Sexuality and breastfeeding: concepts and approaches of primary health care nurses

Abstracts

Este estudo objetiva conhecer as concepções sobre a sexualidade de profissionais de enfermagem que atuam na atenção primária em saúde e identificar como essa temática integra as práticas assistenciais desses profissionais a mulheres nutrizes. Trata-se de pesquisa qualitativa, exploratória e descritiva, cujos sujeitos foram oito profissionais de enfermagem atuantes em três unidades de atenção primária em saúde de município do Norte do Rio Grande do Sul. A coleta dos dados realizou-se via entrevistas semiestruturadas. Para seu tratamento foi utilizada a análise de conteúdo temática, da qual emergiram três temas: concepção sobre sexualidade; a sexualidade e a amamentação; sexualidade e práticas de enfermagem voltadas à mulher nutriz. O estudo permitiu constatar que os profissionais de enfermagem entendem o sentido amplo que a sexualidade representa e a relação que tem com a amamentação, porém não a abordam ao assistirem a mulher em processo de amamentação, sendo suas práticas sustentadas em abordagem biomédica.

Aleitamento materno; Sexualidade; Enfermagem de Atenção Primária

ORIGINAL ARTICLE

Sexuality and breastfeeding: concepts and approaches of primary health care nurses

Alessandra Florencio^I; Isabel Cristina Pacheco Van der Sand^II; Fernanda Beheregaray Cabral^III; Isabel Cristina dos Santos Colomé^IV; Nara Marilene Oliveira Girardon-Perlini^V

^IRN, Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. [e-mail]

^IIM.Sc. in Nursing, University of São Paulo. Teaching Assistant in Nursing at Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. [e-mail]

^IIIM.Sc. in Nursing, Universidade Federal do Rio Grande do Sul. Teaching Assistant in Nursing at Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. [e-mail]

^IVM.Sc. in Nursing, Universidade Federal do Rio Grande do Sul. Teaching Assistant in Nursing at Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. [e-mail]

^VPh.D. in Nursing, Universidade de São Paulo. Teaching assistant in Nursing at Universidade Federal de Santa Maria. Santa Maria, RS, Brazil

Correspondence

ABSTRACT

The objective of this study is to identify the primary health care nurses' concepts about sexuality, and how this theme is integrated within the health care practices of these professionals when working with breastfeeding women. This qualitative, exploratory and descriptive study was performed with eight nurses from three primary health care units in a city in the north region of Rio Grande do Sul state. Data collection was performed through semi-structured interviews. Thematic content analysis revealed three themes: ideation about sexuality; sexuality and breastfeeding; and sexuality and nursing practices aimed at the breastfeeding woman. The study revealed that nursing professionals understand the broad meaning that sexuality represents and the relationship it has with breastfeeding, but they do not approach this theme in the care provided to women engaged in the breastfeeding process, thus their practices are grounded in the biomedical approach.

Descriptors: Breast feeding; Sexuality; Primary Care Nursing

RESUMEN

Se objetiva conocer las concepciones sobre sexualidad de profesionales de enfermería actuantes en atención primaria de salud e identificar el modo en que la temática integra las prácticas asistenciales de tales profesionales a mujeres que amamantan. Investigación cualitativa, exploratoria, descriptiva, cuyos sujetos fueron ocho profesionales de enfermería actuantes en tres unidades de atención primaria de salud de municipio norteño de Rio Grande do Sul. Datos fueran recolectados mediante entrevistas semiestructuradas. Para su tratamiento se utilizó análisis de contenido temático. Emergieron tres temas: concepción sobre sexualidad; sexualidad y lactancia; sexualidad y prácticas de enfermería orientadas a la mujer que amamanta. Se constató que los profesionales de enfermería entienden el sentido amplio que la sexualidad representa y la relación que tiene con el amamantamiento, no obstante lo cual no la aborda al atender a mujeres en proceso de amamantamiento, sustentándose sus prácticas en abordaje biomédico.

