Reflections on sexuality during the climacteric

Abstracts

Estudo qualitativo de abordagem fenomenológica, realizado a partir do depoimento de mulheres entre 48 e 55 anos que haviam apresentado menopausa espontânea há 12 meses ou mais. Os resultados evidenciaram cinco categorias temáticas que foram analisadas e interpretadas à luz do referencial teórico filosófico de Maurice Merleau-Ponty. Dentre as categorias que emergiram dos depoimentos destacou-se o tema: "refletindo sobre a sexualidade", que será apresentado com o objetivo de compreender os aspectos existenciais da vivência do climatério com ênfase no exercício da sexualidade.

climatério; menopausa; saúde da mulher; sexualidade

Se trata de un estudio cualitativo de abordaje fenomenológico, realizado a partir del relato de mujeres con edad entre 48 y 55 años que habían presentado menopausia espontánea hace 12 meses o más. Los resultados mostraron cinco categorías temáticas que fueron analizadas e interpretadas con base en el marco teórico filosófico de Maurice Merleau-Ponty. Entre las categorías que surgieron de los relatos sobresalió el tema" Reflexionando sobre la sexualidad" que será presentado con el objetivo de comprender los aspectos existenciales de la vivencia del climaterio con énfasis en la sexualidad.

climaterio; menopausia; salud de la mujer; sexualidad

ARTIGO ORIGINAL

Reflections on sexuality during the climacteric¹

Roselane Gonçalves^I; Miriam Aparecida Barbosa Merighi^II

^IPh.D., Faculty, Escola de Artes, Ciências e Humanidades da Universidade de São Paulo, Brazil, e-mail: [e-mail]

^IIFull Professor, Escola de Enfermagem da Universidade de São Paulo, Brazil, e-mail: [e-mail]

ABSTRACT

Qualitative and phenomenological study based on reports of women between 48 and 55 years old with spontaneous menopause for 12 months or more. Results evidenced five theme categories that were analyzed and interpreted based on Maurice Merleau-Ponty's theoretical-philosophical reference framework. Among the categories that emerged from reports, the theme "reflecting on sexuality" was emphasized, and is presented with a view to understanding the existential aspects of the climacteric experience, focusing on the exercise of sexuality.

Descriptors: climacteric; menopause; woman´s health; sexuality

INTRODUCTION

One of the phases of women's life cycle is the climacteric, characterized as a passage from the reproductive to the non-reproductive phase, during which the woman's organism has to adjust to different hormonal and emotional environments. In this phase, menopause occurs, which is the permanent cessation of menstruation through a period of 12 months of amenorrhea, deriving from the loss of the ovaries' follicular function and is a mark in the climacteric. Menopause is a natural biological event that can occur spontaneously or be induced through medical intervention, such as bilateral oophorectomy, chemotherapy and pelvic radiography^(1-3).

The signs and symptoms caused by the climacteric include atrophic manifestations of the genitourinary tract system, such as itching, vaginal dryness and dyspareunia. A study carried out with 456 women between 45 and 60 years old showed that the frequency of urinary incontinence related to the climacteric period was approximately 27.5%, with higher prevalence in women in the pre and perimenopause. Dyspareunia and vaginal dryness were less frequent, though more prevalent in the postmenopause period. These symptoms frequently occur between four and six years postmenopause and are related to hypoestrogenism. Approximately 30% of women in this study reported alteration in their sexual life in the last 12 months. Of these, 22% reported diminished sexual interest regardless of the menopausal period. This was the most frequent situation and predominated in the peri and postmenopause, while 66.4% of women had an active sexual life. Of those with an active sexual life, 82.2% reported orgasmic sexual relations. We highlight that women living with their partners present higher prevalence of genital complaints than those who do not. This fact might be explained by the fact that they have a partner and, consequently, greater sexual activity, which would give them a better perception of their low genital tract⁽⁴⁾.

