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Rev. esc. enferm. USP vol.46 no.3 São Paulo June 2012
Body and sexuality during pregnancy*
Natalúcia Matos AraújoI; Natália Rejane SalimII; Dulce Maria Rosa GualdaIII; Lucia Cristina Florentino Pereira da SilvaIV
Ph.D., Professor, Midwifery Program, University of São Paulo School of Arts,
Sciences and Humanities. São Paulo, SP, Brazil, E-mail: firstname.lastname@example.org
IIMidwife. Ph.D. student, Interunit Nursing Program, University of São Paulo School of Nursing. São Paulo, SP, Brazil, E-mail: email@example.com
IIIMidwife. Full Professor, Maternal-Infant and Psychiatric Nursing Department, University of São Paulo School of Nursing. São Paulo, SP, Brazil, E-mail: firstname.lastname@example.org
IVNurse Midwife. Ph.D., Professor, Obstetrics Program, University of São Paulo School of Arts, Sciences and Humanities. São Paulo, SP, Brazil, E-mail: email@example.com
The objective of this ethnographic study was to understand how women experience their body's physiological processes during pregnancy and their effects on sexuality. The study involved seven women living in a poor neighborhood in São Paulo. Data collection was performed through participant observation and interviews using guiding questions. The data were presented in the narrative form and then organized into the following categories: realizing the changes in the body; living with the changes in the body; and feelings and sensations experienced in sexual life during pregnancy and imagining the body after pregnancy. The women referred to the changes in their bodies as discomforts, and expressed their concern that these changes would be permanent. They expressed they hoped that, after childbirth, their body would go back to what it was like before pregnancy and that they would recover their sexual desire. Recognition of these concerns is an essential tool to guarantee appropriate professional practices.
Descriptors: Human body; Pregnancy; Sexuality; Sexual and reproductive health
It can be confirmed that pregnancy requires coping with important vital events, such as physical and psychosocial changes(1), which affect the family dynamics and affective bonding among its members.
For some authors, pregnancy is considered a crisis period, which demands an adaptive response from the stakeholders in this process(2). The pregnancy period demands new forms of balance in view of the changes inherent in this phase. These changes are related with metabolic and hormonal rhythms and with the integration process of a new body image. They affect both the physical and emotional dimensions. One of the dimensions they can influence is sexuality.
Different meanings are attributed to sexuality-related manifestations. These derive from values and cultural practices and evidence various and different socializations individuals experience in their lives: family, types of school, access to different communication means, friendship and neighborhood networks(3). These socializations exert a fundamental role in the individual's construction as a whole, generating forms of interpreting and experiencing sexuality. Thus, when we consider the body and sexuality, we need to take into account a dimension that goes beyond the biological, as they need to be understood in a socio-cultural context, loaded with meanings that are continuously re-elaborated in each person's life and in the history of societies.
some societies, sexual practice with pregnant or menstruated women is
prohibited, as it is presented as something dangerous, which can provoke
impotence, sterility or produce monsters(4). Nigerian women, on the
other hand, believe that sexual relations during pregnancy are beneficial, as
they are supposed to widen the vagina, facilitating labor and delivery. The
same fact can be observed in Japan, where some pregnant women believe that
exhausting exercises like sexual intercourse can lighten delivery(6).
Today, in different societies, sexuality information is increasingly present, stimulating women's greater participation in sexual pleasure. It is considered that women can be involved in sexuality, despite the changes in their bodies deriving from the pregnancy process.
A study on sexuality showed that, during pregnancy, the pregnant women's willingness and wellbeing are directly linked with an active sexual life during this period. The study also showed that factors like sleepiness, sadness, guilt and fear regarding the sex are negatively correlated in the couple's sexual life(3).
Other studies on sexuality during pregnancy show that sexual life can be more active in this phase if the bodily discomfort and physical symptoms are not present. Evidence exists, though, that interest in sexual activity slightly declines in the first term, but is enhanced in the final term of pregnancy. These data, however, vary among pregnant women(7). This reveals that each woman has a different form of dealing with her body, controlling and perceiving it during pregnancy, and difficulties can come up in this process that entail negative implications for her sexual life.
From an anthropological perspective, studies on bodily change and sexuality during pregnancy permit learning about the meanings and cultural values present in these processes and the different ways of experiencing the body and sexuality(8).
In view of the above, the aim of this research was to understand how women experience bodily changes during pregnancy and their repercussions for sexuality.