Descriptores: Lactancia materna; Sexualidad; Enfermería Atención Primaria

INTRODUCTION

According to the cultural approach perspective, sexuality can be considered an expression of life and is related to all human beings⁽¹⁾. As a result, it is individuality and singularity, originated from a progressive historical-social-cultural, private, dynamic, flexible and contextualized structure. In this context, it relates to each person´s individual concept, which is based on the reference framework of their social-cultural groups. Although it is a physical behaviour, it is not restricted to it, and also relates to the manner in which each person has to think, act, portray themselves, dress, adorn, speak, walk, express themselves, look and feel. It is also sensuality, fondness, affection, touch, communication, closeness, pleasure, sexual act, genitals and sexual intercourse⁽¹⁾.

Despite the fact that it can be seen in a very broad sense, a study involving women participating in a group activity about sexuality showed that this subject relates to demonstrations of affection, expressed by gestures such as cuddling, kissing, hugs, and actions which involve the touch and feel of the partner. These women also recognise the importance of appreciation, understanding and dialogue in a relationship⁽²⁾.

There are still only a few studies approaching nursing professionals' concepts of sexuality, some of which touch on the subject through the views of nursing students. In this context, a descriptive study with a quantitative/qualitative approach, aiming to ascertain the manner in which nursing students regard basic terms to understand sexuality, concluded that 100% of the people involved in the research opted that sexuality relates to the group of special features, physiological or morphological (internal), which are determined by a combination of biological, psychological, social-economical, cultural, ethnical, spiritual and religious factors⁽³⁾.

The approach of sexuality during the breastfeeding process is even rarer and it seems to be a silent and often invisible aspect of women´s health during this period. In the research field, there are only a few publications that specifically approach the relationship between these two topics, and some recent studies have been developed in Brazil and internationally^(4-8).

Despite the lack of research, however, although discussions on the topics are rare, it is understood that, in addition to being fostress – a human being who feeds and assists the development of another being -, women also need to be considered as a whole, including gender, and this also means taking into consideration all the social roles assigned to them – as a woman, mother, wife, caregiver , educator, worker and citizen with sexual and reproductive rights. Under this perspective, whist considering gender issues, an understanding is proposed which goes beyond the imminent biological features and includes aspects of human life, like sexuality and breastfeeding. That is a perception is proposed that these are social practices influenced by culture in a determined context⁽⁹⁾. As a result of these theoretical views, aimed at not separating women and fostress, the expression fostress woman is used when referring to breastfeeding women in this study.

It can be noted that, despite the theoretical discussions and social actions, particularly by women, in the search for recognition of the female citizenship rights, including the practice of their sexuality, health care professionals, amongst them nursing professionals, still find it difficult to treat women holistically. In other words, a person with the capacity to be at the same time a woman, worker and mother, but who also needs a certain amount of time to adapt to the changes of sexuality after childbirth and parenthood⁽¹⁰⁾. This difficulty may be associated with the fact that these professionals are part of the same culture, in which the interfaces between breastfeeding and sexuality almost always remain hidden, if not denied, tying themselves to a web of meanings they themselves contribute to building⁽¹¹⁾.

In order to reinforce the relevance of the approach that sexuality and breastfeeding are an integrated phenomenon, it is important to mention that the breastfeeding act involves at least a pair – mother and child. From the beginning, it supplements not only the nutritional aspects, but also the emotional needs of mother and child and establishes skin-to-skin contact and eye-to-eye contact between the two. Therefore, it contributes to the formation of aspects relating to the child's sexuality⁽¹²⁾, not only restricted to sexual satisfaction but also to the possibility of relationships.

All these considerations permit understanding the importance of sexuality in the care process for fostress women. This can help women to actively adapt to their new social roles that result from becoming a woman-mother.

Based on the above, the importance of seeking answers to the following question is considered: What is the understanding of nursing professionals working in primary health care in a city located in the north of Rio Grande do Sul state about sexuality when dealing with breastfeeding women? Taking this into account, this study aims to understand the conceptions of sexuality by nursing professionals working in primary health care and to identify how this subject affects their care practices towards breastfeeding women.

METHOD

Due to its subject, this study has a qualitative approach with an exploratory and descriptive design^(13-14). The study was carried out at three primary health care units in a city located in the North of the state of Rio Grande do Sul, Brazil. One of them is a traditional primary care unit, well known as a care unit for women, in particular during the pregnancy-puerperal period. The other two are Family Health Strategy units (FHS I and FHS II).

