Sex can be an expression of passion, creativity, and love. It involves holding on to yourself, while letting go, feeling secure while taking risks, being in the moment with all your senses while trusting, accepting and sharing.
Normative sexual functioning implies that there is motivation and desire to engage in sex, an experience of pleasurable arousal and orgasm, and the ability to comfortably engage in and enjoy intercourse. Sexual satisfaction is generally defined by the existence of most of these elements, most of the time. Sexual dysfunction describes repeated difficulty in one or more of these areas of sexual functioning.
Several factors may contribute to sexual problems. In addition to a dysfunction of biological systems or the effect of medications, sexual function may be affected by psychological conflicts, mood, relationship issues, lack of education and cultural messages about sex. The paradigm of addressing these seemingly diverse influences on sexual function is known as the biopsychosocial model. This model recognizes that several factors may contribute to sexual difficulties in marriage. For example, on a biological level, hormonal changes, illness, medications or pain the genital area can affect sexual function in men and women. On a psychological level, stress, guilt and conflict around sex, depression or anxiety may affect sexual desire and arousal. Relationship satisfaction and marital struggles certainly may influence the desire to engage intimately.
Finally, social and cultural factors have an influence both on individual sexuality, as they govern many of the messages received about sex in childhood, adolescent and young adult development, and on the couple’s sexual narrative.
Before specifically addressing pregnancy, it is important to acknowledge the pre-pregnancy periods in the couple’s life. Couples in their childbearing years are in one of three different realities. Either they are trying ‘not’ to get pregnant, or they are hoping and trying to get pregnant, or they are already expecting a child. All three of these situations have implications for a couple’s sexual life.
Preventing pregnancy may affect a couple’s sexual life. Fear of unwanted pregnancy may inhibit sexual desire and functioning. Barrier contraception methods may feel technical, often requiring interruption of sexual activity prior to intercourse and affecting spontaneity. Hormonal birth control methods may negatively affect a woman’s libido and contribute to vaginal dryness. Non -hormonal intra-uterine devices are associated with additional menstrual bleeding, often extending the niddah period. Even natural methods (FAM-fertility awareness method) can affect sex by further restricting the days that a couple may engage in intercourse without contraception.
Many couples report that once they begin to attempt pregnancy, their sexual drive and function begin to increase. In women who have used oral contraception, this may be associated with resumption of ovulation and a normative hormonal milieu. This may also result from the motivation to create a baby together and to have fun trying. However, if a couple is challenged with infertility, this is likely to negatively affect a couple’s sex life.
Dealing with infertility increases stress for both partners. Fertility treatment is associated with exposure and lack of privacy, and lovemaking is subject to occur according to instruction and often only at specific times. This can turn having sexual relations into a chore, and couples often begin to experience sex as technical and perfunctory. Physically, hormone treatments can cause the female partner to feel pelvic tenderness, bloating and pain, and affect her mood. Emotionally, couples are often challenged with mixed feelings including anxiety, failure, and even shame. Finally, when a woman does become pregnant, her sexuality and sexual relationship with her husband may be affected as well. Let’s explore these changes from a biopsychosocial perspective, by dividing the stages of pregnancy according to trimesters.
Although women are used to bodily changes, having experienced puberty, menstruation and ovulation, and later in life, menopause, pregnancy most significantly impacts the physical experience of a woman’s body. As such, in the first trimester, there may be a natural decrease in sexual desire. Early pregnancy is often associated with fatigue, nausea, and breast tenderness and these physical changes may inhibit the desire for sex. There may be some emotional lability and anxiety around becoming pregnant and one or both partners may be concerned about possibly harming the fetus or causing a miscarriage by engaging in penetrative sex.
For some couples, the initiation of pregnancy may bring disparate expectations around sex as well. If a couple has been focused on successfully achieving a pregnancy and sex had become very oriented towards “baby-making” one may be less motivated to engage sexually while the other may be looking forward to experiencing lovemaking without the pressure of creating a pregnancy.
