REVIEW: Customs, Culture, and Tradition—What Role Do They Play in a Woman’s Sexuality?

Circumcision and Sexual Medicine

INTRODUCTION

Male circumcision is one of the most frequently performed and debated urological procedures due to its possible implications for sexual health.

OBJECTIVES

The objective of this article is to review the literature on male circumcision and reconcile the scientific evidence to improve the quality of care, patient education, and clinician decision-making regarding the effects on sexual function of this procedure.

METHODS

A review of the published literature regarding male circumcision was performed on PubMed. The criteria for selecting resources prioritized systematic reviews and cohort studies pertinent to sexual dysfunction, with a preference for recent publications.

RESULTS

Despite the conflicting data reported in articles, the weight of the scientific evidence suggests there is not sufficient data to establish a direct association between male circumcision and sexual dysfunction.

CONCLUSION

This review provides clinicians with an updated summary of the best available evidence on male circumcision and sexual dysfunction for evidenced-based quality of care and patient education.

Sexual Habits and Sexual Dysfunctions in a Sample of Patients with Psychotic Disorders Compared to a Group of Healthy Adults

Background: There is a growing body of literature on the association between psychosis and sexual dysfunction. However, most studies have focused on sexual dysfunction and have not investigated the sexual lives of patients with psychosis across a broader range. Material and Methods: Consecutive patients with a diagnosis of acute psychosis or schizophrenia were recruited to the study after obtaining informed consent (n = 46). In addition, healthy control subjects were recruited (n = 52). Sociodemographic and clinical data, psychopathology, and sexual functioning were assessed. Independent sample t-test to determine group differences was obtained. Results: In both the male and female groups, there are significant differences between psychotic individuals and healthy controls in several areas of their sexual functioning: the control group seemed to better perceive Couple sexuality, Self-eroticism, and overall appeared to have a higher Quality of sexual life; on the other hand, the group of patients with psychosis displayed higher scores in Sexual dysfunction. Conclusions: A poor sexual quality of life may be found in patients with psychotic disorders. Assessment of sexual function in these patients is necessary to identify and manage issues and provide support and help to patients in this important area of life.

Development and Validation of a Scale to Measure Adolescent Sexual and Reproductive Health Stigma: Results From Young Women in Ghana

Young women's experiences with sexual and reproductive health (SRH) stigma may contribute to unintended pregnancy. Thus, stigma interventions and rigorous measures to assess their impact are needed. Based on formative work, we generated a pool of 51 items on perceived stigma around different dimensions of adolescent SRH and family planning (sex, contraception, pregnancy, childbearing, abortion). We tested items in a survey study of 1,080 women ages 15 to 24 recruited from schools, health facilities, and universities in Ghana. Confirmatory factor analysis (CFA) identified the most conceptually and statistically relevant scale, and multivariable regression established construct validity via associations between stigma and contraceptive use. CFA provided strong support for our hypothesized Adolescent SRH Stigma Scale (chi-square p value < 0.001; root mean square error of approximation [RMSEA] = 0.07; standardized root mean square residual [SRMR] = 0.06). The final 20-item scale included three subscales: internalized stigma (six items), enacted stigma (seven items), and stigmatizing lay attitudes (seven items). The scale demonstrated good internal consistency (α = 0.74) and strong subscale correlations (α = 0.82 to 0.93). Higher SRH stigma scores were inversely associated with ever having used modern contraception (adjusted odds ratio [AOR] = 0.96, confidence interval [CI] = 0.94 to 0.99, p value = 0.006). A valid, reliable instrument for assessing SRH stigma and its impact on family planning, the Adolescent SRH Stigma Scale can inform and evaluate interventions to reduce/manage stigma and foster resilience among young women in Africa and beyond.

"Adopting self-sacrifice": how Iranian women cope with the sexual problems during the menopausal transition? An exploratory qualitative study

OBJECTIVE

In the menopausal transition sexual problems are an important issue and one of the most frequently presented health concerns of women attending menopause clinics. This study aimed to explore the ways of managing sexual dysfunctions during the menopausal transition among Iranian women.

METHODS

This exploratory qualitative study was conducted in Iran, from May 2013 to April 2015. Twenty-one women in three stages of menopausal transition, aged 42-55 years old, were purposively selected from urban health centers in Mashhad and Gonabad, Iran. Semi-structured in depth interviews were conducted for data collection until data saturation was achieved. All interviews were recorded electronically and transcribed verbatim. Conventional content analysis was used for data analysis using Granehiem and Lundman (2004) recommended method. MAXQDA 2007 software was used for organizing data and managing the process of analysis.