The authors of the study mentioned above state that there are multiple factors affecting sexual expression. The relative influence of the interaction between hormonal and psychosocial determinants and aging itself are not clearly designed. They stress that heat waves, sweating and atrophic vaginitis are the only symptoms described as resulting from hypoestrogenism. A different explanation should be given to other symptoms that are usually attributed to estrogen deficiency or listed as part of the climacteric syndrome⁽⁴⁾.

Professional involvement in women's health motivated this study, which aims to understand the climacteric experience⁽⁵⁾. Results reveal five theme categories, which were analyzed and interpreted in the light of the theoretical-philosophical reference framework of Maurice Merleau-Ponty. Among the categories that emerged from the reports, the theme reflecting on sexuality is highlighted and presented in this study, aiming to understand existential aspects related to the climacteric experience, focusing on the exercise of sexuality.

METHOD

A qualitative phenomenological research design was chosen because it provides the necessary support to understand the phenomenon being a woman experiencing the climacteric, and also because the authors believe that the phenomenological framework embraces human existence in its totality, thus offering the opportunity to interpret an experience.

In this study, seven reports were obtained from women between 48 and 55 years old who had presented spontaneous menopause for 12 months or more and were experiencing the climacteric, regardless of profession, education level, race, life habits, use of hormonal reposition therapy, among others. These variables were not employed as selection criteria because we believe these would not interfere in the results. The criterion age range was defined according to literature, which states that the reproductive cycle phase in which women usually observe the occurrence of menopause is between 48 and 52 years of age. However, in the search for potential participants for this study, a high incidence of hysterectomized women in the pre-established age range was found and, because we believed this fact would affect results, the age range was extended to 55 years of age. Individuals who were submitted to surgical procedures that could interfere in the spontaneous occurrence of menopause were avoided.

Women were contacted depending on the researchers' knowledge and information from other people about the existence of these persons. Data collection in climacteric care services was avoided because women who were already involved in medical treatments would probably have their attention focused on physiopathological aspects related to this phase of life.

Interviews were scheduled and carried out between November 2004 and January 2005. Encounters were planned and places were chosen by the women themselves. Some reports were obtained in households and others in the participants' workplaces.

In compliance with the recommendations of Resolution 196/96 on guidelines and standards for research involving human beings, women were informed about the study objectives and confidentiality and anonymity were assured, as well as their right to choose to participate in the study or not. After clarifications, participants were asked to sign the free and informed consent term in order to participate in the scientific research. Their reports presented in the text were identified with fictitious names. The research project was approved by the Research Ethics Committee at the University of São Paulo at Ribeirão Preto College of Nursing (Process 412/2004/CEP/EEUSP).

The following guiding question was used to obtain the reports: tell me what the climacteric experience is like for you.

The number of women participating in this study was defined by the descriptions themselves. The decision to stop looking for new individuals was based on the set of collected data that evidenced both richness and comprehensiveness of the meanings contained in the reports. In this perspective, seven reports were addressed and considered sufficient to answer the authors' concerns and, consequently, unveil the phenomenon.

Aiming to unveil the phenomenon of the climacteric experience, the analysis procedure recommended by Josgrilberg was used for analysis. According to him, this procedure of analysis aims to approach the description/phenomenological interpretation of the obtained data, that is, detect Units of Meaning (UM) that emerge from discourse, group and categorize them, and perform a re-reading as from the existential categories contained in the adopted philosophical framework as leitmotif of the data analysis⁽⁶⁾.

As already mentioned, it should be noted that, among the themes that emerged from discourses, the theme reflecting on sexuality is highlighted and presented next.

RESULTS AND DISCUSSION

The term sexuality represents a set of values and body practices culturally legitimated in the history of humanity. It comprises not only sexual activity and its biological dimension, but also encompasses the intimate and relational dimension that composes people's subjectivity and their relations with their peers and with their world. It involves body perception and control, the exercise of pleasure/displeasure, as well as values and behaviors in affective and sexual processes⁽⁷⁾.

Because it is such a complex issue, sexuality is usually a topic little valued by the health team. It may be due to lack of knowledge or difficulties in addressing the issue, since dealing with this topic implies knowledge about one's own limitations and problems. Some authors state that health professionals are also part of a socioeconomic and cultural context in which knowledge and practices related to the health-disease process linked to sexuality collide with moral and social issues. Thus, it might justify so little conversation, research and texts about it^(8-9).