The selection criteria to participate in this study involved participants acting in women's care during the pregnancy-puerperal period and who also belonged to the nursing professional category. Thus, from the eight participants, three worked at FHS I, two at FHS II and three at the care unit for women. The number of participants was chosen based on the concept that the ideal sample is one that reflects the totality in its multiple dimensions and that is sufficient to allow the information to reoccur⁽¹³⁾.

In regards to the participants' qualifications, three are baccalaureate nurses and five are nursing technicians or assistants. From these, seven are female and one is male. With respect to the age group, one participant was between the age of 20 and 30, two between the age of 30 and 40 and five participants were between 50 and 60 years old. The period of time working in the nursing field varied from seven months to twenty-two years.

The study´s ethical issues complied with National Health Council Resolution 196/96 and an Informed Consent Term was made available for each participant to sign. Throughout August 2010, after the research project had been approved by the Ethics Commission at Universidade Federal de Santa Maria, under registration number 23081009907/2010-56, the data was collected using semi structured interviews, which were then taped, transcribed and reproduced for analysis and interpretation. This means that firstly all the recorded verbal statements were changed into a written format, accurately and unchanged; secondly, the questions, repetitions and other elements of the statement were removed in a way that did not compromise the analysis; and, lastly, the statement was recreated by transcription⁽¹⁵⁾. In order to assure the anonymity of the participants, their statements were identified using flower names (Orchid, Rose and Violet are female baccalaureate nurses; the others are nursing technicians or assistants).

In addition to the participants' personal details, the semi structured interviews consisted of the following questions: 1) What do you understand by sexuality? 2) Tell me about your care practice relating to breastfeeding women. Talk freely about this. If the participants did not mention sexuality, two more questions were included (which was the case with all the participants). 3) In your opinion, is there a relationship between sexuality and breastfeeding? Comment on this. 4) Do you address aspects of sexuality in the care delivery to breastfeeding women? If so, in what way and why? If not, why?

The data was analysed by thematic content analysis, and its functionality was broken down into three stages: pre-analysis, data examination and result interpretation. In the first stage, the documents produced during the statement transcription and recreation processes previously described were viewed by way of exhaustive reading, with the purpose of absorbing the information; during the examination, data was arranged into categories, and the text was edited and the registration units were grouped according to their thematic similarities; lastly, during the interpretation stage, the understanding and interpretation of the data were sought and integrated to the theoretical reference involving the theme.

RESULTS

Three themes emerged as a result of the data analysis. The first brings up the participants' concepts of sexuality; the second relates to the link between breastfeeding and sexuality; and the third deals with sexuality and nursing practices directed towards breastfeeding women.

Theme 1: Sexuality concepts beyond the sexual act: set of values and relationships experienced by a person

When questioned about the understanding of sexuality, the participants reveal that this is formed by a set of values and relationships a person experienced.

Well... I understand by sexuality not only the sexual act, but I think that sexuality is women liking themselves, is women seeking pleasure not only in their relationships but also in their lives. I think sexuality is a combination, a whole combination, not only the sexual act itself (Violet)

Based on this type of concept, it can be noted that the participants understand that sexuality does not consist of a sexual act only, but is a complex subject and related to, amongst other components, a deeper understanding by the human being of themselves. This understanding is based on the value of what women and men are, or their sense of own worth, or their perception of other people's perception about them. Therefore, sexuality is related to an auto-valuation and, consequently, to the preservation of self-esteem, to something associated to like your own self.

Sexuality is a very complex term (...). In my view, sexuality means women and men knowing themselves in their entirety (Orchid).

Women, in relation to sexuality, have to like, to know and to value themselves, and to know their limits. For me, sexuality is not only the sexual act and the relationship between men and women (Rose).

The participants also understand that sexuality relates to the way in which people behave, being strictly related to each individual´s attributes and is also present in all stages of life from childhood.

It is present (the sexuality) in the way someone dresses, in the way someone acts, even in the way they use gestures and speak (Tulip).

A girl grows up and develops into a young lady, as I have one at home who is so sweet, each day learning more about life, you know? Discovering a woman´s body, it is wonderful! (Daisy).

