Sexual Experience of Iranian Women in Their Middle Life: A Qualitative Approach.

BACKGROUND: Sexual problems are common among the middle-aged women; however, there is no deep understanding of sexuality in midlife. The current study aimed to investigate Iranian women's attitudes and experiences about sexual life changes in midlife.
METHODS: This is a descriptive qualitative study. Seventeen women aged 40 -65 years old were purposively selected from urban health centers in Gorgan, Iran, in 2015. Face-to-face, semi-structured and in-depth interviews were conducted for data collection until data saturation was attained. The resulting data were analyzed based on Graneheim and Lundman's approach. MAXQDA 10 was used for organization of data.
RESULTS: Data analysis demonstrated seventh sub-themes and three themes. The emerged themes were entitled (1) "Continuous paradox over being a sexual agent" with three subthemes of beliefs on asexuality as socially accepted view for women in midlife, changing in motivation for sex and changing in sexual performance, (2) "Considering menopause; opportunities and threats for sexual life" with two subthemes of menopause related cons for sexual life and menopause related pros in sexual life, and (3) "Coping strategies for changes in sexuality in midlife" with two subthemes of different psychological reactions to changes that have influenced the sex and take practical steps for restoration of sexual attraction.
CONCLUSION: The findings demonstrated that middle-aged women in a male-dominant culture encounter paradox over being a sexual agent. In a bio-psycho-social approach, they perceived menopause as an opportunity or threat for their own sexuality. Following the conflicts, threats and changes of sexuality in midlife, they adopt diverse coping strategies to improve their sexual relationships and preserve their family.

INTRODUCTION

Midlife is a unique period; its features are distinct from other age groups.[1] It is believed that middle age begins at age 40 and ends at 60 or 65.[2] By 2050, women older than fifty years old will constitute about one fifth of the global population.[3] Alike the global pattern, Iran’s older population is growing due to increases in the average life expectancy, too[4] so that 8.5 million 40-64 year old women are living in Iran, based on Population and Housing Censuses 2016.[5]

Sexual health is physical, emotional, mental and social welfare in sexuality.[6] Several bio-psycho-social factors affect female sexual function in the middle age.[7] Although the majority of middle-aged women considered sexual activity important in their life,[8] in many cultures, sexuality for older women is less welcomed.[9] Such social expectations negatively affect the sexual health of middle-aged women.[10] For instance, in Iran with a male-dominant context, with priority of male sexual fulfillment,[11] women limit sexuality to childbearing years and consider menopause as the time to say goodbye to the sex and feminine world.[12,13] On the other hand, in conflicts over the importance of sexual relationship to preserve a marriage, and lack of access to sexual health care services, middle aged women benefit from ineffective coping strategies.[12,14] These conditions could accompany with high prevalence of female sexual dysfunction and impairment of quality of life.[14]

Most studies on sexuality in the middle-aged women have been done through medical and quantitative approaches;[7,15] they focused on menopause and sexual dysfunction.[16,17] And quantitative studies could not provide a deep understanding about women’s sexuality and its changes in midlife.[15,18] However, the results of qualitative studies are complex and converse.[8,19] For instance, middle aged women participating in a study describe their sexual desire as a response both to male request and hormones; there are both acceptance and rejection of asexuality; and they consider sexual activity both risky and safe in midlife.[8]

Understanding of women’s experiences and perceptions about sexuality in midlife can help policymakers and health providers to provide appropriate, effective and culturally-based sexual healthcare services.[6] Also, sexuality as a symbolic issue[20] should be addressed in each social context.[6,20] The present study aimed to investigate Iranian women’s perspectives about sexual life and its changes during midlife using a qualitative approach.

MATERIALS AND METHODS

A qualitative descriptive design with conventional content analysis was conducted between April and October 2015.

Seventeen middle-aged women living in Gorgan City participated in face-to-face interviews. Gorgan is the capital of Golestan provinces, located in the northeast of the country south of the Caspian Sea, Iran.

40-65 year-old healthy women who were interested in talking about their sexual and marital relationships were included in the study. Exclusion criteria were having any disabling conditions, uncontrolled chronic diseases and or undergoing induced menopause.

Purposeful sampling with a maximum variation in terms of age, education and economic status was performed. Informed middle-aged women, who had family files at health care centers affiliated to Golestan University of Medical Sciences, were invited by the assistance of midwives who worked in those health centers.

All of the interviews were done by the main investigator who is a female PhD candidate of Reproductive Health. She participated in related courses about qualitative research and had active interaction with her supervisors who were expert in qualitative research. In qualitative health research, in-depth interview is best for sensitive subjects,[21] such as sexual health. Hence, semi-structured in-depth interviews began with an open-end question “please talk about your marital relationship”. We used a general[21] and more well-known question because talking about sexuality in Iranian culture is very hard and shameful, especially with middle-aged and elderly people.[12] And then probing questions were employed according to the participant’s dialogues, to extract more details and to clarify the interviewees’ explanations and examples. Note-taking during interview was used for directing the interview and data analysis. Interviews continued until data saturation was achieved and subthemes and theme were emerged, so in the two last interviews no novel idea or subtheme was achieved.