Other studies also appoint that, when one addresses the theme sexuality, several aspects in the complexity of people's lives are reported. These aspects are not restricted to the biological view but reflect the whole emotional expression of their experience and, at the same time, incorporate the influence of the historical moment experienced^(10-11).

Biological aspects of sexuality, however, considered natural, are overvalued, while others are considered cultural factors, subject to geographical, historical, temporal and spatial differences⁽¹²⁾. Considering time and space, it is highlighted that both are concomitantly experienced and inhabited by all beings, who invariably live in relation to each other. In this inter-relation, they experience pleasures and feelings that nurture and re-feed existence, while the experience of pleasure is as necessary as other vital organic functions⁽¹³⁾.

Merleau-Ponty conceives affection as a mosaic of affective states, pleasure and pain closed on themselves, which oftentimes do not understand each other and can only be understood through bodily organization. This perception is formed in a world and not in a conscience. Thus, sexuality is about intentionality that follows the general movement of existence with power of meaning⁽¹⁴⁾.

In women's biological cycle, everything they acknowledge about themselves is unveiled through their experience in the world in the face of historicity. In this study, women assigned several meanings to sexuality, overcoming barriers and re-signifying some "truths" related to sexuality and quality of life in the climacteric.

To exercise sexuality, a woman has to acknowledge the bodily space and her body acting in this space, making herself present in the world. This can be achieved in the encounter with the other. Living sexuality presupposes reconsidering our role in human existence and placing it at the root of feelings of being-for-itself and being-for-the-other⁽¹⁴⁾.

In the quest to experience pleasure, Tique trailed paths of successes and failures and reveals, as follows:

There was a time [...] that I took it (sex) out of my life because of problems I had in my first marriage [...] I resumed my sexual life afterwards. So I was never very excited about it; I've always hesitated...[...] after the climacteric [...] I've hesitated even more... [...] My husband is a nice person, is affectionate [...] he may not be a nice person the rest of the day, but at that moment he does everything that has to be done [...] so I get excited [...](Tique).

We infer from this woman's report that the movement of existence towards the other, the future and the world can begin at any moment. The reason to exist can be found when one opens up to the other, to the past, when one allows to be permeated by co-existence. It is always possible because, even being absorbed in the body experience and in the solitude of sensations, one does not suppress the reference that there is life in relation to the world. For this reason, reflecting on sexuality and the experience of pleasure involves the experience of the body and not only of a specific moment⁽¹⁴⁾.

In this overlapping of the other on us, of us on the other, we can observe a bond that goes beyond the usual relationship and is characterized by the need for satisfaction of sexual pleasure. This need is latent in all individuals and in some moments in life, because of physical fragility and relations established with the other, this need may be limited and the individual might choose to avoid affective/sexual relationship. This is observed in the following discourse.

Sex is normal. My husband says that I'm distant and that I don't love him anymore. My husband has hurt me a lot [...] I've even been beaten. Now I don't love him anymore. I have another man. The difference lies in the treatment. We live like brother and sister(Ártemis).

We perceive that the experience of sexuality may or may not be affected by the climacteric symptoms. The differential to obtain mutual pleasure is linked to affection, to the desire of being with the other. However, when it happens, the woman seeks to live with the problem, as can be observed in Hera's discourse.

I can't tell why, but it's [...] actually, it should be a better phase for the woman [...] sometimes there's a discomfort because of the dryness and also because [...] like [...] it (vagina) gets more insensitive. There's no pleasure. When you take hormone it is different. It helps a lot! But without hormone?! Really, sex doesn't count [...] it's more partnership (Hera).

If the exercise of pleasure is linked to the relation one has with his(er) own body, with the other and with the world, exercising sexuality is not only having an active sexual life, it is meeting oneself, feeling accompanied, in the presence of the other as a living, active being, as being-with-the-other in a loving environment. If so, physical limitations are not barriers to the pleasure of being with the other. Atena and Deméter report:

I never had any of that. A normal libido [...] always normal [...] so I think it's weird [...]. It has always been very normal to me. When I see people telling I even think it's weird because, for me, it's always been normal(Atena).