This paper discusses a qualitative research that used the ethnographic method, based on medical anthropology. Ethnography was chosen in the intent was to give a detailed description of people's reality, in this case the sexuality experience of women in a certain cultural group.
The study problem was based on interpretative anthropology. One of its pioneers was Clifford Geertz, who defines culture as
the pattern of meanings historically transmitted and incorporated in symbols, a system of inherited conceptions, expressed in symbolic ways through which men communicate, perpetuate and develop their knowledge and attitudes towards life(9).
Thus, the universe of symbols and meanings allows individuals in a group to interpret their experience and guide their actions, highlighting the importance of culture in the construction of the entire human phenomenon. In this perspective, the researcher affirms that culture models individuals as a sole species, but respecting their particularities and contexts(9).
The ethnographies drafted in medical anthropology are similar to traditional ethnographies, but the discovery of knowledge, beliefs and health practices receive greater emphasis. They use a global approach, but emphasize the local perspective and individuals' practices regarding specific health and disease issues. In this focus, the human body has a universal anatomy and physiology, but is conceived and receives care in different forms in societies(10).
Human reproduction has been one theme that, after the 1970's, has been studied from a medical anthropology perspective. Biological events mark reproductive processes. All societies, however, model their members' reproductive behavior, reflecting their core values and structural principles of society as a whole. Medical anthropology research is more restricted to specific places, times and events. Although participants come from different origins, it is considered that they share the same disease, care and cure experience(11).
This study was developed in Jardim Keralux, a popular neighborhood in Eastern São Paulo-SP, with approximately 2,200 families (8,000 people). The growth of the neighborhood was not ordered, and happened without infrastructure, sheltering popular classes. The entire area is legally irregular for housing purposes. The word Keralux comes from a company Keralux S/A Revestimento Cerâmicos, which ceased its activities in 1978 and owned approximately 90% of the area where the neighborhood is structured today. In 1995, illegal allotments were established on these lands. Later, dwellers received a repossession injunction(12).
The health service available to this community is a Primary Health Care Unit (UBS), with the Family Health Program (FHP) as the care base, with two teams. This UBS is a training area for midwifery students from the University of São Paulo School of Arts, Sciences and Humanities (EACH-USP). Besides teaching, since 2006, faculty from the Midwifery Program have developed community service activities in the Orientation for Pregnant Women project. In this group, it was observed that many pregnant women revealed lack of knowledge on their own body and the modifications occurred during the reproductive cycle. Often, the women reported difficulties to deal with these bodily changes, negatively influencing the couple's relation and affecting the sexual life. Therefore, the proposed research aim was set forth.
Thus, research participants were pregnant women in Jardim Keralux who initially participated in a group a faculty from the midwifery program at EACH-USP held in the first semester of 2008. During the research period, the group included 17 women. Twelve of them complied with the inclusion criteria: being a pregnant woman independently of the gestational age; over 19 years of age and living in Jardim Keralux. They were invited to participate, but only seven women accepted to participate voluntarily.
The collaborators' characteristics revealed that their ages ranged between 20 and 41 years, with a majority between 20 and 24 years. Most women came from other cities, mainly from the Brazilian Northeast. We also observed that they had lived in the community for between three and eight years. Living with a fixed partner was the most mentioned marital status among the pregnant women. Concerning occupation, although almost all of them informed they had a profession or had already worked before the pregnancy, at the moment of the research, none of them had a paid job, although many of them expressed the desire to get a job after the puerperal phase. All collaborators had more than five years of education and a majority was finishing or had already finished secondary education. Two participants were multiparous and the remainder primiparous.
Initial contact with the collaborators was established in the pregnancy group at the Primary Health Care Unit of Jardim Keralux. At first, observation was possible and closer contact was established with the pregnant women; participating in the group permitted perceiving the sociocultural scenario for the study and the interrelations among subjects in this scenario, facilitating information access and the understanding of behaviors and cultural practices. Participant observation of the groups took place in the first semester of 2008.
The lead author of this paper conducted the interviews in July and August 2008. They were scheduled according to each pregnant woman's freely elected place, date and time. Most of them indicated their own home, which permitted observing the social context, family and relationship dynamics. The interviews were audio-recorded and, on average, took between 31 and 77 minutes, addressing two open guiding questions: What has it been like for you to experience your body's transformation? What has it been like for you to experience sexuality during pregnancy?
