Sensuality, communication, and self-acceptance as significant factors related to sexual function in infertile women in Jakarta, Indonesia

Abstract

Objective

This study aimed to identify the relationships of the sexual self-efficacy with the sexual function in infertile women.

Method

This cross-sectional study involved 105 women with infertility who participated in the study by completing the questionnaires of Sexual Self-Efficacy for female and Female Sexual Function Index.

Results

The results show the significant relationships of the sensuality, communication, and self-acceptance with the sexual function of the women with infertility (p-value = 0.021, 0.037, 0.018, respectively).

Conclusions

These relationships partially reflect the complex and unique situation of the women with infertility in their life span. Nurses should always apply the caring principles and therapeutic communication while interacting with the women with an infertility problem.

Introduction

Infertility problem is estimated to affect at least 10–15% of married couples globally.¹ This problem has multidimensional impacts encompassing the social, economic, and cultural aspects not only for the individuals but also for the country with demographic crisis.¹ Nonetheless, infertility is especially devastating for the couple, as its implications extend beyond the medical issues of reproductive organs to afflict their economic and psychological status.^2,3

The number of Indonesian women with primary infertility ranks fourth in Asia. A recent study suggests that 21% of women under 35 years-old and 26% of women aged older than 35 consult their infertility problem at the fertility clinics. Nationally, around 12–22% of the productive-age population is estimated to have an infertility problem. In Indonesia, there is only limited data on infertility statistics because of poor reporting. Using a conservative estimation of 15% infertility rate in the population, it is predicted that 6 million women have infertility problem in their reproductive cycle, yet the reported infertility case of the women is two times lower than this prediction.²

The strong patriarchal culture of Indonesia adds more layers of complexity for the women having infertility problem.⁴ It is widely known that gender bias dominates the people's perspective of infertility, especially in the patriarchal society as in Indonesia. The Indonesian society tends to blame women entirely for not being able to produce the offspring, regardless of the actual infertility problem that can also be situated in men. Hence, the inability to conceive a child in a household has eminent consequences, especially for the women. Women with infertility are prone to stigmatization, divorce, abuse, rejection, low self-esteem, and disengagement of social status. In society, the infertility problem considerably weighs more in its social construct than its biological nature.

In line with this notion, Fujiati argued that patriarchal culture discriminates against the women's body to conform to the societal norms; therefore women's body is associated with taboo and discussing sexuality is considered amoral.⁵ In the hegemony of patriarchal culture, women are viewed to embody any reproductive problem, even though the problem may entirely or partially arise from the men. In other words, women, with all their biological attributes, are seen as the source of the problem in the relationship pattern with men. Not only for the problem affecting both men and women but also for the problem which only impacts women, the patriarchal society will still blame the women for having such a problem.

An ethnography study from Bennet in women with infertility in Indonesia revealed that men with infertility problem were in the shade due to lack of empirical understanding and the strong cultural pressure on women to be responsible for the reproductive function than their men counterpart. Aside from that, women with infertility problem often feel imperfect as a woman, depending on how long they were without children. Studies on infertility have described the complexity of the problems of women with infertility.

However, this situation could be vague since either men or women can contribute to infertility problem. Additionally, being infertile can also affect the sexual function of women. This aspect has not been clearly understood in society. It is important to note that the management system of infertility case in Indonesia is still complicated.

Method

The design of this study was a cross-sectional study using consecutive sampling for participant recruitment. 105 women with infertility agreed to participate in the study which was carried out an army hospital in Jakarta, Indonesia. A socio-demography questionnaire containing age, educational background, occupation, and length of marriage was also distributed to the participants. Sexual Self-Efficacy for Female (SSEF) and Female Sexual Function Index (FSFI) questionnaires were used in this study to measure the sexual self-efficacy and the sexual function of the participants.

Inclusion criteria in the sample of this study were: participants were less than 45 years of age and were diagnosed with infertile, with the exclusion criteria of the respondents whose husband suffer from sexual dysfunction. Then the readability test and validity test were conducted at Kartika Fertility Center, Jakarta. We performed univariate, bivariate, and multivariate analysis in this study. The participant characteristics were analyzed for the frequency distribution. The normality test was conducted using the Kolmogorov–Smirnov test. Further, we also performed Chi-Square, t-test independent and Mann–Whitney test to analyze the variables in the study. All statistical analysis was done using SPSS 17 software.

This study has received ethical approval from the Faculty of Nursing Universitas Indonesia Ethics Committee No. 146/UN2.F12/HKP.02.04/2018.

Results

The majority of the participants were working women (65.7%) and had higher education (94.3%). The mean age of the participant was 33.34 years, and they had been married for 6.03 years on average. Most women in this study had primary infertility (85.71%), while 14.29% of them had secondary infertility.

