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ORIGINAL ARTICLE  
Year : 2017  |  Volume : 59  |  Issue : 1  |  Page : 63-68
Study of sexual functioning and disorder in women before and after tubal sterilization (tubectomy)


1 Department of Psychiatry, Bidar Regional Institute of Medical Sciences, Bidar, Karnataka, India
2 Department of Psychiatry, JSS Medical College Hospital, JSS University, Mysore, Karnataka, India
3 Department of Psychopharmacology, NIMHANS, Bengaluru, Karnataka, India

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Date of Web Publication12-Apr-2017
 

   Abstract 

Introduction: Sexual relationship is a basis for mental health and continuity of the healthy generation. There are very few studies on the female sexual functioning, especially in India. Sterilization being the most common contraceptive method, sexual functioning in women undergoing this surgical intervention has not been adequately explored. Available studies have found conflicting results; some have reported that sterilization has positive effects on sexual functioning since anxiety of getting pregnant is abolished. However, few Indian studies have reported a decline in sexual functioning following the sterilization procedure as women lack interest and perceive sexual function only for the purpose of procreation. The cultural differences and lack of sex education among Indian women are thought to be the reason for such a difference.
Materials and Methods: A total of sixty married women above 18 years, who were consulting Family Planning Association, Mysore, for the purpose of undergoing tubal sterilization, and who gave a written consent were interviewed twice; before the sterilization procedure and 6 months post-sterilization. These women were assessed for sexual functioning using female sexual function index and sexual functioning index.
Results: The prevalence of sexual dysfunction in the study population was 36.7% before the tubal sterilization. This rate increased to 71.7% after the procedure which was statistically significant. The common disorders were orgasm, arousal, and desire. Pain disorder was least common. This dysfunction exists across all the ages, education level, occupation, and residence.
Conclusion: The study shows that whatever may be the attribution, tubal sterilization impairs the sexual functioning among women. A proper education and counseling need to be incorporated to prevent the problems.

Keywords: Female sexual function index and sexual functioning index, sexual functioning in women, tubal sterilization

How to cite this article:
Kunkeri SP, Sathyanarayana Rao T S, Andrade C. Study of sexual functioning and disorder in women before and after tubal sterilization (tubectomy). Indian J Psychiatry 2017;59:63-8

How to cite this URL:
Kunkeri SP, Sathyanarayana Rao T S, Andrade C. Study of sexual functioning and disorder in women before and after tubal sterilization (tubectomy). Indian J Psychiatry [serial online] 2017 [cited 2019 Jul 16];59:63-8. Available from: http://www.indianjpsychiatry.org/text.asp?2017/59/1/63/204433



   Introduction Top


The World Psychiatric Association has defined sexual health as “a dynamic and harmonious state involving erotic and reproductive experiences and fulfilment, within a broader physical, emotional, interpersonal, social, and spiritual sense of well-being, in a culturally informed, freely and responsibly chosen and ethical framework; not merely the absence of sexual disorders.”[1] Although evidence suggests that healthy sexual functioning is an important contributor to women's sense of well-being and quality of life, women and their clinicians often avoid discussion of this topic.[2] Surveys conducted in the US and Europe have identified that female sexual dysfunction (FSD) is strikingly prevalent,[3],[4] In India, literature on the prevalence of sexual dysfunction among women is particularly scant.[5]

Various biological, social, psychological, and cultural effects play a major role in the overall mental health of women and in particular on their sexual health.[6] One of the problems women are faced within their sexual relationships is the issue of the necessity of family planning. Particularly in India, increasing population has been a major concern. This led to the launch of family planning program in the 1960s by the government. Studies have revealed that contraceptive methods are in connection with the sexual function and health in different ways. Female sterilization is one of the most common methods of contraception. Sexual function following the use of this method has not been adequately addressed. The effects of sterilization are different in different individuals. Female sterilization may lead to psychological changes.[7] The positive effects result from the disappearance of the fear of unwanted pregnancies, and also side effect of other contraceptive methods and negative effects arise from the sense of loss of reproductive ability.

