Women's sexual health challenges a psychological perspective...

1. Challenges in Obstetrics and Gynaecology
- Psychological Perspective
By
Dr. K. Kumar,
Psychologist
Center for Improving Relationship
and Personal Effectiveness
Women’s
sexual health

2. Changing body and changing the self
Mind body relationships
•Negative attitude towards sex and sexual organs.
•Freud's psychoanalysis theory turning point to new
perspective.
•Role of repressed sexual desire on physical and
psychological health.
•New social studies of sexuality have challenged the idea
of sex as natural.
•Aim is to provide improved care for women patients.

3. Major Transitions
Each transition there is a change, and
psychological challenge
• Menstruation
• Pregnancy
• Menopause
And also covered..
•Sexual violence against women

4. Menarche
• Transition from child to adult…
• first menstrual cycle…

5. Trend in Puberty
Century Age
19 the century 15 - 17
20 the century 13 - 16
21st century 11 – 15
Current study 10 - 14
Early menarche (between 10 & 12 years of age),
Ideal menarche (between 12 to14 years) and
Late menarche (between 14 to16 years of age).
the age at which menarche occurred gradually dropped

6. Early Menarche
Brings many negative consequences…
• Less prepared for changes
• Have more negative feelings
• Poorer body image
• Low self-esteem
• Greater physical symptoms
• More eating related problems
• Experience more emotional conflict
• Increased incidence of childhood obesity
• Risky sexual behaviour and early pregnancy

7. Adjustment depends on
• Age at time
• Amount of preparation
• Cultural factors
• Role model of mother, peer, older sister
• Psychological marker

8. Consequences that girls don’t like
• weight gain
• pimples
• oily skin
• body odor
• temper and anxiety
• confused about sex

9. Late menarche
Ideal leads to better adjustments
They shared some common characteristics…
•Larger family size
•Warmer, supportive and low stress family
•Low fat level, dancer, athlete or regular exercise
•Closer and positive relationship with father
•Have a older siblings
•Open communication within the family including
fathers presents
•Improved health & life style

10. Premenstrual syndrome (PMS)
More than 200 different symptoms have been associated with PMS, but the
three most prominent symptoms are
– irritability,
– tension,
– dysphoria (unhappiness).
Common emotional symptoms
– stress,
– anxiety,
– insomnia,
– headache,
– fatigue,
– mood swings,
– increased emotional sensitivity.
Physical symptoms
– bloating,
– abdominal cramps,
– constipation,
– joint or muscle pain.

11. Premenstrual syndrome (PMS)
Predictors
•Attitude
•Expectation
•Experience
•Role model

12. Pregnancy
• Second major transition to woman

13. Pregnancy
Pregnancy is a time of profound biological, psychological, and interpersonal
change in the lives of many women.
Adjustment depends on
• age,
• health,
• socioeconomic resources,
• work or occupational status,
• Availability of social support,
• birth history, and
• whether the pregnancy is planned or desired.
• Personality factors
• Family dynamics
• Other stress factors

14. Teen pregnancy
• Adolescents appear to have increased risks for
certain potentially serious conditions during
pregnancy, including
•pregnancy-induced hypertension,
•anemia,
•preterm delivery,
•Abortion
•having low-birth-weight infants.

15. Maternal Stress
High levels of life-change stress and
maternal anxiety increase a woman’s risk of
reporting at least one complication during
pregnancy. Effect of stress such as
• decreased uterine activity in labor,
• a longer duration of labor, and
• lower newborn Apgar scores
• Childs future adjustment

16. Acceptance
The results indicate that the women is less
prepared for childbirth and motherhood when
acceptance of the pregnancy is low, and she is
more likely to have conflicts and fears
concerning labor, and to have a longer duration
of labor.

17. Evaluating Acceptance
Characteristics such as:
1. Consciously planned and wanted the pregnancy
2. Happy versus depressed during the pregnancy
3. Degree of discomfort during the pregnancy
4. Accepted or rejected changes in her body,
5. Was ambivalent and experienced conflict

18. Effects on pregnancy
Discomfort such as morning sickness and
some vomiting through the 5th month; these
episodes occasionally triggered short-lived
negative feelings, but she still enjoyed being
pregnant.

19. Effects on pregnancy
Several women were depressed above and beyond the expected mood
swings during their pregnancies; when depression occurred in
these cases, it was not short-lived.
They may think or feel
•anxiety about motherhood,
•the trials of labor and delivery,
•depression concerning bodily changes,
•possible infant anomalies,
•isolation in their new role, and
•career interruption.
•mothering ability,
•childrearing responsibilities
•Financial security

20. Effects on pregnancy
The degree of discomfort experienced during
pregnancy can be another indicator of a woman’s
acceptance of the pregnancy.
It is important to evaluate the following factors:
•Intensity of the discomfort,
•Interferes with normal activity,
•Managed and tolerated.

