Sample characteristics
Fifty-two women aged between 40 and 55 years participated in the study. Their mean age was 47.40 years. All were married except for five women: one was single, three widowed and one divorced. Sixteen women had enrolled at university, fourteen had secondary education (grades 10-12), twelve had an intermediate education (grades 7-9) and ten had an elementary education (grades 1-6) or less. Twenty-eight were housewives. Twenty-seven were Christians and the other Muslims, representing the two dominant religions in Lebanon. Twenty-five indicated that they had started the perimenopause or menopausal period.
Themes
One-third of the participants reflected on difficult sexual experiences that made them unhappy and dissatisfied with their sexual life. Women in their majority did not define their sexual difficulties as physical or affected by menopause or ageing. Women’s sexual difficulties were mainly induced by an inhibiting sexual education and a patriarchal marital relation that favours men’s sexual rights and needs above women’s. Relational problems and the burden of daily life were additional factors that overwhelmed women physically and psychologically and also altered their sexual life. In line with social norms, women expressed their sexual difficulties within the institution of marriage. Key themes in the onset and chronicity of women’s sexual difficulties are Women’s inability to communicate sexual desires and concerns; male-related sexual difficulties; marital conflicts; and sexual difficulties as context and time-bound. Sexual difficulties are explained and supported by the participants’ quotations.
1. Women’s inability to communicate sexual desires and concerns
Contained within this subtheme is the women’s reflection on the challenges of experiencing themselves as sexual beings due to the absence of sexual education and no readiness to sexual life.
One cause of sexual problems is the absence of sexual education in Lebanon. This is so wrong. She does not know how to discover her body and how to enjoy with her husband. In our society, the woman is not at all aware of sexual life when she gets married. Her husband will not enjoy too. She takes time to discover her body (Faten, married in her 30s, university education, individual interview/II).
After many years of marriage, many women described their deep embarrassment, guilt feelings and shyness to see their husbands naked for the first time or to engage in penetrative sex. Thus, frigidity, vaginismus and forced sex were reported as the results. Carmen, a woman who had seven years of psychotherapy due to vaginismus, defined women’s sexual difficulties as their inability to enjoy their body due to their inhibiting feelings. She said:
Here you have the taboos, I mean the interdictions, the no, the shame, and this is not allowed … and until now, many women (single young women) do not know why things are not allowed. The shame and interdictions cause sexual frigidity and lead to problems with the husband after marriage because she is not allowed (to be sexually active) before marriage. Suddenly, she gets married, and everything becomes allowed… Psychologically, you are blocked. How she will do it in 24 hours? … that is why there are a lot of sexual difficulties among women… (Carmen, 43 years, premenopause, university, II).
Ibtissam's husband forced himself on her during their first sexual intercourse while her mother and mother-in-law waited outside to make sure that things had gone successfully, and that the bride's virginity was confirmed. Kamal was another victim of sexual ignorance, although and like Ibtissam, she was a university student at the time of her marriage. Her first negative sexual experiences led to sexual disinterest throughout the long years of her marriage. Her negotiations with her husband to escape this 'tough duty' as she called it, failed. Sexual intercourse was not pleasurable for her. It was just a marital duty done at the husband’s request. She recounted:
I am the type who had an upbringing (conservative). When I got married, I told him: I will iron, wash and clean for you, but do not approach me. Imagine the extent to which we were shy and did not have this. Later on, he helped me get used to him progressively. These things (sex) are not important to me. I am not interested in this thing… I do not like (sex). I do it unwillingly. I am not happy with this… is the least of my worries. I don't like it. What is important to me is the way he treats me (Kamal, university, 55 years, menopause, II).
Many participants expressed the assumption that sexual difficulties are not female-related because there is a 'general assumption' that women are always 'ready to have sex.
The woman is stronger than the man in sex. A man might develop impotence and need to take medication... But I rarely hear of women taking these things. Maybe her hormones are stronger … the woman does not have issues with her sexual life unless she is physically ill. A woman is always ready to respond to a man's needs (Sara, elementary, 49 years, premenopause, II).