All of the interviews were held in a private and calm place in a selected health center, placed in the center of the city. All of the participants were interviewed once, except one case that participated in a supplementary interview. None of the participants refused to participate in the study. Every interview lasted about 50 minutes (30-70 min), and was held in Farsi.

The current study was approved in the Research Council and Ethics Committee affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran with ID number SBMU2.REC.1394.18. Written and informed consent was given by all participants and all interviews were recorded with the consent of participants.

As data on the subject of the study were fragmented and disperse, inductive content analysis was used.[22] The data analysis process was performed continuously and concurrently with data collection and based on the Graneheim and Lundman’s approach.[23] At first, interviews were transcribed verbatim, unit of analysis was chosen, and then each interview text was reviewed for several times to achieve a general understanding of their contents. Then, the context was divided into meaning units; meaning units were condensed while preserving the main concept; condensed units were labeled on by codes (e.g. Table 1) data were categorized and the subthemes were made via comparing similarities and dissimilarities of codes in order to provide a description about the phenomena studied, increase understanding, and make knowledge about it; and finally latent content of subthemes were formulated to a theme (Table 2). It is worth mentioning that although this process was explained in a linear approach, the process of data analysis was a forward and backward movement between the whole context and its parts.[23] Authors reflected on the findings continually and discussed on disagreements until reaching consensus. MAXQDA 10 software was used for organization of data.

Table 1

Examples of meaning unite, condensed meaning unites and codes

Meaning unite	Condensed meaning unites	Codes
“I use a gel for the firmness of my breasts on the day that I’m going to have [sex] relation with my husband, because men usually do not like the loose things”	Firmness of breasts by gel to satisfy spouse	Seeking cosmetic and cosmeceutical routs for repair or beautification
“most of women as old as mine, have [sexual] needs, but they don’t speak about it”	Not expressing sexual needs	showing non willingness to be sexual

Table 2

Examples of meaning unite, condensed meaning unites and codes

Theme		Continuous paradox over being a sexual agent	Considering menopause; opportunities and threats for sexual life	Coping strategies for changes in sexuality in midlife
Sub -theme		1. asexuality as socially accepted view for women in midlife	1. Menopause related cons for sexual life	1. Different psychological reactions to changes that have influenced on sex
		2. changing motivation for sex	2. Menopause related prons in sexual life	2. Take practical steps for restoration of sexual attraction
		3. Changing in sexual performance
Codes	S.C.1	- showing non willingness to be sexual	-Being concern about negative reactions of spouse to menopause	-Denial of midlife changes
		- believe that Sexual activity is suitable for youth	- Menopause as a restriction for reproduction	-role playing in sexual relationships
		- unacceptability of remarriage for middle aged women	-Complications of menopause	-Justifying midlife Changes
		Disregarding the sexual needs for middle aged women by significant others
	S.C.2	- Having excitement during sexual relationships similar to youth	-Having no concerns about unwanted pregnancy in sex	-Seeking cosmetic and cosmeceutical routs for repair or beautification
		- desire for having sex	-Relief from menstruation symptoms and troubles	-Seeking surgical interventions for repair or beautification
		-Decline in sexual desire
	S.C.3	-No change in sexual relationship
		-Increase in hedonism and arousal
		- attempt to experience sex such as young couples

Rigor

Lincoln and Guba’s trustworthiness criteria were considered in all steps of the study. Credibility was increased by providing a detailed description about the participants, data analysis and results, using face-to face interviews, sampling via the assistance of four midwives in order to choose informed participants. For dependability, research report was presented so that other inquiries can easily trail the decisions made by the researchers. Providing some quotations related to every subtheme confirmed the objectivity of the findings. Some suggestions were provided for generalizability of findings.[24] The consolidated criteria for reporting qualitative studies (COREQ) were considered for reporting of the current study.[21]

RESULTS

Demographic characteristics of the participants are shown in Table 3.

Table 3

The demographic characteristics of the participants

Variables	Category	N
Age (years)	40-65	17
Marital life duration (years)	Married and divorced: 5-47	16
	Single participant: 0	1
Having sexual activity	Married	14
	Divorce and single	3
Educational level	BS.cb and more	4
	Diploma	8
	High school and less	5
Menopausal statusa	Post-menopausal	8
	Early menopausal	7
	late menopausal	2
Employment	Housewife	12
	Employed	5
Religiosity	Shiae’	14
	Sonni	3

As defined by Stages of Reproductive Aging Workshop -STRAW

Bachelor of science

Three main themes emerging during data analysis were: “Continuous paradox over being a sexual agent”, “Considering menopause; opportunities and threats for sexual life” and “Coping strategies for changes in sexuality in midlife” (Table 2).