[...] I always said since the beginning of my marriage that sex is a very beautiful and very good thing, since it's done with pleasure and love. It's not something like rice and beans, every day and anytime [...]. So I think that my husband and I get along very well(Deméter).

Expressing affection, pleasure only makes sense when one assumes the importance of the other in one's life. Including the other in one's life means opening to another possibility of living with quality. Thus, living with quality depends on affection, libido towards the body called Eros. Having a feeling different from that is to deny the body life in fullness^(13-14). Acknowledging yet another ability of the Being: living the inner Eros is expressing, through the body, sexuality.

On the other hand, with regard to sexual pleasure in the case of the climacteric woman, it is important to keep in mind that limitations are felt not only in her body. There are physical conditions of her sexual partner that cannot be disregarded. In general, her partner is at an age in which there are virility disorders, often justified by chronic degenerative diseases. Another thing is that the female sexuality has always been involved in myths and taboos that are registered in the collective unconscious and, because it is involved in mystery, sin and prejudice, it is difficult to experience.

Women, oftentimes, submit themselves to a sexual relation with their partners even if it does not provide them satisfaction.

You got to get excited to take some interest. Sometimes, I'll only have interest so as not to frustrate my husband [...] It would be good for me if I had more interest, but I don't know if I think it's so important, because I don't work for it. I got adapted! I try not to cause confusion. Unfortunately women are like this [...] they don't want problems and pretend they're interested. You got repressed during your entire adolescence because of the way you're raised [...](Tique).

It should be considered that the objective world touches the keyboard of "elementary" affective states less and less and, thus, if it is not the experience of pleasure and pain, of which there is nothing to say, individuals are defined by their power of representation and affection is not recognized as an original mode of consciousness⁽¹⁴⁾. So, often, it is possible that women feel pressured to express themselves sexually, as their emotional relationships are realized only through close contact. The discourse of Tique evidences the fact that, if she does not find sexual intercourse a pleasant exercise, it means she has some disorder that needs to be treated.

I've never been someone who has such great need of sex. My husband says: 'you have to see a doctor [...]' I did. I've always felt uncomfortable during penetration. I don't think it's discomfort [...] I don't think it's pleasant [...] don't know if it's because we lose moisture. I have moisture [...] what causes me discomfort is not having disposition, interest. There're days it's better, other days it's not and so this is it [...](Tique).

In view of this report, the exercise of sexuality goes beyond the limits of physical contact and satisfaction of one's desire and libido. The woman experiences sexual activity as a duty that requires offering pleasure to the other, which not necessarily involves reciprocity. The feedback of pleasure, which provides to both partners involved the feeling of contentment, should be mutual. However, if one's self-esteem is low, the presence of the other does not help because, when the self-esteem is nurtured only by the other's look, it does not find acknowledgment, or believes not being able to. Bodily changes that occur in female mid-age, when associated to diminished self-esteem, can lead to diminished sexual desire or, despite the presence of desire, interfere in the exercise of sexuality⁽¹⁵⁾.

Afrodite stresses the importance of sexuality and highlights that sharing experiences is needed. She acknowledges these limitations and searches for solutions.

I was in a marriage that was not very good because there wasn't enough affection, but I've raised three wonderful children, but always surrounded by a lot of little problems. Libido was gone [...] I went to the gynecologist again and told him: 'Dr. I don't have sexual desire anymore, what do I do now?' I'm not old and don't want to stay like this [...] my boobs look like a hanging balloon, my genitals are gone [...] I didn't feel my clitoris anymore, had no secretion, even my underpants hurt me. At this point, I was totally unhappy. It was at that time that my affective relationship was over. Then, I took all exams and he (physician) gave me this eighth wonder, which is Tibolona. Everything came back! Libido is in full power, I have will to live again, to dress up [...](Afrodite).