Theme II: Breastfeeding and sexuality from the nursing professionals´ perspective: a loving breast for the child

There is an understanding that breastfeeding is intimately related to sexuality. This understanding comes from the concept that breastfeeding can mean a strong connection between mother and child and an expression of affection, familiarity, touch and many other aspects that represent sexuality.

I think that every breastfeeding woman is in an exchange of affection, is in an exchange of love and we can see that they feel great affection (...) Well, as I said before, I think sexuality is in everything! I think if you do, if you are breastfeeding, you are activating your sexuality, isn´t it right? (Violet).

In the views of some participants, the breastfeeding process can be seen as a way of expression and a demonstration of sexuality, as it is related to the relationship between two human beings. It is important to mention, however, that this understanding is associated with sexuality that is established in the relationship between mother and child and separated from the demonstrations of eroticism between a woman and her partner, which are the demonstrations related to sexual desire.

Women spend more time with the babies, that is the way they participate... the husband is set aside a little during the breastfeeding process. I think that they are not really thinking about their sexuality (...), we can notice that they are more focused on the baby during this period (Violet).

I think that for them, the couple, it might be a little... it might be complicated and that the husband's situation... whether they want it or not (...), after a mother has a child, she is always going to be closer to the child (Orchid).

Some of the participants also mention that, during this period, the female breasts are seen by fostress women as exclusively for the baby and that both men and women assign to this organ the sole function of breastfeeding.

But many women, since they are breastfeeding, at least it is what I believe, they think that their breasts belong to the baby and that men cannot touch them. Men also – in this situation think that looking at women´s breasts and then feeling pleasure should not happen as they also think that the breasts belong to the baby, isn´t it right?" (Bromelia).

Theme III: Nursing practices directed towards breastfeeding women and the invisibility of sexuality.

In regards to the participants´ care practices relating to breastfeeding, it is noted that these tend to be limited to caring for the body, in particular the breasts the breastfeeding process seems to be focused on. A large part of the nursing care is provided through guidance, aimed at the successful breastfeeding process.

We advise them to look after themselves. The breasts need to be cared for and hygiene must be done very well, they must have good hygiene (...), we check the nipples to see if they are not hurt, to see if they are not bleeding, we look at all these things, we analyse them (Jasmine).

In this context, it can be stated that the nursing practices directed towards fostress women are, most of the time, in general focused on women's breasts, with the primary purpose of maintaining their integrity and the benefits for the infant.

Despite the fact that the participants understand by sexuality the combination of values and feelings present in all stages of life and that is included in the breastfeeding process, it can also be noted that many of them do not list it amongst the practices related to the fostress and, when they do, it is in a shy and prescriptive way.

No! We rarely talk about it (sexuality), we only ask if they are looking after themselves (using a contraceptive method) (Jasmine)

Many of the participants do not seem to be concerned with offering the women (and their partners) a forum, so they can demonstrate their desires during this period of their lives. There is a trend to consider this stage of life as normal, according to criteria which most of the time originate in academic environments, that is, in a place and time far from the the couple's

We explain to puerperal women that they can return to their active sexual lives after forty days and that it is normal for them to feel pain during the sexual act in the beginning, and that they are gradually going back to being active (Violet).

The nursing professionals state that they do not address sexuality if they are not questioned or asked to approach the theme, remitting the reasons why they do not to the other party – the being who receives care.

The problem is that they do not ask us, they do not comment, they do not speak (...), I do not address the subject, I do not address the subject because it is a cultural issue (Begonia).

Not much, it is not something discussed with women, at least not by myself! Now that you are mentioning this... I have never thought about approaching this issue, and also because nobody has ever asked about it. It might be something that is missing, because nobody has really asked about this, and this is not something often mentioned (Orchid).

The data reveals that the participants have a broad view of sexuality and consider it is part of women's lives but, what the breastfeeding period is concerned, their care practices seem detached from this understanding, particularly in relation to couples' sexual desire. It should be mentioned that Nursing bases its actions on concepts, beliefs and learning about its role in health care for people and groups, which are the guides of professional action. In that sense, nursing professionals could believe that, if women consider sexuality an important issue, they will show their interest when interacting with them. Therefore, if women do not take the initiative, the nursing professionals will not either, assuming that they are not interested. From this perspective, if professional nursing activity is based on this idea, then the issue – breastfeeding and sexuality – will be absent in nursing practices.

