Discussing sexuality fosters sexual health.

Every woman seeking reproductive health services carries her entire life story with her. It is a story that providers should be prepared to listen to with respect because it may contain information vital to the woman's health and well-being.

Many aspects of a woman's life affect her reproductive health, including her relationship with her partner and her understanding of, and beliefs about, sexuality. Because of this, providers would be wise to consider discussing such issues with clients, says Family Health International (FHI) researcher Dr. Patricia Bailey, whose work has included research on how contraception affects men's and women's quality of life. "The goal of such discussions would be to foster optimal sexual health, an aim that encompasses much more than just the prevention of sexually transmitted infections (STIs) or unplanned pregnancies," Dr. Bailey says.

The World Health Organization (WHO) defines sexual health as "the integration of the physical, emotional, intellectual, and social aspects of sexual being in ways that are enriching and that enhance personality, communication, and love." Furthermore, WHO states: "Fundamental to this concept are the right to sexual information and the right to pleasure." (1)

PROVIDERS CAN HELP WITH OPEN DIALOGUE

Violence, coercion, discrimination, fear, shame, guilt, false beliefs, and lack of knowledge about sexual issues are barriers to sexual health that many women face throughout the world. But providers can help by discussing with clients the aspects of their lives that may impede optimal sexual health.

"Providing quality reproductive health care is complex and involves an open dialogue between providers and clients about issues that traditionally may not have been discussed during medical consultations," Dr. Bailey says.

IN-DEPTH INTERVIEWS WITH BRAZILIAN DOCTORS

In-depth interviews with 15 gynecologists working in primary health care posts in Rio de Janeiro, Brazil, between 1993 and 1995 revealed that these doctors often found it difficult to discuss with female clients issues related to STIs and sexuality. It was particularly difficult for them to explain to a married woman that she had a genital infection and how she might have acquired it, since such an explanation implied marital infidelity.

"I tell her how she can avoid complications, but I do not get into how she might have been infected," said one of the gynecologists. "I do not think it would be good for her. We do not know how she got infected, and for her to get ideas....I think it is best just to treat it."

When physicians in the study were asked what they typically said to a woman who had an STI, only half reported informing the client that her infection was transmitted through sexual contact. "Look, I try to be neutral and not get involved in her private life," another physician said. "I have a very medical posture. I give her the results of the test and tell if there is a disease...."

In the same study, in-depth exit interviews with 42 women who had been diagnosed with chlamydia at primary health care posts in Rio de Janeiro, where they sought gynecological and prenatal care, revealed that only two of the women understood that their infection was transmitted through sexual contact.

This suggests that their physicians had not discussed the subject with them. The 15 gynecologists interviewed for the study did not attend to these women and in fact worked at other primary health care posts. But direct observation of gynecologists working at health posts where the 42 women were diagnosed revealed that those physicians' attitudes were similar to those of the 15 interviewed gynecologists, researchers reported. (2)

A clear explanation by a medical professional of the source of STIs is not sufficient to prevent infection, but it does serve as a foundation for the prevention of STIs, including HIV/AIDS. Such explanations can be especially important in settings like Brazil, where heterosexual intimate relations are the primary mode of HIV infection in women. (In Brazil, the female-to-male ratio of reported AIDS cases has increased from one female for every 28 males in 1985 to one female for every three males in 1995.)

In the same Brazilian study, even when clients persisted in attempting to discuss how they might have acquired an STI--such as through a partner's infidelity--some physicians avoided discussing the matter.

According to one doctor, "When the patient expresses suspicion of infidelity, I cut her off....I say, look here, what is important is that you have a disease. Both you and your husband have to be treated, right?"

BOLIVIAN WOMEN'S STUDY PROJECT

"But providers should be sensitive to women's concerns about infidelity," stresses FHI's Bailey, who, from 1995 to 1996, helped coordinate an FHI Women's Studies Project that examined how contraceptive use affects the sexuality, quality of life, and stability of couples in El Alto, Bolivia. Data for the study were collected from focus group discussions and in-depth interviews with 110 married women and 35 married men from El Alto.

