Kathryn S. K. Hall1
(1)
Hall Watter Institute, 20 Nassau St. Suite 411, Princeton, NJ 08542, USA
Kathryn S. K. Hall
Email: kathrynhall@comcast.net
Keywords
Sexual dysfunctionCultureCultural sensitivity
4.1 Sexual Dysfunction Cross-Culturally
Sexual dysfunctions as defined by Western diagnostic standards, or at least the symptoms of dysfunction, occur globally with prevalence rates that are similar to those in North America [1]. The fact that these specific sexual difficulties occur around the world should not be surprising given that the basic mechanics of sex do not change from one culture to another. Unfortunately, the epidemiologic surveys to date have not provided a measure of whether Western-defined sexual dysfunctions are more, less, or differently distressing across diverse cultures.
An examination of help-seeking behaviors may shed light on the sexual problems that are most problematic within a culture, although this will likely result in an underestimate of the prevalence of those problems. Across cultures, premature ejaculation (PE) is one of the most frequently reported sexual complaints for which men seek help [1, 2]. In Western cultures, PE may signify problems with control [3], while in many Eastern cultures, it is simply experienced as an abrupt termination of sexual pleasure [4]. Men from Westernized cultures may be interested in learning how to pace sexual arousal and delay ejaculation until their partner has experienced orgasm, whereas men from Eastern cultures might be more amenable to medication to prolong ejaculatory latency [3, 4]. Other anxieties related to ejaculation (nocturnal emissions, guilt about masturbation) account for a high number of patients reporting to sexual health clinics in India and areas in the Middle East [2, 4] and often outrank erectile dysfunction as a presenting complaint. These concerns underscore a cultural belief in the life-enhancing properties of conserving semen, a belief that is not universally shared [5].
While low sexual desire is the most frequent complaint of women in the West, in more male-centric cultures, vaginismus is the primary sexual complaint for which women seek help [6]. The prevalence of vaginismus in non-Western cultures has been attributed to the high premium placed on virginity and the fact that vaginismus interferes with intercourse (and therefore with male pleasure) and can significantly hinder reproduction [7].
4.2 The Impact of Culture
Culture influences sexual dysfunction in three important ways:
1.
2.
3.
In the West, for example, low sexual desire in women is often accompanied by a high rate of refusing sex, a low rate of initiating sex, and an overall reduction in the frequency of sex. Paradoxically, when sex occurs, it is usually pleasurable. Because sex is often equated with love in committed relationships, her low desire will be distressing for the woman (and her partner). Western-trained clinicians will readily recognize this cluster of symptoms as low sexual desire. In other cultures such as South Korea, a wife’s consent and desire are not deemed necessary for the occurrence of sex, as sexual frequency is dictated by the husband’s desire. South Korean women with low desire may engage in frequent but unwanted sex. Sexual aversion or disgust as well as anger at her spouse and disdain for men in general may result [9]. Typically, this symptom constellation would be unfamiliar to a Western-trained clinician, and the sexual issue would in all probability remain hidden behind the overt hostility.
4.3 Assessment
Western-based classification systems are based on a biopsychosocial model of human sexuality [10] and emphasize the pleasure/performance aspects of sexual functioning, our linear view of the sexual response (desire-arousal-orgasm), and the individualism inherent in the culture (e.g., the individual nature of the diagnosis and the individual basis of the distress criterion). Recently a circular model of sexual response has been proposed which described female arousal and desire interacting in a cyclical and mutually reinforcing fashion. This model emphasized the importance of sexual and emotional satisfaction and intimacy in driving women’s sexual behavior [11]. However, in many parts of the world, sex is not a private act (not even necessarily an intimate act) between consenting participants but is a matter of concern for extended families and communities. While an emphasis on male sexual pleasure is universal, female sexual pleasure is more often a neglected dimension of sexuality rather than a prime motivator. Spirituality is very important in many cultures, yet it is often neglected in Western formulations of healthy sexuality and good sexual functioning [12].
Culturally sensitive assessment requires the clinician to understand the presentation of symptoms from the patient’s perspective, recognizing that this perspective is strongly influenced by the culture in which the patient was raised. At present, the best practice is a diagnostic interview as there are limitations to using standard assessment tools. The majority of questionnaires designed to assess sexual function were developed for and standardized on Western populations. When cross-cultural validation has been attempted, significant differences in the factor structure of the questionnaires have been found along with translation difficulties [13–16]. When seeing clients from non-Western cultures, it is suggested that assessment measures be used with caution (e.g., following up with the patient to ensure that the meaning of the questions is clear). However, an overreliance on paper and pencil tests or questionnaires may be off-putting to certain cultural groups [17].
The diagnostic interview is the keystone of a successful and culturally sensitive assessment. It is important to listen carefully to how the problem is described (“I have ruined myself.” “My vagina is locked.”) as this will provide information regarding the patient’s cultural perspective and will help frame treatment options. The cultural context of the problem will involve understanding the patient’s causal attributions as well as the consequences of a successful or unsuccessful resolution of the problem. Ask: What do you think is causing this problem? What have you tried to do to remedy it? What will happen if you cannot fix this problem? What do you expect will happen when the problem is fixed? The culturally sensitive patient assessment is augmented by an awareness of the resources available to the individual or couple, as well as of the cultural impediments to treatment.