Data collection was terminated when the data had provided sufficient description of the study phenomenon. This decision was based on saturation concepts, which refers to the information quality, pertinence, range and quantity an appropriate group of participants provided(11).
The researchers conducted data treatment, which started with the transcription of the interviews. The analysis followed the framework of Janesick(13), with the following steps: locating, in the reported experience, those phrases or assertions that are directly related to the study phenomenon; interpreting the meanings of these phrases as an informed reader; inspecting the meanings to check what they reveal about the essential and recurring aspects of the phenomenon. The findings were interpreted according to the process the same author suggested, as follows: induction process, starts with immersion in the context; incubation process, permits reflection and state of alert to nuances of meanings in the context; illumination, permits a broader perception; description and explanation, to capture people's experience; elaboration of creative synthesis, which includes the meaning and the experience lived.
Before data collection, the study received approval from the Research Ethics Committee at the University of São Paulo School of Nursing, in compliance with National Health Council Resolution 196/1996. The collaborators received guarantees that their identity would be preserved. Each participant received a copy of the Informed Consent Term, and another signed copy was filed.
Next, the identified categories are presented: Perceiving bodily transformations; Living with bodily changes; Feelings and sensations in sexual life during pregnancy; Imagining the body and sexuality after pregnancy.
Perceiving bodily transformations
The women mentioned bodily transformations during pregnancy.
The belly is growing now... I gained four kilos and a half. I had lost six at first (Azalea).
Bodily changes related to valued female beauty attributes, like skin and hair, were indicated.
... pimples attacked my face and back... Mine used to be hidden, now all of the blackheads came out. My hair fell out and it's still falling. My hair is really thin here, at the front... (Rose).
They expressed concern that the bodily transformations would be permanent.
Down here (on the chin), there are some pimples and a lot of my hair fell out, I think I'm gonna get bald (Gerbera).
Some changes pregnancy causes were referred to as discomfort, with negative references, entailing unpleasant experiences, such as breast symptoms:
... at first, what bothered me most was the pain I felt in my chest. My breasts were very sensitive (Azalea).
Reports of digestive discomfort and edema were also found:
... I had a lot of nausea, really a lot, besides the nausea I also threw up, so it was really bad; until more or less the fifth month, then, when the nausea stopped I got heartburn, really strong heartburn, I always threw up, always at dawn, it was really bad, now it got better (Azalea).
... when I wake up in the morning I'm all swollen, my face looks like a ball. I look in the mirror and there's that ball Then as the day advances the swelling decreases and then the swelling in my hands and feet is reduced (Daisy).
Living with bodily changes
The women assessed the growth of their abdomen in different ways. Two women considered it positively, while others found it bad and boring, interfering in their daily activities.
I don't find myself ugly, I think that everyone makes compliments, that I even got prettier, so I kind of like it; I prefer it now that the belly is bigger. Before you couldn't see it, I think it got better now (Azalea).
... it also weighs a lot, it wasn't before, but now it weighs a lot. I walk from here to the market and I'm already dying I have to stop while walking, then I walk and stop. I kind of get breathless, then I stop" (Daisy).
Another collaborator, in the sixth month of her pregnancy, mentioned that the growth of her belly and weight gain made her feel increasingly uncomfortable.
It has been kind of annoying, like in the good sense, I mean. It has changed a lot Now, each day, my belly will grow, I'll get heavier, I think that, as from the sixth, seventh month the women starts to feel more bothered (Rose).
Feelings and sensations in sexual life during pregnancy
Most collaborators appointed the sexuality experience during pregnancy solely as sexual intercourse; they did not express other possible forms of pleasure.
What the pregnant women most mentioned was decreased libido, but their partners understood this well.
... I kind of lost desire. At first my desire had increased, but now it decreased a lot, it's totally different; but not for him, he says that he thinks I'm gorgeous with the big belly... (Azalea).
We know that many factors can interfere in the couple's sexual life during pregnancy and can contribute to hamper the relation. To illustrate this assertion, Daisy appointed the lack of desire to have sexual intercourse due to various episodes of vaginal bleeding and low abdominal pain.
The desire decreased too I don't feel much desire no. Sometimes that desire comes up, but five minutes later I don't want anymore. Sometimes it happens that the baby starts to move and I no, stop, stop And then I'm not able to and now it's hurting a lot too... (Daisy).
Often sexual abstinence was needed during the pregnancy, to accomplish a treatment, whether using medication or not, which turned into yet another factor of interference in the couple's life.
There were some days when I was not allowed to have sexual intercourse, on the doctor's order but afterwards I had (Lily).