RESULTS

Data analysis demonstrated one overarching theme entitled "Adopting self-sacrifice" consisting of three categories and seven sub-categories. Major categories included: (1) Confronting decline of libido with two subcategories of women's libido decline and inability to fulfill husbands' sexual needs, (2) Seeking strategies for coping with two subcategories of looking for experiences of peer menopausal women and choosing how to interact with the husband and (3) Achieving problem solving strategies with three sub-categories of obedience in sexual relationships (Tamkin), employing affection based on religious advice, and giving up own right to reach mutual understanding.

CONCLUSIONS

The major finding of this study was "Adopting self-sacrifice" in the process of managing sexual dysfunctions during the menopausal transition. The reason for choosing this passive approach by the majority of women has deep roots in their cultural and traditional beliefs.

Gender equality and human rights approaches to female genital mutilation: a review of international human rights norms and standards

Two hundred million girls and women in the world are estimated to have undergone female genital mutilation (FGM), and another 15 million girls are at risk of experiencing it by 2020 in high prevalence countries (UNICEF, 2016. Female genital mutilation/cutting: a global concern. 2016). Despite decades of concerted efforts to eradicate or abandon the practice, and the increased need for clear guidance on the treatment and care of women who have undergone FGM, present efforts have not yet been able to effectively curb the number of women and girls subjected to this practice (UNICEF. Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change. 2013), nor are they sufficient to respond to health needs of millions of women and girls living with FGM. International efforts to address FGM have thus far focused primarily on preventing the practice, with less attention to treating associated health complications, caring for survivors, and engaging health care providers as key stakeholders. Recognizing this imperative, WHO developed guidelines on management of health complications of FGM. In this paper, based on foundational research for the development of WHO’s guidelines, we situate the practice of FGM as a rights violation in the context of international and national policy and efforts, and explore the role of health providers in upholding health-related human rights of women at girls who are survivors, or who are at risk. Findings are based on a literature review of relevant international human rights treaties and UN Treaty Monitoring Bodies.

Evaluation of sexual function and quality of life in Iranian women with tubal ligation: a historical cohort study

Tubal ligation (TL) is an option for contraception for women who have completed their family. The existence of sexual dysfunction and impaired quality of life (QOL) following this procedure has been the subject of debate for decades. The aim of this study was to evaluate the sexual function, QOL and other factors affecting Iranian women who underwent TL. A historical cohort study was carried out on 150 women who had undergone TL and on 150 women who had used a condom (as the control group). The sexual function of participants was evaluated and compared using Female Sexual Function Index (FSFI) questionnaire. They were also asked to fill out the Short Form Health Survey (SF-12) for evaluating their QOL. Furthermore, the effects of educational level and poststerilization regret in the women of TL group were evaluated. With regard to FSFI, all mean values were found to be lower in the TL women and the differences between the two groups were statistically significant in all domains. A significant difference was found in sexual dysfunction in orgasm (P = 0.02), satisfaction (P = 0.01), pain (P = 0.006) and total FSFI scores (P = 0.006) between the women regretting vs those not regretting their sterilization. In evaluating the relationship between FSFI and educational level, with the increase of educational level all domain scores increased significantly only in the TL group. There was a significant difference between the two groups in SF-12 scores (69.18 ± 14.05 vs 78.41 ± 12.50; P < 0.0001). Our findings reveal the adverse effects of TL on the sexual life and QOL of women. It is recommended that the awareness and knowledge of health-care professionals regarding the sexual function and QOL in women undergoing TL should be increased.

Promoting women's human rights: A qualitative analysis of midwives' perceptions about virginity control and hymen 'reconstruction'

OBJECTIVES

To explore midwives' perceptions regarding virginity control and hymen 'reconstructions', and how these practices can be debated from a gender perspective.

METHODS

An international group of 266 midwives answered an open-ended question in a Web survey. The great majority came from the Western world, among them, the majority were from Europe. Data were analysed using qualitative content analysis.

RESULTS

Three themes emerged: misogynistic practices that cement the gender order, which revealed how the respondents viewed virginity control and hymen 'reconstructions'; raising public awareness and combatting practices that demean women, which were suggested as strategies by which to combat these practices; and promoting agency in women and providing culturally sensitive care, which were considered to improve health care encounters.