4.4 Treatment
Cultural sensitivity requires that adaptations be made to the way that sexual medicine and sex therapy are practiced. In some cases, very little modification will be required, while in others, major modifications and greater sensitivity are necessary. In extreme cases it may not be advisable to provide treatment. Given that sex therapy and sexual medicine are predicated on the belief that men and women have equal rights to enjoy and to consent (or not) to sex, it is the status of women within the culture that often provides the measure of whether or not Western interventions, even with modifications, are warranted. If the basic assumption of consent cannot be met, treatment should not be offered. If a woman is highly valued and respected within her intimate relationship (marriage) but is not recognized as an equal within the larger culture, her status in the marriage can pave the way for successful and ethical treatment of sexual dysfunction. For example, there are reports of intracavernosal injection (ICI) being given to young Iranian men unable to quickly consummate their marriage due to extreme anxiety [4]. In the traditional and patriarchal culture of rural Iran, it is assumed that an unconsummated marriage is an even greater liability for the wife as compared to her husband, as he would have the option of remarriage not typically open to her. However, even in rural Iran, if there is a great age disparity between the partners or a high probability of divorce, ICI is not offered, as the basic assumption of consent cannot be met. In the West, the standard for consent is much higher and would typically involve including the wife in the treatment process, thus actively seeking her consent and participation.
4.5 Case Example
The case of a young couple from the Middle East with unconsummated marriage illustrates cultural variations in sex therapy, as well as a multidisciplinary approach to treatment. The couple was referred to sex therapy by an infertility clinic. The husband worried that he could not “break” his wife’s hymen (his statement of the problem). He was concerned that his history of masturbation had weakened him (his causal attribution) as he lost his erection just prior to intromission. The young man was concerned that his wife’s family would soon intervene to end the marriage (the consequence if the problem is not corrected). The couple tried unsuccessfully to have intercourse on those mornings when the husband awoke with an erection (what they had tried to do to solve the problem). Instead of challenging “irrational” beliefs, the sex therapist worked with the patient to see if his erectile weakness could be remedied. The patient was prescribed a PDE5i by his primary care physician. The sex therapist gave him exercises to help him gain confidence in his erectile ability and learn to regain an erection should he suffer erectile failure. The patient abstained (for the most part) from ejaculating when doing the exercises due to his belief that conserving semen would strengthen him. The patient and his wife were referred to a gynecologist, who explained female genital anatomy and the physiology of arousal during an external pelvic examination. The patient and his wife were surprised to find that the hymen was not a hard membrane completely covering the vagina as they had both assumed. Sex therapy-assigned vaginal dilation exercises were carried out by the husband, using his fingers (dilators were considered to be a violation of his wife’s virginity). While standard sex therapy practice is to give the wife control of the pace and timing of the dilation exercises (and she does them first), it was culturally important that the husband take the lead. As his ability to get and maintain an erection improved, the patient was reassured that he had not caused lasting damage to himself. The dilation exercises reassured the couple that penetration was possible and would not cause unbearable pain. Sex therapy exercises included relaxation techniques and instructions on foreplay. In 8 weeks the couple was able to have intercourse and therapy ended.
Too often a patient’s culture is viewed as an impediment to treatment, but it may also provide valuable resources for dealing with sexual problems. Patients’ religious faiths may sustain them in a marriage while sexual difficulties are being worked through. Extended family members are also resources, especially in collectivist cultures. I have previously described a case involving a Pakistani couple in which the wife’s parents, highly invested in the success of the marriage, provided housekeeping and babysitting support so that their daughter and son-in-law could do sex therapy homework [12]. Others have described cases where extended family members have attended sex therapy sessions so that they could be informed of the couple’s progress. This assuages their anxiety, buys time for the distressed couple, and often enlists the family’s cooperation in providing time and privacy for sex therapy homework or other sexual activities [7]. The patient can often be enlisted to help problem solve culturally accepted treatment modifications. A not infrequent example would be Orthodox Jewish patients offering to contact their rabbi regarding permission to masturbate to ejaculation if the treatment required it.
At present, sexual medicine has little to offer women seeking to improve their desire and pleasure. These cases may warrant a referral to sex therapy. The referring clinician’s endorsement of sex therapy (and if possible, the sex therapist) is often essential to the referral being accepted and acted upon. While Western medicine is more easily accepted by other cultures, psychotherapy and sex therapy are quite literally foreign concepts. Conversely men and women from cultures where women enjoy equal status with men (e.g., Scandinavia) are excellent candidates for sex therapy, as the value that is placed on female sexual pleasure equals that for men.
4.6 Sexual and Cultural Minority Patients
The challenge inherent in diagnosing and treating sexual problems is compounded for patients who are both sexually and culturally in the minority (e.g., gays and lesbians from Eastern cultures, as well as trans individuals from almost any cultural group). The minority stress experienced by such patients is often severe and may manifest as physical as well as psychological ailments [18]. In these cases referring a patient to a support group regarding their sexual minority status can help when their family of origin or community has rejected them.
4.7 Cultural Sensitivity Is Good Clinical Practice
Cultural and ethnic minorities are an underserved population in sexual health. Only a small proportion of minority patients experiencing sexual problems ask their physicians for help, and an even smaller percentage of physicians inquire about sexual problems [19]. Additionally, many minority patients do not return for follow-up appointments or drop out of treatment early [20]. It is important to make sexual health services accessible for all members of the population who are in need.
Following good clinical practice guidelines in a nonjudgmental and flexible manner will allow for the treatment of most, but not all, patients from diverse cultural backgrounds. The practice of sexual medicine is enhanced by a respect for a patient’s culture, whether that culture is similar or different from that of the treating clinician.
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