Based on Table 1, it was found that 58.1% of participants had a higher level of sexual self-efficacy and most of the participants had no sexual dysfunction (93.3%).

Table 1.

Sexual self-efficacy and sexual function in infertile women.

Variable		FSFI total		Total
		Disfunction (n)	No disfunction (n)
SSE	Higher SSE	2 (1.90%)	59 (56.19%)	61 (58.1%)
	Lower SSE	5 (4.76%)	39 (37.14%)	44 (41.9%)
Total				105 (100%)

Table 2 shows the statistically significant relationships of sensuality, communication, and self-acceptance domains of sexual self-efficacy with the sexual function of the women with infertility (p-value <0.05).

Table 2.

The relationship between sensuality, communication, and self-acceptance with sexual function in infertile women in Jakarta, Indonesia.

Variables		Sexual function		p-value
		Dysfunctionn (%)	No dysfunctionn (%)
Sensuality	Low	6 (3.1)	40 (42.9)	0.021
	High	1 (3.9)	58 (55.1)
Communication	Poor	6 (3.3)	44 (46.7)	0.037
	Good	1 (3.7)	54 (51.3)
Self-acceptance	Poor	6 (3)	39 (42)	0.018
	Good	1 (4)	59 (56)

Discussion

In this study, educational and working backgrounds did not significantly affect sexual function in infertile women. Research by Newton et al. shows that couples with a higher level of education (outside of secondary school) have much lower stress than those with high school education or lower.⁶

Study results of Holka and colleagues in 2015 showed that the majority of the couples with infertility who were willing to undergo treatments for infertility were those with higher educational background. The results of the present study indicate that the sensuality, self-acceptance, and communication are linked with sexual function in infertile women. Sensuality refers to the objective or physical matters that can induce sexual interest and stimulation on the sexual organs. The female body, for example, can visually stimulate men. A study found that the women with infertility enjoyed stimulation on the breast area by their husbands, and women with high self-efficacy level on sensuality domain tended to have more sexual interest. High self-efficacy level on sensuality is also related to the women's ability to reach orgasm and satisfaction in sexual activities. Given the relatively young and productive age of the participants in this study, their self-efficacy on sensuality may naturally arise and contribute to the women's self-confidence.

Women who see themselves sensual are more likely to be conscious of their function as female. When women can develop a connection between their mind and body, their blood pressure, cortisol level, the immune system can be better managed. Moreover, sensuality is not only the expression of love, but it can also be a source of motivation to treat infertility problem and have a pregnancy. Likewise, Afiyanti argued that apart from the sexual activities, interest toward an object or physical contact, affection, compassion, empathy, care, attention, and emotional intimacy can influence sexual self-efficacy in women.

On the other hand, infertility treatment can be supported through medical interventions, family support, and psychological counseling. The family is an important source of support for women with infertility to overcome their stressful situation. A study done by Cutrona and Gardner suggested that individuals with high social support could manage their stress.⁷ Moreover, the adequate coping mechanism can support the success of fertility treatment. Social support is one of the mechanisms of resistance to the challenges of infertility. This can play an important role in reducing negative effects and improving the effects of negative incidents of infertility, increasing self-control and confidence, and the quality of life of the couple.⁸

Our finding also showed a relationship between communication and sexual function in women with an infertility problem. Communication is an interactive and reciprocal process between people, and sexual communication is the process in which the married couples share preferences, seek changes, and respond to changes in their sexual relationship.⁹ Another study indicated a significant relationship between the sexual communication process and sexual satisfaction in couples.¹⁰ This study showed that women with infertility tended to respond well to the type and amount of sexual stimulation asked by the partner. This condition is aligned with the study result of Goodnight mentioning that the sexual communication between couples could bring about the sexual action desired by the partner.

According to Angelis, communication holds a key role in the sexual relationship. Angelis's study demonstrated that married couples with good communication pattern were more likely to have higher satisfaction of sexual life. Good communication practice supports the harmony in the family as well as in the sexual relationship. Effective communication is also important for the self-acceptance in the couples.¹¹

This finding is supported by the previous study finding that the sexual relationship satisfaction in a marriage could be achieved with deep and open communication about the sexual needs between the couple. The couple needs to communicate what and how they can fulfill the sexual needs of the partner. Sexual problems can arise from poor communication, especially since women are more reluctant to convey their sexual-related concerns. Discussion about sex is also avoided due to cultural taboo.¹² Women are mostly perceived as sexual object and are not supposed to aim for sexual satisfaction. With such an assumption, women are primarily concerned if their husband has had enough sexual satisfaction from them, without regarding their satisfaction. Similarly, another study found that open communication is one of the predictors of marital benefit. Women who communicate their infertility problem to their partner have a higher level of marital benefit that can contribute to higher and more intimate marital relationship.⁸ Another aspect of the sexual self-efficacy examined in this study is self-acceptance. Women with good self-acceptance feel comfortable with their own nude bodies when they are having a sexual relationship with their husbands.¹⁰

Our finding showed that the majority of the women with infertility had good body-acceptance. This might be due to the productive age of the participants and the length of the marriage which were mostly less than five years. In such a prime year, women are more likely to have positive body image and good sexual function. Good self-acceptance can stimulate positive response and increase sexual desire during sexual intercourse.