FSD is impaired or the inadequate ability of a woman to engage in or enjoy satisfactory sexual intercourse and orgasm. Worldwide, FSD is a highly prevalent problem for 38–63% of women.[8] The prevalence of these disorders in India is not clear, mainly due to the stigma associated with sex. The reality is that, in our society today, a lot of parents fail to introduce or talk about sexuality to their children and even to those about to get married.[9] It has been observed that so serious is the societal avoidance of this issue that many marriages have been ruined because the couple could not understand; talk less of managing their sexual desire or sex life successfully. Hence, the results of this study can be acknowledged to the importance of proper training and consultation in connection with the sexual satisfaction and contraceptive methods, the cultural conditions of society and the importance of sexual satisfaction in marital life with emphasizing on contraceptive methods.


   Materials and Methods Top


Source of data

Women who were consulting for elective tubal sterilization procedure to the Family Planning Association, Mysore.

Method of collection of data

  • Type of the study: Prospective study using purposive sampling
  • Sample size: 60.


Inclusion criteria

  • Married women aged between 20 and 40 years who are staying with husband for the past 1 year at least
  • Women who visited FPA, Mysore for the purpose of undergoing permanent tubal sterilization.


Exclusion criteria

  • Women who refuse to give consent
  • Women who are not sexually active for any reason.


Procedure

Written informed consent was taken from the cases. They were informed about the survey and were interviewed by female doctor. Adequate privacy and confidentiality were ensured. Cases were interviewed once before undergoing the surgical procedure and again after an interval of 6 months. The sociodemographic details were collected along with contact details. Sexual functioning in these women was assessed using validated scale, female sexual function index (FSFI). Another scale was used only for the second interview, the change in the sexual functioning questionnaire.

Statistical analysis

McNemar's Chi-square test and repeated measures ANOVA were used for comparing sexual functioning before and after the sterilization procedure and among various subgroups. All the statistical methods were carried out through the SPSS for Windows (version 16.0, IBM). The values were compared at 5% (0.05) level of significance for the corresponding degree of freedom P< 0.05 was considered as statistically significant and vice versa. The change in sexual functioning after sterilization procedure in the total study population was found to be statistically significant.

The study population was divided among various subgroups (age >25 years and <25 years), education-illiterate, primary and secondary, occupation-employed and unemployed) and comparison was made using repeated measure ANOVA. Although there was decline in sexual functioning after sterilization among various subgroups, the change was not statistically significant when compared within these subgroups.


   Results Top


This was a prospective study carried out in sixty women who were undergoing tubal sterilization in the Family Planning Association Center Mysore. All of these women were married and completed their family. Among them, 35 were aged above 25, and 25 were of <25 years of age. Most of the women had two children with only 14 had three and only one woman had four children. Around 50% of the study population were illiterate and had never been to school. Among the remaining, 25% had completed primary education and the rest secondary education. Majority of them were hailing from a rural background and were unemployed.

The results showed that sexual dysfunction was found in around 36.7% of the study population before undergoing tubal sterilization. We also found that the most common disorder was orgasm (75%) followed by lubrication (73.3%), desire (70%), arousal (66.7%), and satisfaction (57.14%). Pain disorder was the least common (28.3%). After tubal sterilization, around 71.1% of women had sexual dysfunction and most common disorder was orgasm followed by arousal and desire. The score on sexual functioning index (CSFQ) showed similar findings with more problems in orgasm and arousal compared to other components.

[Table 1] shows the mean scores of total FSFI and its each domain in the study group before and after tubal sterilization. As can be seen from the table, the mean score of total FSFI and each domain has decreased after sterilization which is statistically significant (P = 0.001)
Table 1: Mean and standard deviation of female sexual function index score and each domain before and after tubal sterilization

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Majority of the women had problems with orgasm and arousal after the sterilization procedure as observed with CSFQ scale [Table 2].
Table 2: Core stateless fair queuing-mean and standard deviation after the sterilization procedure

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About 48% of women above 25 years had sexual dysfunction compared to 28.5% of those below 25 years before undergoing tubal sterilization. Sexual dysfunction increased in both the age group of the study population following permanent sterilization. Change in sexual functioning is statistically significant. However, the inter-group comparison was not statistically significant [Table 3].
Table 3: Age and number of women with sexual dysfunction

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The number of women having sexual dysfunction following sterilization was significantly high among illiterate and primary education group, but not among those with secondary education [Table 4].
Table 4: Education and number of women with sexual dysfunction