Only one participant, Racha, frankly talked about her embarrassment or pain during sexual intercourse due to vaginal dryness. She was grateful of her husband’s understanding attitude.
Now that I have no menses, a quite long time ago, I feel dryness. I mean… it is dry, this is embarrassing. I mean it hurts me, yes I have pain during sex. But my husband is so patient… Thank God… (Racha, secondary, 51 years, menopause, Focus Group/FG).
Racha’s experience triggered, on the other hand, two women of the group to sadly reflect on their husbands’ selfishness and sometimes ignorance of their needs.
2. Male-related sexual difficulties
This section focuses on women’s definition of their sexual difficulties associated with their husband’s 'poor sexual performance', specifically, erectile dysfunction and early ejaculation. They also accused their husbands of being selfish, not caring about their own sexual needs. Some women reported being forced to engage in anal sex. They furiously contested their husbands’ sexual behaviour describing it as unpleasant and illegitimate, banned by the society and religion particularly by Islam. These problems had negative impacts on women’s physical and psychological wellbeing. Ten women highlighted their sexual dissatisfaction due to their husbands’ erectile and ejaculatory problems. Their embarrassment was exacerbated by their husbands’ avoidance and lack of communication to manage the situation.
Mada, a 46-year menopausal woman with intermediate education who complained of her husband’s erectile dysfunction, said:
… Because he does not answer me, I say that there is no need to talk… There is no need at all; it makes no difference (whether I tell him or not)… I do not confront him… I feel that he avoids me because he has poor sexual performance… I ask him, but he never answers me. This is frustrating… So I avoid talking with him about these issues (Mada, intermediate, 46 years, menopause, II).
Mada stated that she and her husband had not had sex for the past year and did not even talk about it . During the interview, Mada looked desperate. The need to share her concerns was apparent, considering that her sexual difficulties impacted profoundly on her, physically and psychologically.
Some women interpreted their husbands’ attitude and behaviour as sexual abuse and neglect. Yet, they felt powerless due to the lack of resources and the cultural norms that do not recognize their sexual rights. Women preferred to keep quiet and sacrifice at the expenses of their sexual satisfaction and overall wellbeing. They accepted their situation as their lot in life. As illustrated by Karine, a 43-year-woman with limited formal education:
But what can a person do; in our community, once the woman gets married, it is finished. You get married, and you get children. You have tried to solve your problems, but you failed. What do you do? What is the solution? There are children. You have to sacrifice either your children or yourself. I sacrifice myself (Karine, elementary, 43 years, premenopause, II).
Karine reported on her endurance of her husband’s sexual problems since the time she got married, 21 years ago. Being obedient to her husband, who warned her to keep his problem hidden, she was so cautious about discussing her case until she was firmly assured of the confidentiality of the interview.
Lana faced the same problem with her husband, whom she accused of sexual impotence. She expressed her rights for sexual pleasure and criticized the gender-based social norms that overlook women’s sexual needs. She said:
The man sleeps with his wife and does nothing… You feel that you become used to that… He (her husband) enjoys it, and that is. It does not count if the woman enjoys or not. This is also my right, my right. If the situation was reversed …., I do not think that he would have been patient... He would have blamed me 20 times. He would have cheated on me or married another woman … But when the problem is from the man, you have to keep quiet (Lana, secondary, 50 years, perimenopause, II).
Despite her anger, Lana, like the majority of women, expressed her readiness to seek help to satisfy her husbands’ sexual needs provided the situation was reversed.
But I am not keen (for sex), it is just for him (her husband); so that he does not say that I neglected him... If he likes it, no, I try; I try to do everything (to please him)… If my husband wants (sex) and I have sexual dysfunction, I treat myself. But if my husband is impotent, why do I have to treat myself?