CONCLUSIONS

Virginity control and hymen 'reconstructions' are elements of patriarchy, whereby violence and control are employed to subordinate women. To counter these practices, macro and micro-level activities are needed to expand women's human rights in the private and the public spheres. Political activism, international debates, collaboration between sectors such as health care and law-makers may lead to increased gender equality. A women-centred approach whereby women are empowered with agency will make women more capable of combatting virginity control and hymen 'reconstruction'.

Young women's perceived health and lifetime sexual experience: results from the national survey of family growth

INTRODUCTION

Sexuality is a component of health and well-being for all women, including adolescents. Yet relationships between young women's health perceptions and sexual behavior are unclear.

AIM

We examined associations between perceived health and lifetime sexual experiences among young U.S. women.

METHODS

We used data from 4,413 young women ages 15-24 years in the National Survey of Family Growth, 2002-2008. Descriptive, bivariate, and multivariate statistics estimated relationships between categories of perceived health and types of lifetime sexual experience.

MAIN OUTCOME MEASURES

A self-rated health Likert item and sexual history questions were administered with a computer-assisted survey instrument.

RESULTS

Young women reported excellent (30%), very good (41%), good (23%), and fair-poor (6%) health. Sexual experiences included vaginal (64%), oral (64%), and anal (20%) sex. Negative experiences included involuntary sex (11%) and sexually transmitted infection (STI) history (8%). In multivariate logistic regression models, lower perceived health ("good" rather than "excellent") was positively associated with vaginal (odds ratio [OR] 1.5, confidence interval [CI] 1.1-2.1, P = 0.02), oral (OR 1.5, CI 1.1-2.1, P = 0.005), and anal (OR 1.4, CI 1.0-2.0, P = 0.03) sex. In models stratified by age, point estimates for vaginal (OR 1.8, CI 1.2-2.6, P = 0.002) and oral (OR 1.9, CI 1.4-2.6, P < 0.001) sex were higher among adolescents ages 15-19 years, but associations were insignificant among young adults ages 20-24 years. When controlling for negative sexual experiences, point estimates were stable in models including STI history but statistically insignificant when including involuntary sexual experience. Other characteristics associated with sexual experiences varied by type of experience and included age, race/ethnicity, employment situation, poverty level, insurance status, childhood family situation, religious service participation, cohabitation/marital experience, and body mass index.

CONCLUSIONS

  Further investigation is warranted to disentangle potentially negative relationships between perceived health (as well as response bias and more objective health outcomes), sociodemographic factors, and diverse sexual experiences among young women in the United States.

Sexual dysfunction in multiple myeloma: survivorship care plan of the International Myeloma Foundation Nurse Leadership Board

The World Health Organization describes sexuality as a "central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious, and spiritual factors." Currently, no research has been conducted regarding sexual dysfunction in patients with multiple myeloma; therefore, information related to the assessment and evaluation of sexual dysfunction is gleaned from other malignancies and diseases. In this article, members of the International Myeloma Foundation's Nurse Leadership Board discuss the definition, presentation, and causes of sexual dysfunction; provide recommendations for sexual assessment practices; and promote discussion among patients with multiple myeloma, their healthcare providers, and their partners.

Female genital mutilation/cutting and issues of sexuality in Egypt

Female genital mutilation/cutting (FGM/C), officially referred to as female circumcision and at community level as tahara (cleanliness), is still prevalent in Egypt. This study was designed to examine the role of female sexuality in women's and men's continued support for FGM/C, and their perceptions of its sexual consequences. The study was conducted in 2008-09 in two rural communities in Upper Egypt and a large slum area in Cairo. Qualitative data were collected from 102 women and 99 men through focus group discussions and interviews. The clitoris was perceived to be important to, and a source of, sexual desire rather than sexual pleasure. FGM/C was intended to reduce women's sexual appetite and increase women's chastity, but was generally not believed to reduce women's sexual pleasure. Men and women framed sexual pleasure differently, however. While men, especially younger men, considered sexual satisfaction as a cornerstone of marital happiness, women considered themselves sexually satisfied if there was marital harmony and their socio-economic situation was satisfactory. However, sexual problems, including lack of pleasure in sex and sexual dissatisfaction, for whatever reasons, were widespread. We conclude that political commitment is necessary to combat FGM/C and that legal measures must be combined with comprehensive sexuality education, including on misconceptions about FGM/C.