This woman's discourse unveils that the body is an object of pleasure and that, in the exercise of pleasure, it is also possible that the Being feels the importance of the other. But what distinguishes us from other animals is that the satisfaction of this pleasure does not end with the orgasm. Sexual life cannot be limited to an organic part and one understands existence not through sexual life. What gives sense to life is the possibility of sharing experiences, emotions, pleasure, joy and sorrow.

Therefore, sexuality is internally linked to the Being. This condition is expressed in Demeter's discourse.

The relationship is normal as always. It is not every day, it is something well planned. Nothing has hindered me in sex [...] my husband and I get along very well. Now there's dryness and during sexual intercourse I really felt it (Deméter).

This discourse reveals that living sexuality involves a multitude of feelings: being with the other, feeling the other and understanding the multiple possibilities of relationship.

It is highlighted that sexuality does not end with hormonal deficiency, but it changes in the connection among a multitude of factors, interpreted in individual histories, interrelated, in a certain context and time⁽¹⁵⁾.

Thus, the pleasure of being together and the desire to share experiences with the other can be achieved through the acknowledgment of ourselves, as subjects who seek to redeem ourselves as Beings, and how can we do this without considering the "other" in our lives?

Many times, in the experience of sexuality, one faces beliefs and values that are extended to life. For example: sometimes the need one has to be alone can be a generalized manifestation/expression of a certain state of sexuality, of another way of being in the world. Thus, in making existence, sexuality assumes such a general meaning that there seems to exist osmosis between sexuality and existence. That is, if existence melts in sexuality, reciprocally, sexuality melts in existence, so it is impossible to determine, to decide or to act, the part that belongs to sexual motivation and the part that belongs to other motivations. It is impossible to characterize a decision or an act as "sexual" or "non-sexual" ⁽¹⁴⁾.

This is the coming and going of existence. It means continuously experiencing emotions, gains and losses. All is existence.

FINAL CONSIDERATIONS

Life is movement. It is an eternal flow that slides slowly but intrinsically focused on the biological and life cycle. To appropriate this movement of the body, of its coming and going in the world, considering its complexity as a live file of what has been experienced, the first step is to assume limitations imposed by bodily changes, aware that they are part of individuals' natural evolution and are tools used to mature and grow as Beings.

With regard to health care, it is important to acknowledge that Hormone Replacement Therapy (HRT), subject of many scientific studies, can compose a list of treatment options, provided that their risks and benefits are measured and individually considered and that, once access to it is guaranteed, women have the right to choose, to control signs and symptoms of estrogen deficiency, which bring considerable discomfort to most women.

Nurses, as members of the multidisciplinary team, have the role to establish a horizontal and dialogical relation with women, so that they feel valued and motivated to reflect on their way of life and limits. Group dynamics can help women to perceive their own demands, acknowledge what they know and what they feel. It also permits the interaction of technical with empirical knowledge on sexuality, encouraging them to understand the totality their experience is inserted in⁽¹⁶⁾.

In teaching, themes and ways of teaching them need to be included in health course curricula, focusing on the interconnection of reason, science and sensitivity, so that the professional is educated with a view on complexity and subjectivity. Disease should not be the primary focus of the program content, but regarded as a response of the body to processes that are experienced and not only in its aspects of neutrality and objectivity, as if one could subdivide an individual into a list of signs and symptoms.

In research, parallel to the development of biotechnologies that meet biological aspects of the health-disease process, it is important to develop studies with a view to unveiling other phenomena of the climacteric experience, based on scientific principles that can appoint other routes to care delivery.

In summary, we believe that this study specifically contributes to the women's health area, given the paucity of published studies addressing the climacteric and its association with the sexuality issue, broadening the discussion and reflection on biopsychic and sociocultural aspects of this phase in the female reproductive period.

Recebido em: 7.2.2008

Aprovado em: 23.12.2008

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1

Paper extracted from Doctoral Dissertation

Publication Dates

• Publication in this collection
  15 June 2009
• Date of issue
  Apr 2009

History

• Accepted
  23 Dec 2008
• Received
  07 Feb 2008