21. Sleep Disorders
It is normal for sleep patterns to be altered during
pregnancy. The most common pattern consists of longer
sleep and more naps in the first trimester, normal sleep
in the second trimester, and numerous nighttime
awakenings in the third trimester. Frequent awakenings
toward the end of pregnancy are partly caused by
•increased urinary frequency,
•pain,
•fetal movements, and
•difficulty finding a
•comfortable position

22. Role of social support
The significance of the pregnant woman’s relationship with
her mother has been emphasized in the literature as an
important factor in adaptation to pregnancy and
Motherhood. A positive relationship with the mother also
predicted successful adaptation to pregnancy. Predicting
factors are,
• availability
• reactions to the pregnancy
• willingness
Coping skills and communication are important
factors in interpersonal relationships and the
adaptation to pregnancy.

23. Role of social support
What she needs from others
(a) Empathy (understanding, tolerance, supportiveness)
(b) Cooperativeness
(c) Availability (sharing and communication)
(d)Trustworthiness (reliability)
Predictor of marital bond
(a) Closeness
(b)Conflicts
(c)The husband’s adjustment to his new role, specifically
his identification of a fatherhood role.

24. Role of social support
Preparation for Labor
(1) Doubts and fears
(2) Level of confidence
(3) trust the medical-nursing staff

25. Depression
Mild to moderate symptoms of depression are relatively common during
pregnancy, in a woman’s life it is most vulnerable period.
Depression can impair the
• mother’s nutritional intake and prenatal care,
• Using potentially harmful addictive substances, drugs
• Suicide attempts.
Postnatal depression is an affective disorder lasting more than 2 weeks,
• Depression reduces a woman’s ability to function
effectively at home or work
• Impair relationships with family and friends.
• Behavioral and emotional problems in children.

26. Depression
• Diagnosing depression can be more difficult
during pregnancy because insomnia,
decreased energy, decreased concentration
and appetite changes are common to both
pregnancy and depression.
• Untreated antenatal depression significantly
increases the likelihood of postpartum
depression.

27. PTSD
1) women with histories of sexual abuse whose traumatic
memories are reactivated by the experience of pregnancy
and childbirth
2) women who develop posttraumatic stress disorder as
a result of traumatic childbirth experiences
3) women who develop both posttraumatic stress disorder
and pregnancy because of a rape, abuse and sexual violence.
Even with no preexisting trauma history, childbirth itself is a
sufficiently traumatic experience for some women that it
produces symptoms of posttraumatic stress disorder.

28. Maternity blues
Maternity blues typically begin 3–4 days after
delivery and peak on days 4–5. The most
frequently reported symptom is weeping. In the
first few hours after delivery, crying may be
accompanied by happy feelings.
women described themselves as “low spirited”
they did not consider themselves to be
depressed.

29. Maternity blues
Researchers have also described
• irritability,
• lack of affection for the baby,
• hostility toward the husband,
• sleep disturbance,
• headaches,
• feelings of unreality,
• depersonalization,
• exhaustion, and
• restlessness
Dramatic changes in hormone and electrolyte balance and fluid
volume level occur during labor and the postpartum period.

30. Perinatal loss
Recent longitudinal, prospective studies indicate
that at 6 months after pregnancy loss, women
report significantly greater distress, such as
•anxiety,
•physical complaints, and
•especially depression

31. Effects of Perinatal loss
Shock
Confusion
Memory lapse
anxiety,
restlessness,
irritability,
somatic distress.
sadness,
Preoccupation
loneliness,
guilt,
anger,
Hopelessness
Over the next year, the parents gradually become reconciled to this
permanent loss; everyday activities are resumed, vigor in other relationships
and the world in general is renewed, and capacity to feel pleasure is restored.

32. Perinatal loss aftermath
• Flashbacks of the hospital experience,
• intense anxiety on returning to the hospital,
These feelings may take the form of tired,
bored, numbness and angry behavior or of
somatic complaints.

33. Infertility
The stigma associated with infertility and the ensuing feelings of
• Shame
• Failure
• Worthlessness
A series of feelings experienced by many couples,
– Denial
– Anger
– Isolation
– Guilt
– Grief
Some couples may fail to resolve the problem and continue to seek new
treatments, even after every potentially beneficial method has been tried.

34. Infertility
When infertility affects a marriage, a key area
that often deteriorates is sexual functioning and
enjoyment.
• Negative effects on the sex life
• lessened sexual desire
Most investigators have found that women tend
to be more distressed by infertility than are
their male partners.