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About 68.75% of women among unemployed group experienced sexual dysfunction following sterilization compared to 35.4% before sterilization, which was statistically significant. Similarly, 83.3% of women who were employed had sexual dysfunction following the operation while only 41.7% of them had such problems before the procedure. However, this was not statistically significant (P = 0.063) [Table 5].
Table 5: Occupation and number of women with sexual dysfunction

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Women from both rural and urban background had statistically significant decline in sexual functioning following the sterilization procedure. However, inter-group comparison was not statistically significant [Table 6].
Table 6: Residence and number of women with sexual dysfunction

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   Discussion Top


In this study, we assessed the sexual functioning of these women before and after undergoing tubal sterilization using the FSFI scale. Although women were shy and hesitant initially, rapport could be established after some time. Women reported that no doctor had asked about sexual functioning so far.

The results showing sexual dysfunction in around 36.7% of the study population before undergoing tubal sterilization is similar to the sexual dysfunction found in general population. Studies carried out worldwide had reported sexual dysfunction among females in the range of 38–63%. The results of this study were consistent with another study exploring the sexual dysfunction in married south Indian women, which stated that one-third of study population had sexual dysfunction. The findings are also consistent with other studies from the US and England which reported sexual dysfunction among 43% and 41%, respectively.[3],[10]

People in our country, especially women are hesitant to speak about their sexual problems. This is due to the influence of our culture, where exist a centuries-long taboo on the discussion of sexual matters. Most people are ignorant and lack knowledge about sexuality to the extent that, few do not even know the name of their genital organs. Brotto et al.[11] hypothesized that an individual's perception of sexual difficulty is influenced by his/her notion of normal and abnormal sexual function, which is related to one's sense of self which in turn is related to culture. It is impossible for men, and particularly women, to identify or acknowledge that they have a sexual dysfunction when their culture gives them no basis for comparison.[12] Even among those who realize any problem with their sexual functioning they do not like to discuss it with any other person (including the spouse and their doctor).

One of the most detrimental of the erroneous beliefs is that sex is not as necessary for women as it is for men. Women are taught that a woman does not need the sexual release that a man does, that a man's sexual needs are greater than a woman's, and she must accommodate to his needs. Women are raised to passively play up to this male-dominant action, and those who are more obedient and passive are encouraged. Men, on the contrary, are portrayed and raised as strong, aggressive, and dominating figures, and this concept is carried into everyday sexual and marital relationships. Because this sexual discrimination is regarded as natural, intimate relationships between men and women are seriously distorted.[13]

We also found that the most common disorder was orgasm (75%) followed by lubrication (73.3%), desire (70%), arousal (66.7%), and satisfaction (57.14%). Pain disorder was the least common (28.3%).

Studies carried out by Singh et al.[14] and Varghese et al.[15] had reported similar findings with orgasm being most common and pain least common disorder among different domains. Most of the women had reported that they never initiated the sexual act as they believed it would not be acceptable to their male partner. Garfield [16] had stated “If a woman believes she is not supposed to express herself sexually, she may inhibit her natural desire for fear she will appear unfeminine.” Women in our study had expressed similar concerns and believed initiating a sexual act is the job of their husband, but they have to oblige whenever he demands for it, irrespective of their desire and interest.

Desire and orgasm problem was more among women with age >25 years, lower education level and those belonging to rural background. Various reasons for this significant finding could be because of the lack of sexual knowledge among these women, especially those coming from a rural background and who are uneducated.

After tubal sterilization, around 71.1% of women had sexual dysfunction compared to 36.7% before undergoing the procedure. Previous studies have shown variable results, with most of the western studies stating a favorable outcome on sexual functioning following sterilization. These studies explained their findings as sterilization had a positive outcome and relief from the fear of getting pregnant. Few of these studies had made an assessment by just asking the patients about their sexual functioning, and no objective assessment was performed using a validated scale. Few other studies had not assessed the baseline sexual functioning of the women before sterilization procedure; however, the assessment of change in sexual functioning was done only following the procedure on a cross-sectional sample.