Other women dared to discuss during the interview their husband’s sexual behaviours that they found undesirable and painful, particularly the practice of forced and anal sex. As articulated by Sara:
Sexual difficulties? Of course
I told you when he goes beyond the limits and wants to have anal sex. These problems happen. I do not accept this because I am not an animal to be treated in this way. If he loves me, he has to take care of me so that I give him this thing from my heart and with love (Sara, elementary, 49 years, premenopause, II).
Sara noted that to prevent her husband’s behaviour, she convinced him that anal sex is unhealthy and might cause him fatal infectious diseases. Yet, Zeina who faced the same problem was unable to change her husband’s "sexual perversion" as she said; being economically independent, she stopped having sex with him. Zeina reported that her sexual deprivation resulted in psychosomatic problems that required psychotherapy.
I am a human being, like him, I have my feeling, my, my, my,... [silence], what can I say? Because of that, I am suffering. I can not ventilate; I cannot satisfy my needs. This caused me a lot of pain, everywhere in my body (with tears in her eyes), and anger (Zeina, secondary, 52 years, menopause, FG).
3. Marital conflict
Common in women’s narratives was the perception of the spouses’ relationship as central to their sexual difficulties. They complained of a pile-up of events that were difficult to handle with the husband, and that led to poor and ineffective communication between the two spouses. Marital conflicts hurt women and created negative feelings towards their husbands such as resentment, indifference and disgust. Believing in the interplay of the physical and psychological factors in sexual life, women asserted that sex could not be satisfying if it is not driven by emotions and mutual attention between the spouses. Feeling uncomfortable inhibits sexual desire and pleasure and engenders sexual difficulties. Sex becomes a duty and abuse for women.
One participant explained that from her perspective, sexual life is not only about penile penetration; otherwise, it becomes what she termed 'disgusting'. In the same vein, another woman declared that at the beginning of her marital life, sex was pleasurable. Presently and because of marital conflicts, she had feelings of rejection and anger towards her husband. She stopped caring for him and completely lost sexual desire and orgasm. This was also the case for Sally, who claimed her total sexual disinterest and frigidity as she does not love her husband.
By the way, sorry, I do not have any sexual desire. I do it only at his insistence—no way, impossible. I do not have the desire. There is no way that I feel like it. I do not love him (Sally, university, 49 years, premenopause, FG).
Sally supposed that she would have had sexual desire if she was with another man, implying that sexual difficulties are relational rather than biological. The other women of the group supported Sally’s opinion and gave testimonies of their sexual life to ascertain that "women could not be instinctively driven" as they said. Another example was illustrated by Quinana, who declared that the primary purpose of participating in the study was to talk about what she described as a 'miserable sexual life'. She described herself as an 'automated sex robot' for her husband, who she described as rude and abusive. She stated that every time she has sex, she hates herself more and more.
My husband makes me feel that I am only important for this thing (sex). Because of that, I hate sexual life. I need to feel that I am a woman and then take what you want… I accept everything, poverty, misery, taking care of the house, cooking food every day… but I need him to value my efforts and then you can take from me whatever you want. With a strong tone, she said: I give you; you do not take by yourself; I give you… This thing makes me sad… I do not have any rights… I like sex to happen with love… (Quinana, secondary, 40 years, menopause, II).
When asked about why Quinana continues to have sex with her husband, she replied that she obeys him; otherwise, he violently beats her in front of the children and seriously harms her. Lacking love and respect, she reflected on her situation with apparent bitterness and chagrin.
Uguette was another victim of her husband’s moral, physical and sexual abuse. She courageously voiced her disappointment in front of women in one of the focus groups:
When you get married, you say that this is the person that I want to live with... get joy with him, and found a nice family... You devote yourself, body and soul; then you are confronted by the truth… The man you dreamed about disappointed you; you become disgusted with him... if he sleeps with you, you do not want him. You just want him to finish and leave you alone. This means that you are not happy, and sexual issues are inhibited... It is very important to feel that you are desired, to feel that you are a woman (Uguette, secondary, 54 years, menopause, FG).