DISCUSSION

In this study, the participants' concepts of sexuality meet the results of other investigations, in which sexuality is viewed as something that, in addition to the sexual act, involves love, demonstrations of affection, sensuality, the way people think, act, dress, in short, expressions that are part of everyone's lives^(1-2). This understanding is supported by considerations indicating that sexuality refers to a succession of complex aspects that are not limited to biological factors, but involve countless emotional expressions and historically experienced influences⁽¹⁶⁾.

Sexuality is also viewed as an aspect of life relating to all people, which takes into consideration each person's singularity and involves attitudes and representations; it is originated along with socialization and refers to intra and inter subjectivity, dynamic, flexible and contextualized and, for this reason, developed by all social beings^(1,9). It is, therefore, a hybrid between nature and culture, in so far as it is recognised that nothing is absolutely nature and that culture is always present in it.

The results, in particular the ones showing that, during the breastfeeding period, the breasts are considered the baby's exclusivity and that the care of fostress women is focused on the breasts, particularly aiming to provide breastfeeding conditions and ensure its benefits to the child, might be explained as a consequence of a cultural inheritance from a period of time when the breasts were not erotised, when a functional and alimentary perception of the breasts prevailed⁽⁶⁾. The existence of a cultural trend towards biological and pathological chare practice⁽¹⁾ may explain, at least partly, the practices the participants mentioned which are more strongly directed at preventing and curing specific injuries to the breasts. In addition, the approach to nursing care practices can also reflect health policies' focus on the importance of breastfeeding and on the role of being a mother based on this view, and the content diffused by the media.

Furthermore, the social obligations relating to the exercise of the maternal roles can contribute to the formation of part of the ideology underlying the professionals' concepts and practices in this study. This understanding can be related to the study, in the theoretical framework of the model to take risk or ensure benefits⁽⁷⁾. The author considers that women's sexuality during breastfeeding is changed due to maternity. According to the adopted model, these changes are associated with some factors. Among these factors, emphasis is given to taking on more roles due to the child´s birth, amongst them the role of fostress-mother stands out and which, as a consequence, results in prioritising the child and their health.

The study participants emphasized the exchange of affection and knowledge between mother and child as one of the factors related to breastfeeding which can be linked to sexuality. Based on this idea, it is deduced that the participants understand breastfeeding as a defining factor for sexuality aspects between mother and child. In this perspective, breastfeeding is seen as a facilitator of the link between mother and child because, in addition to the nutritional benefits, it enables closeness and interaction between this couple. A study in this area, aiming to identify the maternal feelings women expressed during intimate contact with their children immediately after birth, showed that, when mothers feel their children's face in contact with their breasts, they see breastfeeding as a reunion, something beyond the breastfeeding act, an act capable of reuniting the child's body to the mother's⁽¹⁷⁾.

Based on theme II, it is noted that, under the participants' views, the relationship between breastfeeding and sexuality is related to the expression of love between mother and child, which contributes for the care practices to be focused on this area – the couple mother and child. As a result, the infant is the focus of care for the breastfeeding mother, and this can be justified, amongst other reasons, by the child's socio-cultural value in western society, which was originated in the mid-17^th century⁽¹⁸⁾. Besides the child's value and the view that breastfeeding is the interaction between mother and child, the care practices seem to consolidate, in particular, in the biomedical model, which was a social invention originated around the same period that childhood was created and which still strongly influence the health care practices⁽¹⁹⁾.

Despite the fact that pregnancy and breastfeeding cause countless changes to women's body, when overcoming the biomedical model, it is important to consider that these changes are broader and more complex and also relate to the changes in the social roles attached to maternity, which are demands beyond a breastfeeding body. Thus, performing the maternity role, in which breastfeeding is included, and still recognising themselves as women demands knowledge and understanding of themselves, which can be a result, at least in part, of health educational programs promoted by nurses and strengthened by other nursing professionals, as a discussion forum about the relevant aspects of sexuality is provided ⁽²⁰⁾.

