questions, sexual myths and misconceptions may be addressed. This can result in significant changes in sexual attitudes and behaviours
Make SPECIFIC SUGGESTIONS: provide specific instructions/suggestions to help woman change sexual behaviour to achieve/restore sexual health. The woman may need referral to an appropriate professional if knowledge and skills are lacking
Provide INTENSIVE THERAPY: provide highly individualized therapy, so referral to a specialist counsellor is necessary
Adapted from Annon (1974).
SUMMARY OF KEY POINTS
■ Sexual health is multifaceted and difficult to define. It is a legitimate human right and midwives have a professional responsibility to enable its attainment.
■ Sexual behaviour is a private and sensitive issue that some women may not wish to discuss with a midwife, who is perceived as a stranger.
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■ Private, confidential and comfortable environments facilitate initiation of discussions and open and honest disclosures of sexual health concerns relevant to women’s actual or perceived needs. Acceptance and respect for individual uniqueness and right to self- determination should be shown at all times.
■ Midwives should be self-aware, have knowledge of sexual phenomena, and know their limitations and referral pathways. Negative sex attitudes and unconcealed judgemental values and beliefs influence care provision and acceptance.
■ Sexual health is a public health issue and midwives’ role within the multidisciplinary team should be further acknowledged.
■ Challenges and barriers to sexual health promotion can be overcome by sensitive education, collegiate and managerial support.
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