Conscious of the violation of her sexual rights, Uguette described herself as a passive recipient who is filled and left like 'garbage'. Although she was the wage earner of the family, she 'sacrificed' herself for her children and refused to leave the house to avoid social stigma.
The husbands’ reported egoism and selfish sexual behaviour exhausted women and increased their marital conflicts that, in turn, intensified their sexual difficulties.
Sexual difficulties happen if the man is self-centred and wants to enjoy himself without caring about his wife… the man does not control himself… the insistence on his wife to always have sex just for himself… it is very important that the woman enjoys… This is in his nature; he does not care about his wife if she enjoys or not… Another issue relates to man insistence to have sex regularly ignoring her fatigue and concerns... His instincts drive man. In the majority of sexual relationships, women do not enjoy. It is all about the psychological context of the sexual relation (Dalia, university, 46 years, premenopause, II).
In the same line, Tressy said:
Life is not fair. It is the power of the stronger. My husband is not at all like this. In the end, you are tired, and you lose your interest. You become unhappy with sex, with everything. Your life is affected. Sex is not just an act; just a duty?! no… (Tressy, intermediate, 45 years, premenopause, FG).
4. Sexual difficulties as context and time-bound
In this subtheme, sexual difficulties are framed within the challenges women face in their daily life as wives, mothers and workers in addition to personal health issues. These overwhelm them and limit their sexual interest and pleasure. For instance, Tamara, who is the only breadwinner of the family, explained:
If I have poor sexual performance, this does not mean that I do not want (to have sex). The problems of life are enormous, and you reach a point where you are tired… Social, financial and family burdens affect it (sexual life) without doubt and cause sexual difficulties. You need suitable conditions to accept the other… I often experience these situations… (Tamara, university, 49 years, perimenopause, FG).
In the same line, a conversation was initiated between two women of another focus group by saying:
Tressy. So, at some point, if nothing is happening between man and woman [meaning sex], I don't know if it is caused by poverty or worries … (Tressy, intermediate, 45 years, premenopause, FG)
Sally approved Tressy's opinion. She said:
As for me, anything in the society, like what she said, the money, anything may affect me. My husband! No, no way! Nothing can affect him. As for me, if he does not work for one day, I am troubled… (Sally, university, 49 years, perimenopause, FG).
Sally added:
If my daughter is sick, I get troubled. Anything can make me nervous. So no way (making sex).
Tressy continued by saying:
Sexual life fades between the spouses. There is boredom, quarrel, and sexual life fades with the burden of life.
Reproductive health burdens like delivery, breastfeeding and infertility problems might also cause sexual difficulties. Mirvat, who has been facing infertility problems for seven years, said:
The feeling that you have put in the extra effort at the expense of your psychological status to stimulate the desire of your husband who himself might arrive from his work hungry and not in the mood because the timing is right. This is one of the worst things that might happen in marital life… At this moment, (she stopped talking and then in a hesitant voice said) I feel destroyed and often (she cries) I have uncontrollable crying when I finish (Mirvat, university, 41 years, premenopause, FG).
Mirvat's account was quite compelling and made all women in the focus group sympathize with her; they gave her advice to reduce her distress.
Another aspect of women’s sexual difficulties was exemplified by Rayan who complained of an altered body-image and low self-esteem due to excessive weight gain. Such a portrayal that is dissonant with the idealized image of women’s body triggered her negative feeling about herself and affected her sexual desire and capacity to satisfy her husband’s sexual needs. This, in turn, made her more frustrated. She reported that:
I am upset because I feel sad; I cannot wear what I want. I do not like to sleep with my husband a lot. I pretend that I am tired. I am intimidated because of my obesity. This bothers me. I have been in this way for 5 to 6 months. I can't wait anymore. He used to enjoy it, but I didn't. My husband is still young, only 50 years old (Rayan, elementary, 45 years, premenopause, II).