Often couples increase their sexual frequency during the second trimester and report improvement in sexual pleasure and satisfaction. From a physical perspective, there is often a decrease in nausea and tiredness. Vaginal blood flow increases significantly during pregnancy and this process often results in experiencing increased sexual arousal and more orgasmic intensity. In fact, some women report their first experience of orgasm occurred during their first pregnancy. From a psychological perspective, women often become more comfortable with their bodies as they begin to appear distinctly pregnant rather than ‘full’. Women’s body image may improve in particular due to breast enlargement or feeling confident as a pregnant woman and taking on that identity.
In the third trimester, sexual intercourse may become more challenging. Late pregnancy can be associated with a myriad of physical complaints related to pregnancy, which can include back and hip pains, varicose veins, urinary discomfort, hemorrhoids and heartburn, The “missionary” position may be uncomfortable or even impossible due to the growing abdomen and difficulty lying on the back. Women may report pain due to intense uterine contractions, either when reaching orgasm, or with male ejaculation, as chemicals known as prostaglandins in the semen can intensify uterine contractions. Vaginal lubrication at this stage may actually be somewhat reduced as blood flow is increased at the pelvic region rather than the vagina. Frequently, the muscles of the pelvic floor become weaker towards the end of pregnancy which can affect both female arousal, as vaginal contractions are related to arousal and orgasmic intensity, and male arousal, as he may perceive less friction on his penis during intercourse. Some women experience urinary leakage which may inhibit them sexually.
It is important to note that expectant fathers may also experience changes that affect mood and sexual function. Concerns about harming the fetus, anxieties regarding fatherhood, and difficulty adjusting to change, may contribute to functional problems that may include reduced libido, erectile problems or premature or delayed ejaculation.
The best way to address disparities is through communication. Unfortunately not all couples are skilled at effective communication, which involves listening, reflecting, validating, empathizing, and both assertively and with vulnerability, inviting the other partner to understand his/her position. Furthermore, when it comes to communicating specifically about sex, people often find it more difficult to establish a comfortable language to express their feelings.
It is important to emphasize that physical and emotional changes are normal and both partners are encouraged to honestly and openly communicate their feelings to one another, in order to experience the pregnancy together in a positive way. Often, the couple is empowered to share deeper emotional intimacy in early pregnancy, as many couples wait until the second trimester to reveal their status such that this is a shared secret between two people. This along with the shared excitement and expectation often strengthens the bonds of intimacy.
As noted, pregnancy is related to change and adjustment and couples are advised to communicate their concerns and desires to one another. If one or both partners express fear that sexual activity will harm the fetus, it is important to consult with and receive reassurance from the physician. In most low risk pregnancy situations, sexual activity including intercourse is completely safe, as the fetus is well protected within the confines of the surrounding membranes. Intercourse may be contra-indicated when there is a history of premature delivery or when there is multiple gestation or other high-risk situations. Generally, intercourse is contra-indicated when there is placenta previa, premature cervical dilation, or premature rupture of the membranes. In all these cases, it is best to consult with your physician
Adjustment may be required in both values and attitudes about sex, as well as in sexual activity. Couples should consider that hugging, kissing, massage and oral and manual stimulation are all legitimate forms of sex and that not all intimate and sexual situations must conclude with intercourse. Adjustment in sexual positions for intercourse should be considered as well.
The Postpartum period:
The postpartum period is marked by significant change not only physically, but also in the family and in society. The immediate postpartum period is generally one of the mixed experiences that normally include happiness and euphoria, along with exhaustion, stress anxiety, and in some cases, depression.
Physical symptoms related to the postpartum period are related to recovery from the pregnancy and birth process, significant changes in the hormonal milieu, and lack of sleep. Physical symptoms may include bodily pain, genital and breast soreness, difficulty changing positions due to abdominal and pelvic floor weakness, and pelvic floor related symptoms that may include urinary incontinence.
Emotionally, the postpartum woman may experience mood swings and may doubt herself regarding her ability to care for her and feed her child. She may be attempting to process the birth experience as well, as she navigates attempting to take care of her own basic hygiene and nutrition while caring for others. In my practice, I have encountered couples that were very surprised to discover that sexual relations were subject to modification after childbirth. Male partners have often reported that they did not know or anticipate this, and assumed that sexual relations would resume as prior to childbirth, given only the cooperation of the baby.