In one focus group, several women discussed the impact of their husbands' infidelities. "No, I don't like sex," a woman said. "He treats me badly and he goes with other women. And now he has these large pustules on him. I don't know what they are. He'll disappear for two or three nights and when I ask him, he always says he was with a friend." (3)

Cultural beliefs about how active a woman should be in sexual relations can influence how a woman feels about her sexuality. One-half of the women interviewed in the El Alto study, for instance, said they did not consider it proper for married women to initiate sexual relations with their spouses. Many Bolivian men expressed the same view. However, the male focus group participants also agreed that one reason they become involved with their extramarital lovers is because, unlike their wives, their girlfriends initiated sex. (4)

"Women need to know that it is normal to be active participants in sex," Dr. Bailey says. "A sympathetic and caring provider who brings up the subject of sexuality with clients and creates an environment where it is comfortable for clients to talk about sex can show clients that it is OK to think about and even articulate these things. Then women might be less nervous about bringing up the subject with their partners."

There is another key reason why providers should consider talking with a woman about her sexuality and relationship with her partner: In some settings, intimate partner violence can limit a woman's access to health care or even prevent her from protecting herself against unplanned pregnancy or STIs.

STUDY OF VIOLENCE IN RELATIONSHIPS IN INDIA

A study from 1995 to 1996 of 6,632 married men living with their wives in Uttar Pradesh, India, found that abusive men were more likely than non-abusive men to have STI symptoms and to engage in extramarital sex. The study also found that unplanned pregnancies were more common in abusive relationships.(5)

"Women do not always have the power to make decisions about when they are going to have sex, how they are going to have sex, and what, if any, contraceptive method or disease-preventing methods they are going to use," says Jane Schueller, FHI's associate director of training and education. "And, if a woman has a partner who has multiple partners outside their marriage, she is at greater risk of an STI or HIV/AIDS."

Even violence that has taken place many years ago can affect the reproductive health of a woman. Research has shown that women who grow up in abusive homes are at higher risk for unplanned pregnancies. (6)

ABUSE IN NICARAGUA, SIERRA LEONE, INDONESIA

The fact that intimate partner violence is common in many settings is reflected in recent research. A 1995 population-based, household study of 488 women aged 15 to 49 years in Leon, Nicaragua, found that 40 percent had been physically abused by a partner at some point in their lives. (7)

Another survey conducted in 1994 among 144 women in Sierra Leone, West Africa, found that two-thirds of the women had been physically abused by a partner and more than half had been forced by their partners to have sexual intercourse. The majority of study participants were recruited from family planning clinics and hospital clinic waiting rooms in Freetown and in the Northern Province, but some were also recruited from marketplaces, a refugee camp, and a teacher's college. (8)

A 1999 study conducted in the Purworejo District of Central Java, Indonesia, among a population-based sample of 765 married women who were recruited from a longitudinal study of health during pregnancy found that one in four had been physically or sexually abused by her husband. (9)

Intimate partner violence can affect a woman's reproductive health in many ways. In addition to being at increased risk of an STI and unplanned pregnancy, abused women are at higher risk for having induced abortions, pine-term labor, low birth-weight babies, and various gynecological problems. For this reason, some experts feel that reproductive health clinics may be an ideal place to screen for intimate partner violence.

CLINICS NEED TRAINING ABOUT PARTNER VIOLENCE

A 1997 FHI survey of 607 women from El Alto and La Paz, Bolivia, supports this premise. Nearly half of some 40 percent of women who reported experiencing intimate partner violence said they had visited a reproductive health clinic within the past year. (10)

"Reproductive health services are well-positioned to screen women for intimate partner violence:' says Donna McCarraher, an FHI research associate who coordinated the FHI study "But programs that intend to provide screening need to ensure that everyone in the clinic is thoroughly trained and committed to preventing intimate partner violence."

Program managers also need to evaluate whether staff have sufficient time to offer such services, she says. And policymakers and program managers need to define what to do if they identify victims of intimate partner violence through screening. If they plan to refer women for counseling or shelter, then program managers need to set up and maintain such a system, McCarraher says.

PROVIDERS NEED TO CONSIDER CULTURAL, SOCIAL FACTORS

Cultural and social factors-some obvious, others less so- strongly influence the reproductive health decisions of women in many settings throughout the world.

A woman's ability to work and earn an income that she can control, for instance, can influence whether she can pay for health services.

Religious prohibitions, expectations about fertility, knowledge and beliefs about contraception, self-esteem, relationships with friends and family members, and freedom of movement all influence their decisions. Providers who understand these influences and establish open and respectful communication about the circumstances of clients' lives and decisions help those clients maintain optimal sexual health.

"Providers should not forget that many women are living in a context where they are not making unilateral decisions about their reproductive health," stresses Dr. Bailey, whose work has included research on contraception and quality-of-life issues.

Research has found, for instance, that social factors can influence a woman's access to reproductive health care and limit her ability to make decisions about reproductive health issues.

