Sexual expectations and needs of middle-aged women: A qualitative study.

BACKGROUND: Securing a healthy sexual relationship during middle-agedness would cause new needs and expectations in women, considering the special changes of this period. Therefore, the present study was conducted to determine the sexual needs of middle-aged women.
METHODS: The present study was a qualitative study with content analysis approach. Participants were 15 middle-aged women; their expectations and needs about sexual relationship were gathered using in-depth semi-structured interviews. Data were analyzed using Graneheim and Lundman inductive content analysis.
RESULTS: The main themes that were appeared in the present study included "the need for information" with subcategories of "the need for information about physiologic changes" and "information about psychological changes;" "the need for sympathy" with subcategories of "the need for receiving appropriate feedback" and "appropriate space for expressing the emotions;" "the need for changing social norms" with subcategories of "accepting middle-agedness by the society" and "the need for changing the concept of femininity;" and finally "the need for repairing the sexual relationship" with subcategories of "solutions for solving sexual problems" and "paying attention to the new aspects of sexual relationship."
CONCLUSIONS: Results showed that middle-aged women have various sexual needs and expectations and paying attention to these needs and expectations could affect the improvement of the sexual and mental health of middle-aged women and their families.

Introduction

Facing middle-agedness is a crisis in human's life which is accompanied with more changes and complications in women compared to men.[1] Having multiple responsibilities during this period, menopause and its side effects, changes in the appearance and the body, weight gain, retirement and financial problems, empty nest syndrome, onset of chronic diseases, and disturbed sexual relationship are some of the common changes in women during middle-agedness.[234]

The collection of these changes and disorders would negatively affect the quality of life, women's ability to cope with the changes of this period, and their sexual relationship and could disturb the health of middle-aged women.[5] Therefore, sexual health, as a part of the reproductive health, is a strategic need for achieving the Millennium Development Goals.[5]

The correlation between couples’ good communication and proper sexual relationship during middle-agedness with women's quality of life has been proven.[67]

Karaçam et al. in a study conducted on aggravating factors for menopause symptoms and quality of life in Turkish women reported that the quality of sexual relationship during middle-agedness could be considered as an important factor in their mental health and quality of life during middle-agedness.

Appropriate sexual relationship with the spouse is dependent on individual's lifestyle, recognition of one's self as a human being, and others’ attitude and manner toward them, and since sexual relationship is associated with society, culture, and values more than any other activity, it would affect all the aspects of women's life, especially during middle-agedness.[8]

Obermeyer in a study about the effect of culture on women's menopause reported that messages that women receive during the middle age from their society could be effective on their emotions, sexual relationships, and quality of life.[8]

Appropriate sexual relationships with the spouse could lead to finding an appropriate adaptive pattern with the changes during this period, and it has an important role in the mental health of women and the family.[9]

Although women still have sexual needs during their middle age, physical and mental changes during this period might affect their expectations and needs; expectations that mostly will not be expressed under the pressure of the cultural context. Since in Iran, like most of the traditional societies, sexual matters would not be discussed due to their cultural taboo, mostly, expressing women's marital and sexual needs is considered a challenge.[1011]

Hence, Ramezani et al. in a study about related factors to sexual dysfunction among Iranian women stated that lack of fulfillment of sexual expectations in Iranian women is considered a related factor to occurrence of sexual dysfunction.[10] Hoseini Tabaghdehi et al. in their study about related factors to occurrence of sexual dysfunction in Iranian women suggested that the development of interpersonal relationships between couples and paying attention to their sexual expectations could decrease these disorders.[11]

Furthermore, understanding the sexual needs of middle-aged women, as an ultimate goal and purpose in preventive interventions, improvement of health, and optimal distribution of health care among this group, could be effective.[1112131415]

So far, many national and international studies have been conducted regarding different aspects of reproductive and sexual health of middle-aged women, but no studies have evaluated the marital needs of these women and described its components. Therefore, the present qualitative study was conducted to determine the sexual needs and expectations of middle-aged women in Iran and to describe its components.

Methods

The present qualitative study was conducted with qualitative content analysis approach. This study was approved by the ethics committee of the Isfahan University of Medical Sciences by ethical code: IR.mui.rec. 1394.3.256.