The findings in our study are in similar lines with few other studies which reported decreased sexual functioning in women following sterilization procedure.[17],[18] The studies from Indian population had reported decline in sexual functioning following sterilization although at a lower rate (Rakshit 25%, Khorana and Vyas 65%).[19],[20] Furthermore, the scores on CSFQ scale showed decreased frequency of sexual intercourse after tubal sterilization. This could be explained by the influence of culture on the woman's perception of sexual functioning. The act of sex has been considered as one for the purpose of procreation and not recreation. This is in contrast to west were women enjoy their sexual life and are concerned regarding their sexual functioning. Male-dominated sexual culture of India has been and continues to be very phallic-oriented. Because the male sex is considered sexually superior to the female sex, sexual intercourse is not perceived as a mutually intimate interpersonal relationship.[21] Rather, it is perceived as a physiological or primitive event, a kind of tension release for the male and for his pleasure. Females are only the passive participants. Most of the women indeed consider it as a duty to submit themselves to their husband for the sexual act. Although most of them find it to be disgust and lack interest, they consider it as their responsibility.

Women after tubal sterilization since can no longer become pregnant; they find it is not really necessary to have a sexual life. They lack interest, focus all their attention and energy in bringing up their children.[22] They lose interest in sexual act, although they continue to do it forcefully as desired by husband. The women though have problems with sexual functioning, never consider it to be a disorder or report to doctors on their own. In fact, most of the physicians as well fail to make an attempt to enquire details regarding sexual functioning. It is important to realize that sexual functioning plays a major role in the quality of life and that help is available for these problems.

The results also showed that most common disorder was orgasm followed by arousal and desire. The score on CSFQ showed similar findings with more problems in orgasm and arousal compared to other components. Normally, woman's motivation to be sexual are complex and include increasing emotional closeness with her partner (emotional intimacy) and often increasing her own well-being and self-image (sense of feeling attractive, feminine, appreciated, loved and/or desired, or to reduce her feelings of anxiety or guilt about sexual infrequency).[23],[24] Sterilization procedures has been found to have negative psychological effects as it makes women perceive a loss in femininity as they lose their power to become pregnant.[25] This makes women less confident of their own body and their ability to participate in sexual act. Women with low confidence and motivation find it difficult to get aroused and reach orgasm.

The other reasons for our findings could be the fact that most of our study population was in their postpartum period and breastfeeding. The women life after having children changes drastically which may contribute to her sexual problems.[26] This could be explained by nonsexual distractions of daily life and women preoccupation with the child and its upbringing. Women are overwhelmed with responsibilities and stressors, often making it difficult to be able to give fully of themselves while engaged in sexual activity.[27] If a woman's mind is focused on sexual sensations, her body can enjoy it more fully. If she is tired from a long hard day of work or has been stressed for a long period, it may be difficult to get distracting thoughts out of her mind, even if she truly desires her partner. Few studies [28],[29],[30],[31] refer to distractions, fatigue, and preoccupation as being the most pervasive barriers to a woman's enjoyment of a satisfactory sexual experience.

Breastfeeding also plays a role. It has been linked to low coital activity, low sexual desire, and low sexual satisfaction of females and their partners. A negative influence of breastfeeding is caused by higher levels of prolactin which suppresses the production of gonadotropin and results in hypoestrogenic state. Next factor is fatigue and change of view on breast function in both partners (nutritional vs. sexual).[32],[33]

Although there was such a high rate of sexual dysfunction, women did not perceive it as a disorder and never discussed this with their doctors. Indian women are not sensitized to the sexual function as a biological need and something which is pleasurable. Sexual functioning is viewed as an act for the sole purpose of procreation. It is important to realize that sexual functioning plays a major role in the quality of life and that help is available for these problems. It is, therefore, important to sensitize Indian women to the pleasurable effects of sexual function and help them to have a better quality of life. Women need more information on their physiological and psychological issues relating to sex as well as in-depth studies to help cure sexual functioning problems. This could be made possible by educating women about the sexual function. This has to be done at school and even at home by parents.

Many women have suffered in silence for years because sexual problems were not something that a woman could talk about. Women should be made to feel free to talk about their sexual function. Treating physician should also make an enquiry about this as any other routine biological function.

Limitations

  • Longer follow up would lead to further insights into the relation between sexual functioning and tubal sterilization
  • A larger sample size would be helpful to determine more significant results and comparison within various sociodemographic variables would be possible
  • Women in our study were in the postpartum period and breastfeeding which could have negative effects on sexual functioning.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Correspondence Address:
Shweta Patil Kunkeri
Department of Psychiatry, Bidar Regional Institute of Medical Sciences, Bidar, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5545.204433

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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