Post genital mutilation giant clitoral epidermoid inclusion cyst in Benin City, Nigeria

OBJECTIVE

To report overall occurrence, and the mode of presentation and management of girls with post genital mutilation giant clitoral epidermoid inclusion cyst in an African subregion.

METHODS

This is a prospective experience with female patients who presented at two centers in Benin City, Nigeria, between January 2005 and December 2009 with clitoral epidermoid inclusion cyst following underground traditional female genital mutilation performed on neonates.

RESULTS

In total, 37 patients were seen with clitoral epidermoid inclusion cyst, 15 (40.5%) were post pubertal girls who could no longer cope with giant cyst that measured more than 3.5 × 6.5 cm in size at an average age of 17 (range 14-21) years. Ignorance, financial constraints, and the fear of possible prosecution by anti-female genital mutilation agencies were reasons for late presentation. Consequently, rapid increase in size of all cysts (100%), mass effect producing dragging discomfort in the vulva of 14 (93.3%) girls, social stigmatization of 12 (80%) girls by peers and spouses, sexual difficulty experienced by 10 (66.7%), and irritating bulge in the perineum of 10 (66.7%) girls, were the most common indications for surgical consultation. Outcomes of cystectomy that included total clitoridectomy performed on on an outpatient basis mainly with local anesthesia were encouraging with no incidence of recurrence recorded on 1-4 years postoperative follow-up.

CONCLUSION

Late presentation of girls with giant post genital mutilation clitoral epidermoid inclusion cysts was common. More campaigns against female genital mutilation and government policy aimed at encouraging patients with complications to seek early medical attention, and free treatment for those who present early are advocated.

Sociocultural dimensions of HIV/AIDS among Middle Eastern immigrants in the US: bridging culture with HIV/AIDS programmes

The population of Middle Eastern immigrants in the US has been increasing dramatically over the past 30 years, growing from 200,000 in 1970 to 1.5 million in 2000. These immigrants and their descendants constitute an important new population of interest for public health and other social programmes. With this addition to the cultural diversity of American society, it is important for healthcare programmes to be responsive to the unique cultural needs of those of Middle Eastern origin and to include them in healthcare curricula. This need is particularly imperative for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) intervention programmes, where the reduction of risky behaviours is essential to controlling the epidemic. When Middle Easterners emigrate to the US they must adjust to the American culture, which leads to preservation of some aspects of their culture and adjustment of behaviors to match American customs. This article aims to present sociocultural factors of HIV risk behaviours that are specific to Middle Eastern culture. The article also provides recommendations for HIV/AIDS-culturally appropriate intervention programmes.

Disappearance of female genital mutilation from the Bedouin population of Southern Israel

INTRODUCTION

Recently, clinicians in Southern Israel perceived that the practice of female genital mutilation had disappeared entirely in the Bedouin population. We previously studied the prevalence of this practice in 1995.

AIM

We decided to survey again the Bedouin population focusing on those tribes previously reported to perform this practice.

METHODS

Eighty percent of the interviews were done by an Arabic-speaking psychiatrist and 20% were done by an Arabic speaking nurse in the gynecologic clinic of a large Bedouin township or the gynecologic clinic of a smaller Bedouin township. Women were asked if they would be willing to answer a few questions about their past and if they were willing to have the gynecologist, with no additional procedure, note whether any operation had been performed on their genitalia.

MAIN OUTCOME MEASURES

Physical examination by gynecologist and an oral questionnaire.

RESULTS

One hundred and thirty two women were examined. No cases of any scarring of the kind reported in the previous study were found on physical examination.

CONCLUSIONS

FGM has apparently disappeared over 15 years in a population in which it was once prevalent.

Measurement of the thickness of the urethrovaginal space in women with or without vaginal orgasm

INTRODUCTION

The physiology and anatomy of female sexual function are poorly understood. The differences in sexual function among women may be partly attributed to anatomical factors.

AIM

The purpose of this study was to use ultrasonography to evaluate the anatomical variability of the urethrovaginal space in women with and without vaginal orgasm.

METHODS

Twenty healthy, neurologically intact volunteers were recruited from a population of women who were a part of a previous published study. All women underwent a complete urodynamic evaluation and those with clinical and urodynamic urinary incontinence, idiopathic detrusor overactivity, or micturition disorders, as well as postmenopausal women and those with sexual dysfunction were excluded. The reported experience of vaginal orgasm was investigated.