It should be noted that all the care practices relating to the breastfeeding process the participants mentioned are important and need to be taken into consideration in care delivery to fostress women, but they are not the only aspects to be considered. In order to break up with established and decontextualized knowledge, it is important to develop care practices which view fostress women in their totality and support the acknowledgement of their complexity, their particularities and their needs, involving biological, psychological, cultural and social aspects, including sexuality^(20-21).

The results, based on this study´s care practices, show that maternity brings up a sexuality in which the eroticism between women and their partners is not taken into consideration, since the breasts are considered the child´s exclusivity, and it is strong enough (in a socio-cultural sense) to subordinate women´s desires that are absolutely not related to the child. Based on this, the care practices developed inside the culture of the group involved in the study, breastfeeding and sexuality have no interface in its erotic aspects.

The fact that sexuality cannot be seen, touched, and is completely subjective and abstract can be part of the reason why the health care professionals do not know of or find it of little value in their care practices⁽²⁰⁾, and this seems to be the case for this study's participants. When relating the findings of this study with theoretical support, it can be noted that, while holistically assisting a woman who becomes a mother, it is necessary to consider that being fostress is only another role that she plays in that moment of life and it is important to mention that the issues relating to sexuality in its various expressions constitute essential matters nursing professionals need to address, particularly nurses⁽²¹⁾.

CONCLUSION

In response to the study objectives concerning sexuality concepts, the findings show that the nursing professionals view sexuality as a combination of factors which are part of the human being in its interaction with another human being and themselves, and has a strict association with breastfeeding, since both are formed by factors that permit the inter-relationship between two human beings and are based on affection, touch and several other aspects. There is an understanding that, when taking on the new conditions imposed by maternity, and also taking on breastfeeding when desired and possible, women are exercising and stimulating their sexuality through countless interactions involved in the process and showed by way of touch, affection, feelings and the relationship with the baby.

From this point of view, based on the cultural webs in which the nursing professionals and the women they care for build and entangle themselves, the results of this study show that the breasts, the maternity symbol, is only for the child and link women during the puerperal period to the priority exercise of some maternal functions, in this case breastfeeding, and exclude sexuality, particularly in its erotic aspect.

Also in response to the objectives of this study, the participants reveal that the care practices directed towards breastfeeding women are primarily aimed at ensuring the achievement of breastfeeding and are focused on the biomedical findings that take into consideration the biological and physiological aspects of breastfeeding directed to the body, in particular the breasts, aiming to prevent injuries to the nipples and consequently the child's well-being. Within this culture, sexuality seems absent in nursing care, in particular when it is attached to erotic matters.

The importance of nursing professionals to consider women in their different social functions should also be emphasized – as a mother, fostress, wife, worker, that is, women who have lives beyond their children. In these terms, efforts to include breastfeeding women's partners in nursing care seem necessary. For this to happen, the creation of health education centres is suggested – an example are group activities involving couples, aiming to provide spaces for listening, dialogue and knowledge exchange, seeking to approach the meanings and feelings relating to maternity and sexuality.

In order to achieve this, the theme sexuality and breastfeeding in its different interfaces needs to become part of nurses' education, from their graduation to their professional practice through permanent education. Based on this type of project, the nurses who take on their duties in health care would be likely to have a more complete understanding of its users and would be able to assist with the development of this service, turning them into potential spaces for listening and assistance to women's, men's and children's demands –human beings with relationships.

It can be pointed out that a weakness of this study is the joint analysis of the information issued by the baccalaureate nurses, nursing technicians and assistants, due to the fact that they have different academic backgrounds and duties which can, in theory, result in different concepts and practices and point to the development of new studies.

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^*

Sexualidad y amamantamiento: concepciones y abordajes de profesionales de enfermería de atención primaria de salud

¹

. As an example, advice about the couple's need for sexual abstinence during the puerperal period was mentioned.

Publication Dates

• Publication in this collection
  30 Jan 2013
• Date of issue
  Dec 2012

History

• Received
  14 Feb 2012
• Accepted
  31 Mar 2012