35. Menopause
Menopause is both a natural and a universal event in
the human female life cycle. Psychological symptoms
have been associated with menopause are,
• Depression
• Irritability
• Mood swing
• Accelerated weight gain
• Fatigue
• Elevated stress

36. Menopause
Certain life stresses may be temporally linked with
menopause.
•Major illness or disability in her spouse,
•Death of her spouse,
•Employment uncertainty for either partner,
•The need to care for one’s own elderly parent(s), loss of
support from important friends or family through illness,
death, or geographic relocation.
•Adolescent children
•Empty nest syndrome
•10%–85% decrease in sexual interest.

37. Sex related Diseases
Psychological distress
• Anger
• Anxiety and fears
• Depression
• Helplessness
• Guilt
• Future childbearing and fertility,
Similar feelings experienced patients diagnosed
with life-threatening illnesses, such as cancer.

38. Consequences
• Family relationships and reproduction
• Impaired social functioning
• Sexual functioning
• Work
• Existential issues
• Suicidal feelings

39. What is our role if..
Patients present personal problems like
sexual difficulties, partner and family conflicts,
stressful life events, Sexual violence, abuse,
How can the health professionals respond to
these demands and problems?

40. Violence against women
Sexual violence is a serious public health and human rights
problem with both short- and long-term consequences on
women's
– physical,
– mental,
– Sexual
– Reproductive health.
Greatest risk of sexual and physical violation will come from
someone a woman knows and trusts a parent, a caretaker, a
person she is dating, or an intimate partner and teachers.

41. Forms and contexts of sexual violence
• Rape
• unwanted sexual advances
• sexual harassment
• Demanding sex in return for favours
• Sexual abuse
• Forced marriage
• Including the marriage of children
• Denial of the right to use contraception
• Forced abortion

42. Symptoms
Often the abusers prevent their partners from receiving medical care.
Women trapped in abusive relationships may be immobilized by
– Depression
– Panic attacks
– Acute stress disorder, or PTSD
Don’t ignore the following symptoms
– Sleep and appetite disturbances,
– Fatigue, dizziness,
– Weight change,
– Physical symptoms associated with depression,
– Anxiety, or posttraumatic stress.
– Suicidal ideation or attempt
– History of mental illness or disability

43. Educate them
Anyone seen in a clinical setting should be asked
specifically about past and current abuse. It is important
to let women know that
• Abuse experiences are common.
• You are willing to listen.
• You believe her and are concerned.
• The abuse is not her fault and no one deserves to be
treated that way.
• Resources are available to help her if she is currently in
danger.
• She will not be judged or stigmatized as a result of what
she has said to you.
• All information will be kept confidential

44. Patient-centered communication
Patient-centered communication: In patient-centered communication, the patient
gets space and time to tell her story (narrative). The questioning is much more of
a Socratic dialogue with reference to the patient’s expression and feedback.
There is respect for and response to emotions.
• Waiting: Giving the patient time to think and express herself. This means that the
physician has to learn “not to talk” but use silence and pause as a means of
encouragement.
The basic elements of patient-centered communication are as follows ;
•Active listening: The health provider learns to listen in a way that encourages
the patient to tell her story by
• Echoing: Repeating a specific word or expression of the patient to
signal attentive listening and that the physician follows the patient’s
story.
• Mirroring: Reflecting body language or a whole verbal sequence in the words
of the patient.

45. Summary
• Each transition involves changes and challenges, most
of the women successfully cope up with the demands.
• Physical, Psychological distress or temporary, if lasting
for more than 2 weeks other factors such as stressful
life event or abuse other factors has to be checked and
provide extended help.
• Not only physical but also psychological help is
essential.
• Sometime health provider is the only source for her,
learn to do more than what you believe, you can

46. Recommended Readings
Books
•Psychological Aspects of Women's Health Care; The Interface Between
Psychiatry and Obstetrics and Gynecology, Edited by Nada L. Stotland,
&Donna E. Stewart. American psychiatry press.
• Psychological aspects of women's health care: the interface between
psychiatry and obstetrics and gynecology., by Jayne Cockburn & Michael E
Pawson. Springer.
Web resources
Psychosocial Aspects of Selected Issues in Women’s Reproductive Health:
Current Status and Future Directions
http://www2.warwick.ac.uk/fac/med/study/ugr/mbchb/phase1_08/semes
ter2/healthpsychology/integration/reproductive_health.pdf
Early life circumstances and their impact on menarche and menopause
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287288/

47. About CIRPE
CIRPE - Center for Improving Relationship and Personal
Effectiveness is a NGO which provide psychotherapy
and counselling services for individuals, couples or
groups experiencing emotional difficulties.
Services:
Creating awareness
Counseling
Training
Research

48. Thank you
Reach me @
www.kumarmahi.com