Samples for the present study were selected using purposive sampling method. Participants were middle-aged women who referred to the health centers of Isfahan, Iran, to receive health-care services. The age of the women ranged from 35 to 60 years; women who were willing to participate in the study and were able to describe their experiences, emotions, and expectations were included in the study; women who were all speaking Persian, living in Isfahan, and married and living with their spouses at the time of the study were included in the study. Data were gathered using in-depth semi-structured interviews and observation at private environment, which was prepared by the presence of the researcher for in-field observation, interviewing and reporting at the health centers of Isfahan.

During the interviews, the changes in the face and body of the participants that could determine their emotions toward the subject were observed, and the time of expressing the mentioned changes relative to the start time of the interview was recorded. These signs were written in parentheses at the time of transcribing the interviews to achieve a better understanding of the text for the researcher. All of the interviews were conducted by the researcher. All of the interviews were recorded with participants’ permission, and for two participants, due to lack of time, interviews were completed at two stages.

After each interview session, the researcher transcribed the entire interview, notes, and in-field observations. Accurately listening to the words of the participants, confidentiality of the information, respecting the participants, and showing sympathy during the interviews were the principles that regarded at all the stages of the study. The researcher tried to make an appropriate communication with the participants, and after explaining the goals of the study, he/she obtained participants’ consent for participation, recording the interviews, and re-interviewing, if needed.[15]

All of the participants were allowed to withdraw from the study at any desired time. The main questions that were repeated in almost every interview were as follows: What changes did you encounter in your sexual relationship during middle-agedness? What are your sexual needs and expectations during middle age?” The interviews were continued using phrases such as “please explain more.” Duration of the interviews varied from 45 to 90 min, and the number of samples was not determined at the beginning of the interviews; finally, interviews ended by theoretical saturation of conceptual classes after interviewing 15 participants during 11 months.

Data were analyzed using Graneheim and Lundman inductive content analysis.[16] Each interview was analyzed right after ending. At the first step of analysis, each interview was considered as a unit of analysis. All of the interviews were transcribed verbatim, and to find the main themes and meanings of the texts, all of the texts were repeatedly reviewed before coding. At the second step, words or phrases that were related to one concept or were gathered around one central conceptual unit were considered as a meaning unit or coding unit.[16]

At the next step, condensation was performed meaning that the size of the text was reduced while maintaining its meaning until condensed meaning that units or primary codes were achieved. Then, at the abstraction step, by researcher's understanding or rational analysis of the primary codes, they were labeled and abstracted or inferential codes were extracted. At the fourth step, after inferentially forming the codes, similar codes were merged into each other and codes with similar concepts were categorized with each other and formed the subclasses. In fact, categories were inferentially formed from raw data and the researcher used comparative method for forming the categories, and then, by comparing the subclasses with each other, similar classes were merged with each other. This was continuously performed by comparing the classes against the entire data, and eventually, using inferential method, similar subclasses were categorized into main classes.

To assure the reliability and validity of the study's data, which are called rigor and trustworthiness in qualitative study, member check method was used. The extracted codes were read to two middle-aged participants. Furthermore, other methods such as prolonged engagement, deep appropriate relationship and dedicating sufficient amount of time, and time integration were used. Furthermore, the results of the study were given to the researcher's peers for reviewing and approving the results.[17]

At the revision step, all of the extracted codes were approved without any changes. To provide transferability of the data, participants were selected with maximum variety from different socioeconomic classes, different educational levels, and different groups (considering their job, place of residence, educational level, and social, economic, and ethical status).

Results

In the present study, 17 eligible middle-aged married women were invited for participation and data of the study were gathered and saturated through 17 interviews conducted with 15 participants. The mean (standard deviation) age of the participants was 48 (3.1) years. Table 1 represents the characteristics of the participants.

Table 1

Demographic characteristics of the participants

After analyzing the data of the study, 398 primary codes were extracted, and after condensation, 134 inferential codes, 16 subcategories, 8 subclasses, and 4 main classes were achieved. The achieved main classes were “the need for achieving information,” “the need for sympathy,” “expecting changes in social norms,” and “the need for repairing the sexual relationship,” which represented sexual needs and expectations of middle-aged women [Table 2].

Table 2

The main classes, subclasses and abstracted sub-categories

Main Class 1: The need for achieving information

The need for achieving information was one of the main classes, which was emphasized by most of the participants. Most of the women mentioned that increased awareness about physiologic changes during middle age and also recognizing the psychological changes of middle age would make them have a more relaxed sexual relationship, knowing that some of the occurred changes are natural.