MAIN OUTCOME MEASURE

The urethrovaginal space thickness as measured by ultrasound was chosen as the indicator of urogenital anatomical variability. Designated evaluators carried out the measurements in a blinded fashion.

RESULTS

The urethrovaginal space and distal, middle, and proximal urethrovaginal segments were thinner in women without vaginal orgasm. A direct correlation between the presence of vaginal orgasm and the thickness of urethrovaginal space was found. Women with a thicker urethrovaginal space were more likely to experience vaginal orgasm (r = 0.884; P = 0.015). A direct and significant correlation between the thickness of each urethrovaginal segment and the presence of vaginal orgasm was found, with the best correlation observed for the distal segment (r = 0.863; P < 0.0001). Interobserver agreement between the designated evaluators was excellent (r = 0.87; P < 0.001).

CONCLUSIONS

The measurement of the space within the anterior vaginal wall by ultrasonography is a simple tool to explore anatomical variability of the human clitoris-urethrovaginal complex, also known as the G-spot, which can be correlated to the ability to experience the vaginally activated orgasm.

The Prevalence and Causes of Sexual Problems among Premenopausal Turkish Women

INTRODUCTION

Sexual dysfunction in females is an important public health problem worldwide. It is suggested that sexual problems among women are more common than the number of diagnosed female sexual dysfunction (FSD) cases indicates.

AIM

To determine the frequency and causes of sexual problems among premenopausal and married women who attend primary healthcare facilities.

METHODS

This study was conducted at the Mother and Child Health and Family Planning Center. All women who attended this center during a 3-month period were included in the study. Sexual problems were evaluated via questionnaire and a standardized scale known as the Golombok Rust Inventory of Sexual Satisfaction (GRISS). MAIN OUTCOME MEASURE. A cross-sectional study.

RESULTS

Although a total of 422 women aged 19-51 years were eligible for inclusion in the study, the participation rate was 27%. Nearly two-thirds of the women were aged 20-34 years, and of this group, 84.3% were unemployed. According to self-reports, 15.7% (18) of the women had sexual problems, whereas the prevalence of sexual dysfunction using GRISS was 26.1%. Vaginismus (41.7%), infrequent intercourse (39.1%), and nonsensuality (38.3%) were the most common complaints of the women with sexual problems. The rate of sexual dissatisfaction was found to be 7%. Sexual problems among women who had a long-term marriage (more than 11 years) and who were sexually inexperienced at the time of their marriage were significantly higher (P = 0.036, P = 0.034, respectively). It was found that discussing sexual problems with husbands and healthcare professionals did not reduce sexual problems.

CONCLUSIONS

According to GRISS, nearly one-quarter of the women were suffering from sexual problems. The most common sexual problem was vaginismus, followed by infrequent intercourse. It is suggested that inadequate knowledge and the attitudes of spouses and health workers in primary healthcare settings are the important causes of FSD in this population.

Controversies in Sexual Medicine: Is Elective Vulvar Plastic Surgery Ever Warranted, and What Screening Should Be Conducted Preoperatively?

INTRODUCTION

Elective vulvar plastic surgery was the topic of a heated discussion on the list-serve of the International Society for the Study of Women's Sexual Medicine. At the suggestion of a board member, it was determined that this discussion might of interest to journal readers in the form of a published controversy.

METHODS

Six people with expertise and/or strong opinions in the area of vulvar health, several of whom had been involved in the earlier online discussion, were invited to submit evidence-based opinions on the topic.

MAIN OUTCOME MEASURE

To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine.

RESULTS

Goodman believes that patients should make their own decisions. Bachmann further states that, while that is a woman's right, she should be counseled first, because variations in looks of the vulvar region are normal. Johnson furthers this thought, discussing the requirement for counseling before performing reinfibulation surgery on victims of female genital cutting. Fourcroy emphasizes the need to base surgical procedures on safety and efficacy in the long term, and not merely opportunity at the moment. Goldstein and Goldstein state that, based on the four principles of ethical practice of medicine, vulvar plastic surgery is not always ethical, but not always unethical. Sklar pursues this thought further, pointing out specific examples in regard to the principles of ethics.

CONCLUSION

Vulvar plastic surgery may be warranted only after counseling if it is still the patient's preference, provided that it is conducted in a safe manner and not solely for the purpose of performing surgery.