1. Continuous Paradox over Being a Sexual Agent

Participants’ descriptions about what is socially accepted and what is their sexual wishes and performances were categorized into three subthemes.

1-1. Asexuality as socially accepted view for women in midlife

Most of participants show non-willingness to be sexual even if they were sexually active. “The majority of women as old as me do not talk about their sexual needs; they are hindered by modesty” (65 years old, 10 months after her second marriage).

Some women considered sexual relationships specific to the period of younger age. “I consistently thought that the pleasure of sex ended by frothy and then no one would be in the mood for such things” (50 years old, 35 years of marriage).

1-2. Changing motivation for sex

Sexual motivation is someone’s desire to participate in sexual activity and what she/he wants to do in sex.[25] Contrary to the asexual representation of the middle-aged women in society, most of the participants were interested in having active and pleasurable sexual relationships. Some women also wished they could behave like young couples in their intimate and sexual relationships. “I like to do what young people do in their relationships” (65 years old, 35 years of marriage).

The changes in sexual desire were almost predictable based on the context of marital life and couples’ interactions. A participant who was upset for her spouses’ neglect and dictatorship during the first decades of marital life stated: “After my fifties, I have become as hard as a stone and I have no feeling for my husband” (50 years old, 35 years of marriage).

1-3. Change in sexual performance

Sexual performance refers to what individuals do in sexual relationships.[25] The participants’ experiences regarding changes in sexual activity were divergent and related to contextual factors. Some participants who were concerned about common beliefs about older women’s asexuality considered themselves sexually comparable to young married women. “I think I am as those newly married women” (46 years old, 23 years of marriage).

Some stated more experience and less shame in relation with their spouse making sex more pleasurably in midlife:“I believe that sex gets better when one gets older, because she gets more information and experiences” (43 years old, 21 years of marriage). “Now, modesty [hojb’o haya] has disappeared for me, so sometimes I’m the initiator” (60 years old, 40 years of marriage).

2. Considering Menopause, Opportunities and Threats for Sexual Life

The participant’s attitude toward midlife and sexual relationship was between positive to negative, depending on expectable advantage and disadvantages of menopause.

2-1. Menopause related cons for sexual life

Some women were worried about the negative attitude of their spouses about menopause, so they even did not inform him. “When I reached menopause, I didn’t talk about it because some men think that when a woman get menopause, she loses her sexual desire” (52 years old, 32 years of marriage).

Some believed that menstruation has positive effects on women’s health and menopause causes many diseases; as a result, they had a negative attitude toward menopause. “I don’t like to reach menopause because it is frequently said that menopause causes sore legs and backache. Monthly period removes the toxins accumulated in the women’s body during a month” (46 years old, 23 years of marriage).

As reproduction was assumed as a goal of sex in heterosexual relationships, for women who intended to have children, menopause was an unpleasant event. They know menopause as an alarm for finishing childbearing opportunity. “You know, everything is over for me, I couldn’t have even one baby” (48 years old, Single).

2-2. Menopause related pros in sexual life

Some women considered menopause as an opportunity to get rid of unwanted pregnancies, contraception issues and more peace of mind in the sexual relationship. “I believe that sex gets better after menopause because you are no more worried about unwanted pregnancy” (51 years old, 26 years of marriage).

Also, some women feel free from menstruation troubles and restrictions such as forbidden vaginal intercourse during menstruation. “There is no limitation for us; we can have sex every time we decide”. (60 years old, 40 years of marriage).

3. Coping Strategies for Changes in Sexuality in Midlife

The last emerged theme was about how participants deal with the double-inconsistent situation in aging and sexuality. It encompassed two sub-themes.

3-1. Different psychological reactions to changes that have influenced sex

In order to go through changes arising from aging and menopause, some participants denied or positively justified the postmenopausal changes. “I wasn’t changed, (she stresses)… for me, vaginal roughness acts alike barbed condom. It helps my husband ejaculate faster”. (52 years old, 32 years of marriage).

Playing the role of a young woman during sex was another strategy among some of the middle-aged women. “I try to act as I did when I was young; in this way, my husband knows that I’m still fresh enough to satisfy his needs” (60 years old, 40 years of marriage).

3-2. Take practical steps for restoration of sexual attraction

The majority of the participants referred to their different attempts to increase their sexual attraction. In this regard, some mentioned look at the appearance via clothes, make up, cosmetics and cosmeceutical interventions on the face and body. “I care for my appearance. I did liposuction last year and get a face massage every week” (45 years old, 15 years of marriage).

A number of participants were about to have pelvic prolapse repair and deemed repair and surgery necessary to attract their husbands. “At present, I have cystocele. I’m seeking to have [a repair] surgery” (57 years old, 42 years of marriage).