Information about physiologic changes

Many of the participants mentioned their physical changes during middle age with concern and some of them were worried about which of these changes are natural. Many of them needed to gain information from a reliable source. In this regard, participant no. 9 mentioned (P9):

“Well, I don’t know exactly whether my vaginal dryness is natural at this age or not. This matter has affected my sexual relationship, but if I hear it's natural from a reliable source, then I would be assured.”

The need for learning principles of health protection after the occurred changes during middle age was also mentioned by some of the women and they were willing to learn about self-care especially regarding sexual relationship during middle age. A 50-year-old woman stated that (P3):

“To have a healthy sexual relationship, you should be healthy. We should learn how to take care of our health after the changes in our physical system during middle age so that we could have a healthier relationship.”

Information about psychological changes during the middle age

Having information about the psychological changes of men and women during middle age was another concept that was mentioned by most of the participants. The need for understanding psychological changes, which are experienced as the middle age crisis by the individual, was mentioned as one of the needs that might affect sexual relationship. In this regard, one of the women said (P8):

“My husband has not learned about what women would experience during middle age. He does not know about my hot flushes and my state of mind. It is obvious that our relationship, our sexual relationship, would be disturbed.”

Some of the participants mentioned that they were expecting to gain better communicational skills and consequently experiencing better sexual relationship, following awareness about psychological changes during middle age. One of the participants mentioned (P14):

“I feel that if a physician or a psychiatrist would assure me and my husband that these changes in our mood and sexual desire are natural, then we would be relaxed and understand each other's condition better. Then, we would be able to have a better personal relationship, and obviously, we would have a better sexual relationship afterwards.”

Main Class 2: The need for sympathy

Husband's sympathy was one of the needs, which was mentioned by most of the participants as one of the aspects of healthy marital life. In an empathic relationship with their husband, they expected to receive appropriate feedback to the middle age changes that have occurred for them and they were searching for an opportunity to express their feelings about these changes to their sexual partner.

Expecting to receive appropriate feedback

Many of the women in their empathic relationship with their spouses were searching for a feeling to approve that the physical and psychological changes that have occurred to them during middle age are understood. Accepting and understanding the occurred changes in women by their spouses, in the view of many women, would lead to an appropriate feedback that might be effective in improvement of their sexual relationship. A 46-year-old participant said (P13):

“I want my husband to understand such a terrible feeling could be caused by menopause. I want him to show it in his behaviors that he shares my feelings. This way, I would feel he is closer to me.”

In this regard, another woman mentioned (P2):

“By his behaviors or jokes, my husband has shown me that my loosened body or that I don’t have periods anymore are not important to him. This would make me feel really good. I would even feel more desired for having a sexual intercourse.”

Creating appropriate condition for expressing the feelings

Following an empathic relationship with their husbands, some of the participants were looking for an environment to express their disturbed feelings about the occurred changes during middle age freely and to create that environment they needed to have confidence in their husbands. They believed that expressing the feelings was a sign of intimacy with the husband that could lead to a better sexual relationship. In this regard, one of the participants mentioned (P5):

“Sometimes, I tell to myself how good it would be if my husband would ask me to go for a walk together and then he would be so close to me that I could easily tell him if I accept his suggestion for sexual intercourse less than before it is because I am ashamed of him to understand that my breasts and body have loosened.”

Another woman said (P4):

“I wish me and my husband were so intimate that I could easily tell him after menopause, my sexual desire has decreased. Maybe then, we could both try and reach a conclusion for improving our sexual relationship.”

Main Class 3: Expecting changes in social norms

Based on the perceptions of some of the participants, one of the factors which is effective in people’ opinions about the concept of femininity is the dominant social norms of the society that are mostly rooted in the culture and traditions. Some of the participants mentioned the need for changes in these social norms. Women's perception of these social norms was effective on their adaptability with changes during middle age and could form one of the aspects of a satisfactory sexual relationship.

Accepting the changes during middle age by the society

The value burden that society would refer to the concept of middle-agedness is effective on the positive belief of people about this period. Many of the participants stated that their adaptability with the physical and psychological changes of middle-agedness is dependent on the value of middle age concept by the society. They believed that it is necessary for the society to have a positively valuated approach toward the changed roles and responsibilities of women during middle age. Society's positive approach toward middle-aged women would give them an acceptable and valuable image for them and their spouses which could be effective in improvement of their sexual relationship. In this regard, one of the participants stated (P6):

“For example, the fact that in our society when a woman get older, it is not appropriate for her to wear any color she wants or puts on any kind of makeup she wants, would make you to repeatedly remind yourself that you are no longer the same spirited and attractive person anymore. So, consequently, your sexual desire would be decreased during the middle age.”