Sexual life after childbirth, as in any stage of life and as mentioned previously, is affected by physical, psychological, relational and social factors. Desire for sex may decrease due to physiological factors, particularly in breastfeeding women. After childbirth, there is a dramatic decrease in estrogen and progesterone. Prolactin, which is secreted in order to stimulate the milk supply, decreases sexual drive. Lactating women often experience vaginal dryness that can inhibit desire and contribute to painful intercourse. Obstetrical stitches due to tearing or episiotomy may increase sensitivity and pain. Progesterone birth control pills may also contribute to decreased desire.
Pelvic floor disorders, such as weakness, incontinence, prolapse and flatulence may be common after childbirth, and these certainly contribute to inhibition and lack of desire to engage in sex.
It is important to acknowledge that research suggests that anywhere between 8-20% of women suffer from postpartum depression that may contribute to decreased sexual health. Moreover, anti-depressant medication is likely to decrease her sexual functioning as well. Physical changes may affect a woman’s body image and sense of herself as a sexual being. She may feel negative about the weight she has gained and how her body has changed. Conversely, she may enjoy her newer shape and fuller breasts, and this may facilitate her sexual drive. Women who are breastfeeding may feel inhibited by leaking breasts or the perception that her breasts are meant now for the baby. The dual role of the breasts as providing bonding, attachment and nutrition to her infant, along with the sexual role, may feel confusing and dissonant for many women. It is not uncommon for some women to not want their husband to touch their breasts at all during the period that they are breastfeeding. The psychological experience of fathers must be acknowledged as well. New fathers may experience anxiety and exhaustion, which may impact on their sexual functioning. They may feel isolated or jealous by the mother-infant bond, and they may feel conflicted about initiating sex with their wife, or may fear causing her pain with intercourse. On a relationship- dynamic level, it is important to acknowledge that the family system has changed, and the couple dyad is now shifted to include another individual, one with many needs. For a woman taking care of a baby, and especially when there are other children, (and even more so if her professional life involves caring for others,) she may perceive sex as a chore. She may view her partner’s desire for sex as another person whose physical needs she must fulfill. In addition, much of the needs a woman has for attachment and intimacy, are being fulfilled with her infant.
Several strategies are available for couples experiencing sexual problems. One strategy is to reframe existing models of sexual function that imply that both partners must experience spontaneous desire before choosing to have sex. Newer models of sexual function, particularly female sexual function, suggest that motivation is as powerful as desire, and that women are often motivated to engage in sexual activities in order to achieve emotional intimacy and have a pleasurable experience. Although at different times in life, and in particular, the postpartum period, spontaneous desire may be decreased, being open and receptive to a sexual experience with her husband for the purpose of being close is likely to trigger sexual arousal, assuming she is relaxed and open to that possibility. Once sexually aroused, desire then kicks in resulting in a satisfying sexual experience. This reframing helps to alleviate anxiety and normalize the experience of women who feel that their lack of spontaneous sexual desire is pathological and dysfunctional.
Maintaining a healthy sexual relationship with one’s partner requires investing in the intimate relationship. Couples should learn to create space for themselves, take walks together and go on dates. Both partners should also have some time alone in their schedules for themselves. Prolonged desire discrepancies may create power struggles. All relationships are challenged with power struggles. Couples don’t always agree on everything and important issues such as kids, education, religion, in-laws and money, to name a few, can be a source of conflict, which can challenge relationships. Creating intimacy in relationships is not about never having an argument or disagreements as couples don’t always have to agree. Rather, it is about how quickly you recover from arguments and about bringing your authentic self to your partner, with your vulnerabilities and sensitivities. Finally, it is important to be able to experience sex not only something you do or have, but rather an expression of an intimate and erotic energy that a couple shares. It may be expressed in the bedroom, but does not begin there. It is present with the way the couple engages, and even looks at one another.