DISCUSSION

The findings of this study challenged the common views regarding asexuality of the middle-aged women. In the present study, being asexual was a socially accepted script for middle-aged women alike other male-dominant cultures.[8,15] Thus, participants to comply with androcentricity and older women’s asexuality norms encounter a continuous paradox over being a sexual agent. They imitate to be unwilling to have sex and hide their sexual needs in public even whilst they are sexually active. Similarly, U.K women’s challenge to align with “old women asexual scripts” and their sexual desire resulted in “counter-narratives” in a qualitative study,[26] and British middle-aged women deemed asexuality undesirable for themselves and admissible for older women.[8] Therefore, this inconsistency is the feature of women’s sexuality in midlife.

According to our study, despite the repressed sexuality in outward, some middle-aged women acted less modest and more actively in their sexual relationships. However, some other reported less motivation and activity. It is difficult to break up the role of bio-psycho-social factors on sexuality, but it sounds that interpersonal scripts such as partners’ characteristics[26] and the context of relationship[15] were as important as biology in middle-aged women’s perception about sexual behavior changes. As indicated in a study, in the evaluation of sexual problems of old age women, it might be explored that “not being with the right person” rather than aging and hormonal deprivation was the real reason of the problem.[26]

Most of the participants had a positive attitude and were motivated to have sexual relationships, but their attitude about the effects of menopause on sexuality was divergent. Consistent with another study, women’s attitude about menopause was dependent on the expecting advantages and disadvantages of menopause.[17] Unlike the results of the current study, in a cross-sectional study, more than half of postmenopausal women had a negative attitude toward sex.[27] A point worth considering is that more than 80% of women in the aforesaid study had sexual dysfunction and the trade-off between these two variables can lead to an overestimation of women’s negative views. In other words, women’s negative attitudes might be aroused from unpleasant and problems of sexual experiences during menopause such as vaginal atrophy and dyspareunia. Therefore, menopause could be perceived in a range of between “a physiological phenomenon” and “deprivation of femininity”[13] based on how bio-psycho-social factors influence their sex life.[15] Helping women to overcome wrong beliefs and successfully adapt with climacteric and aging changes could result in more positive sexual perceptions.[28]

In the present study, some women were concerned about their spouses’ reaction to the menopause. Similarly, one study reported that women’s concerns about how to deal with their male partner’s complaints about vaginal atrophy was a reason for poor relationships in midlife.[15] However, in contrast to that study, our participant’s concerns were not the partner’s sexual complaints, but it was aroused from male negative attitude that consider menopausal and aged women unsexy and good-for-nothing. Our participants perceived that as a threat for the stability of the family. This situation not only deprived middle-aged women of their husbands’ support to get along and cope with the changes of this critical period,[29] but also the significance of having sexual attraction and as a result preservation of the family[14,30] was a source of fear and worry.

The findings of the present study indicated that women for adjustment to sexual changes had negative psychological reactions such as denial, role-playing and justification and sometimes took some steps to improve their appearance. In a study, English menopausal women used role-play and fake-orgasm for sexual satisfaction of male partner.[15] In a qualitative study in Iran, Middle-aged women who were concerned about own inability to fulfill their husband’s sexual needs gave up their own right to be compatible with husband’s sexual needs.[14] Also, another study reported that Thai midlife women occupied themselves with work, family and religious activities.[19] Generally, in a deal with paradox and threats of sexuality in midlife, women apply divergent coping approaches. It could range from “sex-ignoring” as a most ineffective to “negotiating with partner” as the most effective strategy.[8,14,15,19] Our participant’s strategies might be classified into the middle range strategy.

Exploration of the middle-aged women’s sexual life experiences using a qualitative approach was the strength of this study. But sexual health is a sensitive research subject, which might dispirit the participants to express themselves overtly; however, all of the women participated voluntarily and had enough assurance for the private interview. Although the generalizability of the findings is not an attribute of qualitative studies, the findings might be generalized whether logically or theoretically.[23]

The results of the current research can be a basis for future research in a different socio-cultural context with more variable samples. In addition, concerning the gender-based differences in sexual behaviors, it is suggested that some studies should address the middle-aged men, the spouses of the middle-aged women and healthcare personnel. The result of such studies could help health policy makers, health care providers and all those involved in promotion of sexual health of the middle-aged people.

CONCLUSION

This study showed the perspectives of middle aged women’s sexual life in a male-dominant and family centered culture. The findings reflect that women have a continuous paradox over being a sexual agent in midlife. Following the conflicts, threats and changes of sexuality in midlife, they adopt several coping strategies to preserve and improve their sexual relationships. Submission of ineffective coping strategies suggests the necessity of counseling and education for women in order to better accept and cope with sexual changes in midlife.