New approach toward the concept of femininity

Some of the women mentioned that, in the society, the concept of menopause is considered a kind of weakness which is effective on the concept of femininity during the middle age. Furthermore, the definition of beauty which is presented by the media should be changed so that middle-aged woman could also fit in that description and could have sexual relationship with a positive belief about their femininity. In this regard, one of the women said (P12):

“My colleagues and relatives were talking about menopause in a way that I already believed after menopause, bone pains and reluctance toward sexual intercourse would definitely occur. They have even told me that do not tell your husband that you have become menopausal; hide it from him. I was in a condition that I, myself, limited my sexual relationship because I believed that it was the natural course after menopause.”

Main Class 4: The need for repairing the sexual relationship

Another mentioned need was the need for repairing the sexual relationship. Most of the middle-aged women stated that they would like to experience satisfactory new sexual relationship with their spouses during this period. They were looking for a source to solve the occurred sexual problems and mentioned that despite changes such as decreased sexual desire and vaginal dryness, it is still possible to experience sexual relationship with new aspects and concepts and feel satisfied.

The need for improving the quality of sexual relationship

Considering the physical and psychological changes during the middle age and decreased sexual desire in women, many of them mentioned that they wanted to improve the quality of their sexual relationship and regarding their current physiology experience a new kind of relationship. Many believed that over years, their sexual relationship has become boring and monotonous and were willing to enjoy sexual relationship with their spouses in a new way which is more adaptive with their current body system. In this regard, one of the participants said (P10):

“My pelvic and bones are a little painful after menopause. I also have vaginal dryness. Having sexual intercourse the same as always is no longer pleasant for me. I would like my husband to learn new ways so that less pressure would be on me. This way, I would also have a chance for enjoying myself.”

Paying attention to new aspects of sexual relationship

Although women had experienced changes such as vaginal dryness and decreased sexual desire during the middle age, which were effective on the quality of their sexual relationship, they mostly believed that if their spouses would consider having sexual intercourse without being concerned about becoming pregnant as an advantage, it would help improving the quality of their sexual relationship. Furthermore, some of them believed that couples should change their beliefs about sexual relationship during the middle age and should look for a different type of relationship than the passionate sexual relationships during the youth. They considered peace as the purpose of sexual relationship during this period and not just experiencing the passion and pleasure. They believed that changes in this concept could lead to experiencing better sexual relationship among most of the middle-aged couples. In this regard, one of the participants stated (P4):

“During our youth, although sexual intercourse was pleasant, it was associated with the stress of pregnancy. I think now I and my husband need to lie down besides each other and remind ourselves that it is time to experience sexual intercourse without the stress of pregnancy. I think we both need this peace in our sexual relationship.”

Discussion

The present qualitative study was conducted to determine the sexual needs and expectations of middle-aged women. In data analysis, four main classes of “the need for achieving information,” “the need for sympathy,” “expecting changes in the social norms,” and “the need for repairing sexual relationship” were extracted.

”The need for achieving information” was one of the main classes that was extracted from content analysis of the middle-aged women's statements. It seems that awareness about the physical and psychological changes during the middle age and becoming sure of the natural course of these changes would decrease women's anxiety and make them adapt with the changes during this period more peacefully; consequently, accepting the current conditions would lead to the improvement of their sexual relationship. Previous studies have also shown that stress and emotional problems are effective in the quality of sexual relationship during the middle age.[1218]

Different studies have shown that when the middle-aged do not have a positive approach toward their physical and health condition, their sexual performance would be disturbed.[161718]

Cuadros et al. have shown that insufficient knowledge in middle-aged women would cause negative approach toward their physical and health condition and their sexual performance would be disturbed.[18]

It has been reported that increased awareness about the physiologic aspects of reproduction and sexual changes during different periods of life would increase sexual satisfaction.[19]

Kim also reported that sexual health during each period of life has its requirements which are directly related to the individual's information and awareness.[20]

Another main class of the present study was “the need for sympathy.” Participated women stated that they expected to receive appropriate feedback from their spouses about their changes during the middle age.