STUDY IN PAKISTAN FOCUSES ON SOCIAL SYSTEMS

In Northern Punjab, Pakistan, a 1997 study involving in-depth interviews and focus group discussions with married and unmarried men and women found that village social systems implemented to protect the honor of women and their families limited women's mobility and access to health care.

Unmarried women faced the greatest restrictions and were often kept at home unless medical care was urgent. Several respondents also said unmarried women had to avoid frequent visits to providers, which could suggest a health problem related to sexual activity. (11)

BANGLADESH STUDY ON BARI DWELLINGS

A woman's position within her extended family has also been found to limit women's reproductive health care choices. In rural Bangladesh, where many families live in grouped dwellings known as baris, a 1994 study found that a woman's social position within a ban could limit her access to reversible, modern contraceptive methods.

This study of 2,861 women living in 936 bans found that daughters-in-law and sisters-in-law of ban leaders used reversible, modern contraceptive methods less than wives of ban leaders. Access to those methods may be limited by either the ban leader or his wife, the researchers suggested. (12)

THAILAND STUDY SHOWS FAMILY NETWORKS MATTER

But social factors do not always have a negative effect on women's reproductive health. A recent study in Thailand found that the more external kinship ties households have, the more likely women in those households are to use modern forms of temporary contraception. (13)

Interpersonal communication through household kinship networks, both within and outside the village, may facilitate the spread of information. Kinship networks may provide greater economic resources with which to purchase modern contraceptive methods, the researchers noted.

"Social networks really matter," says Dr. Elaine Murphy, senior program advisor at the U.S.-based Program for Appropriate Technology in Health, whose work has focused on how client-provider interactions affect quality of care. "Clients often hear about family planning services and especially about specific methods from family members and friends."

Research shows that cultural and social factors also influence women's knowledge and beliefs about contraception and reproduction, their self-esteem, and their feelings about sexuality, which in turn affect their reproductive health decisions.

BOLIVIAN STUDY SHOWS NEGATIVITY, MISTRUST

A 1993 study based on in-depth interviews with 30 indigenous Aymaran women in La Paz and El Alto, Bolivia, found that many of the women had ambivalent, if not negative, feelings about sex. (14) "The interviews make clear that the women's reticence to speak of sexuality and reproduction is something that most of them learned at an early age," the study's authors noted. "They grew up in households where sexuality was not discussed and they soon learned that it behooved them not to ask questions or to appear to take any interest in such matters."

The study found that two-thirds of the women were not given clear information about reproduction when they were growing up and many did not understand how pregnancy occurs.

"They learned that sexuality was shameful and dangerous," the researchers said, "and they were told that they needed to 'take care of themselves' and avoid pregnancy, but they were not told how."

Although the study did not specifically address whether the women disliked sex, the researchers reported "an aversion to sex was apparent. Wives of men who wanted sex infrequently indicated that they considered themselves lucky.

Such feelings may explain why the rhythm method and other forms of family planning involving long periods of abstinence were so popular among the women, the researchers said. More than half used some form of the rhythm method. Four of the 30 relied on a combination of abstinence, prolonged breastfeeding, herbal infusions to induce menstruation, and abortion. Only eight used modern contraceptives.

Mistrust of health care providers may have been another factor influencing the reproductive health choice of these women, the researchers said. Many of the women feared modern contraceptives and a number of them anticipated being discriminated against and receiving poor treatment because they were Aymaran. Several said that providers could not be trusted to tell the truth about contraceptive side effects and reported that providers dismissed their concerns about these effects.

In some cases, the women's mistrust was based on their own past experiences. Two of the women said they had been pressured into continuing the use of an intrauterine device (IUD) although they had asked their providers to remove them because of side effects. A physician told one of the women, "You're fine: Healthy as a girl!" "That's all he said," the woman added, "so I just went away."

"When clients do not trust providers, they may be less apt to seek out their services and to obtain from them accurate reproductive health information that is otherwise unavailable.

This was the case in the Bolivian study, where researchers found that reliance on natural methods of family planning in the absence of knowledge about how to correctly use such methods led to many unplanned pregnancies. Two-thirds of the women had had at least one induced abortion or had tried to terminate a pregnancy, the study found. Almost one third reported unplanned pregnancies "that resulted in the birth of infants who subsequently died in unclear circumstances that might be interpreted as passive or active infanticide," the researchers said.

RESPECTFUL COMMUNICATION

Respectful and open discussions between providers and clients can create opportunities for providers to learn about factors influencing clients' decisions. Wisdom of this sort is necessary for providers to be able to offer counseling that is truly applicable to the circumstances of their clients' lives.