We have to highlight the importance of the body image on sexual health is women with positive body image had a higher level of perceived sexual function.¹³ Another study conducted suggested the positive association between sexual function, sexual satisfaction, and all variables of the body image. Sexual satisfaction can be influenced positively by higher self-esteem and less negative thoughts on body Image.¹⁴

According to Menning, there are five psychological phases experienced by individuals with infertility, i.e. denial, anger, a period of grief, acceptance of infertility, and resolution to infertility.¹² It is important to understand the psychological process of the women with infertility to help women going through the period of anger to acceptance and resolution to infertility. Women with infertility who had religious affiliation viewed infertility as God's plan. Strong spirituality gives meaning to infertility as the willingness of God which will lead to virtues. Acceptance and a positive mental attitude can improve the chance of success of the medical intervention to infertility. Being hopeful also helps women with infertility to withstand the possibly long and challenging journey of infertility treatments. Spirituality and religious beliefs are often explored by patients as they grapple with feelings of abandonment by God, and some may question their faith. However, the same spiritual or religious ideologies can be utilized as a supportive tool to reduce symptoms of stress and anxiety.³

Lamont and Canada mentioned that the biopsychosocial, biological, psychological, interpersonal, and cultural factors influenced sexual function.¹⁵ Indonesian society, however, has a common gender bias in perspective on infertility. Women's sensuality and body-acceptance are closely linked to how the women with infertility put themselves in the right perspective. Their individual perspective will affect their ability to engage in the sexual relationship with their husband. Indonesian women typically “accept” their infertile condition and how the society sees and treats their infertility issue. Such gender construct may contribute to the unfairness and lack of transparency of the women sexuality.

Infertility has been described as a threat to a woman's social well-being and security. Regarding the sociocultural aspects of play, for many women, being a mother is the most important role in their lives; mothers are considered as a fundamental component of their identity. Role of culture (socio-cultural) influences among various tribes in Indonesia are thought to affect the stress experienced by infertile couples, especially among women (wives). Asians, including Indonesians, are patrilineal; in related habits, a woman is respected by the birth of a son. When a woman is unable to bear her children, not only does she suffer shame and disappointment, but her family is also ashamed in the eyes of her husband's family.⁶

Zakiyudin Baidawi in his book ‘Women's Studies Encylopedia’, touched upon the cultural concepts which distinct the roles, behaviors, mentality, and emotional character of the men with those of women.⁵ Bennet also argued that in Indonesia the right of sexual reproductive health is heavily affected by the failure to address the sexual problem itself. This condition might lead to the gender gap in the treatment of sexually transmitted diseases that contribute to infertility. The issues of sexually transmitted disease and men infidelity barely surface in the infertility counseling. This reflects the moral sexual inclination toward men and the social hierarchy of the sexual-reproductive health¹⁶.

Sensuality, communication, and self-acceptance of the women with infertility can be improved through support from the health care providers. Building the women's confidence by giving verbal persuasion, sharing experiences between peer in the group of women with infertility can be the main strategy to help women resolve their infertility problem. In addition, support from the environment can also boost women's self-confidence and self-esteem. The health care providers need to encourage good communication of the married couple to explore their feelings and also to support each other in overcoming the infertility problem. In fertility counseling, according to Bennet, the married couples with infertility problem expected more interactive and patient-oriented counseling.

The impact of infertility on marriage relationship largely depends on the sociocultural context. Culture contributes to shaping the roles of the women to be centralized in the reproductive function. Having children is seen as mandatory for women and marriage is commonly defined as the legal way to produce offspring. Therefore, being infertile may immensely affect marriage life. Furthermore, social support can serve as a mediator of the distressing experience of infertility¹⁷. A previous study showed that a psychological intervention using their social support system could reduce the negative effects of the infertility.¹³ The observation results of their study showed that most women with infertility attended the fertility clinic accompanied by their mother or sister, indicating the social support system of the women.

Another study found that younger women with infertility were more likely to feel secure and optimistic, while the older women felt otherwise, hence requiring more emotional support from their social circle.¹⁸ Support from the partner, family, and friends is essential to maintain hope and positive coping mechanism of the women with infertility¹⁹.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgements

This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1860/UN2.R3.1/HKP.05.00/2018.