Valadares et al. also reported that women's body image and sense of attractiveness would decrease during the middle age and would disturb their sexual life. However, accepting the changes during the middle age by the spouse and understanding their current condition would lead to increased positive feelings toward oneself and improved body image in women, which are effective in improvement of sexual relationship.[21]

Burri et al. reported that positive body image in middle-aged women is predictive of their sexual satisfaction. Statements of the participants in the present study indicated that for having an empathic relationship with the spouse and improving the quality of sexual relationship, middle-aged women would require having a more honest and confident space between themselves and their spouses; they considered the need for intimacy as one of their sexual needs during this period[22] which is in line with the results of the present study.

Multiple studies have indicated that intimacy and love between the couple would increase individual's health in different aspects.

It was also revealed that individual's sexual performance during the middle age is directly related to different aspects of emotional relationship with the spouse,[23] which confirms the results of the present study.

Changing social norms about the changes during the middle age was also one of the main expectations of women in the present study. According to the participants, individual's approach toward the changes during middle age is greatly dependent on the social norms. Therefore, it is necessary to create a positive approach toward menopause and women's roles during the middle age through acculturating. Furthermore, the need for changing the definition of beauty in the media, in their opinion, along with the mentioned factors, caused women to have a better feeling about middle-agedness and their current conditions and body and so initiate sexual relationship with more desire. Valdez et al. reported that the messages that the middle-aged receive from the society would affect their dissatisfaction with their current physical condition.[24] In addition, it has been approved that sexual activity, more than any other activity, is involved with culture, society, and emotional values.[25] Unfortunately, in some societies, women's value and attractiveness are only defined by their reproductive ability.[26] In this regard, George reported that menopausal women are considered less valued in the societies due to their inability for reproduction.[27] However, results of the study by Aumer revealed that society's culture could induce individuals to consider attractive and this matter could affect their sexual relationship and satisfaction.[28]

It was also revealed that individual's sexual performance during the middle age is directly related to different aspects of emotional relationship with the spouse,[24] which confirms the results of the present study.

Changing social norms about the changes during the middle age was also one of the main expectations of the women in the present study. According to the participants, individual's approach toward the changes during middle age is greatly dependent on the social norms. Therefore, it is necessary to create a positive approach toward menopause and women's roles during the middle age through acculturating. In addition, the need for changing the definition of beauty in the media, in their opinion, along with the mentioned factors, caused women to have a better feeling about middle-agedness and their current conditions and body and so initiate sexual relationship with more desire.

Valdez-Hernandez et al. in their study reported that messages that the middle-aged receive from the society would affect their dissatisfaction with their bodies and could also be effective on their sexual dissatisfaction.[24]

Furthermore, Hvas has reported that sexual activity, more than any other activity, is involved with culture, society, and emotional values.[25] Unfortunately, in some societies, women's value and attractiveness are only defined by their reproductive ability.[27] In this regard, However, results of the study by Aumer revealed that society's culture could induce individuals to consider attractive and this matter could affect their sexual relationship and satisfaction.[28]

Another result of the study indicated the need of middle-aged women for “repairing their sexual relationship.” Some of the women stated that they needed to learn new sexual skills to create diversity in their sexual relationship and resolve their current sexual problem.

Woloski-Wruble et al. in their study showed that middle-aged and even elderly women are willing to continue their sexual activity by repairing their sexual relationship, and this would increase their satisfaction with life.[23]

In the present study, women stated that they needed to achieve new aspects of sexual relationship by experiencing sexual relationship without stress and changing the concept of sexual relationship.

Kim reported the effect of interventions for sexual relation repair on improving the style of sexual relationship in the middle-aged for improving their quality of life has already been reported.[20]

The physiologic changes in the reproductive system such as vaginal dryness are associated with sexual pain that could make sexual relationship dissatisfactory if other needs that could increase sexual stimulation would not be provided.

Although this study was aimed to determine the needs and expectations of middle-aged women, in the conducted interviews, separating women's sexual needs and expectations from their emotional needs which are caused by aging was not possible in some cases; this was one of the limitations of the present study.

Conclusion

Considering the effect of sexual health on individual's mental health, it is necessary for the policy makers and providers of women's health to create an appropriate context for educating the middle-aged women to understand their sexual needs. Furthermore, it is recommended to perform similar studies about the sexual needs of men during middle age so that a more accurate program would be developed to richen the relationship of the couples.

Financial support and sponsorship

The study was financially supported by Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.