"Only interactive and dynamic counseling can identify clients' needs, risks, concerns, and preferences within their life-stage and life-situation," Dr. Murphy noted in a recent analysis of client--provider interactions. (15) The analysis also emphasized the importance of individualizing counseling, treating clients respectfully, counseling on method side effects, and providing clients with the contraceptive method of their choice.

In the case of the Bolivian study, where natural family planning methods were preferred by the majority of the women, the researchers recommended that providers educate clients to use these methods effectively rather than trying to convince them to use other methods.

"Providing clients with the contraceptive method of their choice is an important way that medical practitioners can help women maintain optimal reproductive health," Dr. Bailey agreed. "Women who have succeeded in getting to a clinic often have a pretty good idea of what they want. Providers should respect that." In fact, research has shown that a woman who receives her contraceptive of choice is more likely to continue using the method. (16)

MEXICAN STUDY SHOWS COUNSELING HELPS

Providing women with adequate counseling on method side effects can also improve the chances that they will continue using the method, research has shown. (17) Such observations were confirmed in a 2001 study conducted in Merida, Yucatan, Mexico, which found that method continuation rates of injectable depotmedroxyprogesterone acetate (DMPA) were substantially higher among women who received extra counseling on side effects than among those who received only routine counseling: 83 percent and 57 percent, respectively. (18)

"Counseling on side effects is extremely important," Dr. Murphy says. "Providers should talk with clients about how certain contraceptives can affect a woman's body and also about how they can affect a woman's sexual relationship. In some cultures, for example, where there is a taboo on intercourse during times of bleeding, IUD use may be discontinued because heavy bleeding or spotting are frequent side effects of this method. Thus, IUD use may produce a conflict between a woman's desire to delay childbearing and her sexual desires or those of her partner."

Counseling women, especially youth, about how contraceptive use affects health in general might also prevent some women from making unhealthy--even life-threatening--sexual health decisions.

CONCLUSION

Still, few providers make discussions regarding sexuality part of their practice.

But research conducted in Egypt through the Population Council's Frontiers in Reproductive Health project has shown that sexuality counseling can be successfully integrated into services at family planning clinics.

The 1999 study was conducted in four Egyptian Ministry of Health and Population clinics and two private clinics affiliated with the ministry

Nurses and physicians for all six clinics attended a two-day contraception training session emphasizing barrier methods. Staff at three of these clinics received three additional days of training on sexuality, gender, and counseling.

The study showed that medical practitioners who went through sexuality training were less inhibited about discussing sexuality-related issues with their clients.

Clients attending the intervention clinics were more likely to have been counseled on how their chosen contraceptive could affect their sexuality than clients in control clinics (41 percent versus 22 percent).

Clients in intervention clinics were also more likely to have had a sexuality-related discussion with their provider unrelated to family planning than clients in control clinics (44 percent versus 18 percent). Sexuality discussions in intervention clinics seemed to promote clients' adoption of barrier contraceptive methods.

"This study challenges the belief that women do not like to talk about their sexual problems," said Population Council researcher Dr. Nahia Abdel-Tawab. "Once rapport is established, they can talk frankly about sexual difficulties with a physician whom they trust."

To continue to improve communication about sexuality-related issues, the study's authors recommended that providers be trained to manage simple sexual problems and to counsel women about how various contraceptive methods can affect sexual relations.

They also recommended that the government develop a referral system with teaching or university hospitals for women with more complex sexual problems as well as public health messages encouraging women to ask family planning providers about their sexuality-related concerns. (19) All in the name discussing sexuality to foster sexual health.

REFERENCES

(1.) World Health Organization, Education and Treatment in Human Sexuality: The Training of Health Professionals, Technical Report Series 572 (Geneva: World Health Organization, 1975).

(2.) K. Giffin and C. M. Lowndes, "Gender, Sexuality, and the Prevention of Sexually Transmissible Diseases: A Brazilian Study of Clinical Practice," Social Science Medicine, vol. 48, no. 3, pp. 283-92.

(3.) A. Camacho, J. Rueda, and E. Ordonez, Las Majeres de El Alto se Descubren a si Mismas: Impacto de Ia Regulacion de la Fecundidad sobre la Establidad de Ia Pareja, Ia Sexualidad y la Calidad de Vida (Research Triangle Park, NC: Family Health International and Proyecto Integral de Salud, 1997).

(4.) S. Pauslon, "Cultural Bodies in Bolivia's Gendered Environment," International Journal of Sexuality and Gender Studies, vol. 5, no. 2, pp. 125-40.