Pain was also reported as one of the causes of interference in the sexual relationship; besides, one woman mentioned fetal movements during the couple's intimate moment as a factor of interference.
It's really difficult. There's pain at the bottom of the belly, malaise, fatigue (Gerbera)
... First it was good, but now now I can't do anything anymore, because sometimes it hurts,... (Daisy).
Despite knowing that the sexual act does not directly interfere with the fetus, the way the woman perceives the situation causes anxiety and fear of harming the baby.
... there has been some bother due to the belly. So, it's more in my head really, I get anxious, afraid. Kind of restricted, afraid of hurting, which I know has nothing to do with it, right? Fear of hurting and of having some problem. Then my head's all thinking about that. Then there's no way you're going to have sex (Rose).
Imagining the body and sexuality after pregnancy
Participants reported on expectations regarding bodily changes in the puerperium. Fear of not getting one's former body back is reinforced based on other people's information. The women themselves start to experience this process during pregnancy, when unexpected weight gain, stretch marks and cellulites come up. Weight gain appears in the women's testimony merely as a concern with esthetics, to feel well with themselves, in the relation with their husband and with not being replaced by another woman; they do not relate this factor as a health issue for themselves and/or the fetus. Azalea manifests a negative view on the body after birth; she thinks it will get very ugly; perceives that the belly is growing too much and that this will result in flaccidity and stretch marks.
... I think it's gonna get really ugly, everyone says it gets ugly afterwards. Ah I think that well, everyone says: then your breasts will fall, they'll stay like that, it will get ugly, it won't be the same as before and I can see my belly stretch too much and then get very flaccid, full of stretch marks too some have appeared only in the breasts; that's my depressive part of pregnancy (Azalea).
Violet is afraid of getting fat and with a deformed body.
... the only thing is that I'm just scared of getting too much fat, 'cause I'm short and I also have faith in God that I won't get fat after my pregnancy, after I get the baby I don't want to get a deformed body, I hope I won't get stretch marks, nor varicose veins, tears in my breasts of itching, right, 'cause there are many women who get tears (Violet).
Two collaborators display perspectives of getting back to normal and report the need to take care of the body so as not to get deformed and get back better than it was before the pregnancy.
... I think I'll gain some more weight before the end and afterwards I'm gonna try to get better, back to normal, I can say back to normal, because I want it to get back better than it was, 'cause I really intend to take care of myself. I wasn't; I wasn't because I was focused on the house, on kids, on objects... (Lily).
After birth I hope to get thin, without any stretch mark I hope not to get fat after I get the baby, like, during the first month I know that I won't get back to what it was before, I know that doesn't happen, you'll breastfeed, be swollen... (Violet).
Tulip mentions the need for help with physical exercises to loose weight.
After birth I think I'll have to do a Cooper (laughs). I'm weighing 70 kilos, I'm short, while I've got the belly it's OK, but afterwards? From the others I lost 8 kilos; and even walking I lost 8 kilos (Tulip).
Gerbera's concern is with keeping the big belly.
That's my only concern, with keeping the broken belly. I'm not that concerned with the rest, with cellulitis, stretch marks, that doesn't concern me, that's my only concern (Gerbera).
The participants talked about how they think sexual life will be after birth.
I think the delivery won't entail any consequence. No, I don't think so. He doesn't think that it will either (...) birth doesn't influence sexual activity (Violet).
One of the participants told that she heard from some colleagues:
Ah... you get a normal birth, then it gets weird, because with the normal birth the baby will come out, so ah no! then it will get wider, like, the entry, it will get then it will get horrible, it will lose elasticity, that's what I heard from colleagues and women (Azalea).
Another pregnant woman says that sexual life may be somewhat impaired if the child is big or also if some pathological process occurs involving the uterus, which demands its removal.
(...) it can entail consequences for my sexual activity if the child is big... if it's something that aggravates the uterus Because there are some women who, sometimes, depending on the pregnancy, may even lose their uterus or some disease can come up because of that (Lily).
The uterus was seen as an important organ in sexual experience, also according to another participant:
the woman's uterus is like an elastic, it opens to have the child, then it returns, closes, it will get normal again, it will get virgin again, it won't get virgin, because it's not virgin, but it will get as it were virgin again, normal (Violet).
This pregnant woman expects that, after the pregnancy, her sexual life will get back to what it was before:
(...) I only hope that my desire comes back, because I totally lost desire I'm only concerned with that, that I won't get back to normal after birth, like it was before (Azalea).