(5.) S. L. Martin, B. Kilgallen, A. O. Tsui, et al., "Sexual Behaviors and Reproductive Health Outcomes: Associations with Wife Abuse in India," Journal of the American Medical Association, vol. 282, no. 20, pp. 1967-72.

(6.) P. Dietz, A. Spitz, R. Anda, et al., "Unintended Pregnancy among Adult Women Exposed to Abuse or Household Dysfunction during their Childhood,,, Journal of the American Medical Association, vol. 282, no. 14, pp. 1359-64.

(7.) M. C. Ellsberg, R. Pena, A. Herrera, et al., "Wife Abuse among Women of Childbearing Age in Nicaragua," American Journal of Public Health, vol. 282, no. 14, pp. 1359-64.

(8.) A. L. Coker and D. L. Richter, "Violence against Women in Sierra Leone: Frequency and Correlates of Intimate Partner Violence and Forced Sexual Intercourse," African Journal of Reproductive Health, vol. 2, no. 1, pp. 61-72.

(9.) M. Hakuni, E. Hayati, V Marlinawati, et al., editors, Silence for the Sake of Harmony: Domestic Violence and Women's Health in Central Java, Indonesia (Yogyakarta, Indonesia: CHN-RL GMU, Rifka Annisa Women's Crisis Center, Umea University, Women's Health Exchange, Program for Appropriate Technology in Health, 2001).

(10.) D. McCarraher, P. Bailey, T. Polo, et al., Determinants of Partner Violence and the Role of Sexual and Reproductive Health Services among Women in Bolivia (Annual meeting of the American Public Health Association, Washington, DC, November 14-18, 1998).

(11.) A. Khan, "Mobility of Women and Access to Health and Family Planning Services in Pakistan' Reproductive Health Matters, vol. 7, no. 14, pp. 39-48.

(12.) N. Kamal, A. Sloggett, and J. Cleland, "Area Variations in Use of Modern Contraception in Rural Bangladesh: A Multilevel Analysis," Journal of Biosocial Science, vol. 31, no. 3, pp. 327-41.

(13.) J. Godley, "Kinship Networks and Contraceptive Choice in Nang Rong, Thailand;' International Family Planning Perspectives, vol. 27, no. 1, pp. 4-10, 41.

(14.) S. Schuler, M. Choque, and S. Rance, "Misinformation, Mistrust, and Mistreatment: Family Planning among Bolivian Market Women," Student Family Planning, vol. 25, no. 4, pp. 211-21.

(15.) E. Murphy, "Client-provider Interactions in Family Planning Services: Guidance from Research and Program Experience," in Recommendations for Updating Selected Practices in Contraceptive Use, Volume II (Washington: U.S. Agency for International Development, 1997).

(16.) S. A. Pariana, D. M. Heer, and M. D. Van Arsdol, Jr., "Does Choice Make a Difference to Contraceptive Use? Evidence from East Java," Student Family Planning, vol. 22, no. 6, pp. 384-90; C. Huezo and U. Maihotra, Choice and Use-Continuation of Methods of Contracepcion: A Multicentre Study (London: International Planned Parenthood Federation, 1993).

(17.) N. Cotton, J. Stanback, H. Maidouka, et al., "Early Discontinuation of Contraceptive Use in Niger and The Gambia," International Family Planning Perspectives, vol. 18, no. 4, pp. 145-49; Z. Lei, S.Wu, and R. J. Garceau, "Effect of Pretreatment Counseling on Discontinuation Rates in Women Given Deposmedroxyprogesterone Acetate for Contraception," Chung Hua Fu Chan Ko Tsa Chih, vol.32, no. 6, PP. 350-53; N. T. Thom, P. T. Anh, A. Larson, et al., "Introductory Study of DMPA in Vietnam--An Opportunity to Strengthen Quality of Care in Family Planning Service Delivery," Lessons Learned Workshop, Hanoi, October 12, 1998.

(18.) T. Canto De Cetina, P. Canto, and M. Luna, "Effect of Counseling to Improve Compliance in Mexican Women Receiving Depotmedroxyprogesterone Acetate," Contraception, vol. 63, no. 3, pp. 143-46.

(19.) "Discussion Sexuality in Egyptian Clinics Is Feasible," Population Beliefs, vol. 6, no. 6, p. 6.

This article was adapted from three articles titled, "Discussing Sexuality Fosters Sexual Health," "Life Circumstances Influence Decisions," and "Training Providers to Talk about Sex," which appeared in volume 21, number 4 of Network, published by Family Health International in Research Triangle Park, NC

-Editor