During the different phases of women's lives, transformations occur in her body and alterations in the way it is perceived, making them feel less sensual and less sexually attractive, because they do not correspond to the culturally disseminated esthetic pattern(14). This study addressed these issues and the participants reported on the perceptions and sensations they experienced in their bodies during the pregnancy.
If, on the one hand, the women expressed their enchantment with the abdominal size, on the other, they reported concern with its exaggerated growth, including the appearance of stretch marks, flaccidness and "broken belly" (local abdominal fat), fearing that these marks will not disappear after the pregnancy. The physical attributes established by the current society have been dictating a beauty pattern women do not always reach and, when they find themselves outside the model due to their pregnancy, they are afraid that these changes will be permanent, which could entail rejection by their partner.
A study demonstrated that some women were affected in their self-image and self-esteem, as a result of the bodily changes during pregnancy that influenced the post-partum. Women in that study also evidenced changes in their behaviors and in the way of dealing with motherhood, appointing differences between pregnancy, when the baby is still being generated, and when, after birth, (s)he is present in their lives; they strongly emphasized bodily transformations though, affirming a negative influence on their sexual life(15).
Today, the valuation of the body and physical beauty have been exacerbated and widely disseminated in the media, imposing the esthetic pattern of "good shape"(4). We verified that, with regard to bodily care, a ritual exists during pregnancy, expecting that the body will return to the pre-pregnancy state. Most collaborators reported weight gain as a causal factor of their image's deformation. Although they refer to a single body, the women demonstrated a division between the body as a mother (during pregnancy), which can be fat, which society naturally accepts, and the idealization of a woman's body after birth, which should be thin and compatible with current esthetic standards.
As for the study participants' bodily transformations, they also reported physical discomfort related to the digestive system and edema, appointed as something negative that affected wellbeing. A study involving 147 pregnant women appoints that the symptoms deriving from the pregnancy period, associated with the digestive system, such as nausea and vomiting, caused limitations in the women's daily lives, affected comfort and also reflected in family members' lives(15).
In this study, most women defined sexuality as a synonym of the sexual act; they reported decreased libido during pregnancy, which the partner understood well. The participants cited some causes that interfered in sexual experiences, such as pain during the sexual act, indisposition, fatigue, low abdominal pain and sexual abstinence. After having experienced this bodily state and the lack of sexual desire, they hope that the body, which felt desire and pleasure before the pregnancy, will return after birth; thus, they seek previous experiences when they were not pregnant to outline their expectations.
The participants reported changes in their sexual life, talked about the fear of hurting or interfering in the baby's vitality, entailing the notion of the sexual act during pregnancy as something that, in certain situations, can be dangerous or harmful. A study about the body and sexuality in the puerperium showed that, when they had sexual intercourse with their partner, many women felt ashamed, concerned and bothered by the presence of the baby. Thus, they see sex as something belonging to the adult phase of life and give the child the place of the sacred and purity, which are cultural values(16).
The process involving pregnancy and motherhood appear as a daily construction in women's lives. Therefore, it is important to get to know the pregnant women's reality and the difficulties faced during this period, so as to find solutions jointly.
Pregnancy is a very important period, which entails physical, psychological and social modifications for women, generates new meanings and demands adaptations. Medical anthropology served as support to understand the meaning of the body and, at the same time, of sexuality for pregnant women, as pregnancy represents a moment loaded with biological and psychological changes, in which social and cultural values are interwoven, significantly contributing to the way each woman experiences this process. This shaped the understanding that pregnancy entails not only (local and systemic) bodily, but also psychological and social changes, so that women seek support in their social network, where the meanings that support their life experiences are born.
These study findings permitted the understanding about body and sexuality changes during pregnancy, supporting care in this aspect of female life. Hence, in any health education proposal, the base should be the women's worldview, their culture, prioritizing life experiences, which is the first step in high-quality care delivery. Understanding the women's experiences becomes extremely important for the development of nursing and midwifery health and teaching actions. By proposing actions for a given population, nursing, as a fundamental element in care delivery, nursing needs to acknowledge sociocultural factors, as each society behaves in a unique way. Therefore, previous knowledge on the community is needed, and also on the meanings attributed to phenomena, which is fundamental to obtain success in the established targets.
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*Taken from the dissertation: "It's the usual life: body and sexuality in the birth process", University of São Paulo School of Nursing, 2009.