**2. Background**

The focus that this chapter deals with, lays in the cross-section of midwifery and sexuality, however these two components is hard to separate completely. The state of the motherhood is obviously bound up with definitions of sexuality. The interlinking with sexual identity, sexual activity and motherhood is very complex tangle to unpick [8]. Midwifery is closely connected with sexuality of a couple; the birth is the take of the period that started with the sexual act. As sexual intercourse is not just the physical act, also pregnancy, birth and processes after the birth cannot be considered only bodily – they are multidimensional in its nature, affecting emotions, social and spiritual aspects of individual. These effects are not limited only to woman, but affect the family as a whole.

The intercourse, pregnancy, childbirth, breastfeeding and establishment of new relationships after the birth are very intimate milestones of the family life. As Price [9] acknowledges: "The physical changes of woman are linked also to her views of her sexual self". Her changing physical shape reveals that she is recognized by others as a sexual being [10].This process affects all aspects of her life.

The midwife that actively enters in the life of the couple/family during these periods must be therefore consciously aware of the emotional value of these periods for the clients. Already in 1975 World Health Organization acknowledged [11]: "Opportunities for the provision of sex information and counselling are particularly likely to arise in services for maternal and child health, family planning, mental health, community health, abortion and sterilization, and sexually transmitted diseases".

### **2.1. Midwifery**

There are many subthemes of midwifery that are closely connected to the management of issues of sexuality, however because of the above reasons, the author exposed the most evident connections, such as empathy or emotional work, communication skills and ethics.

### *2.1.1. Empathy and emotional work*

Empathy is essential for the effective provision of midwifery care [12]. However, in case of dealing with sexuality issues, is even more crucial. It helps midwife not to invade in womens' intimacy. In relating empathy to the therapeutic relationship of a midwife, it is seen to require midwife to be intuitive, with the woman then being able to show the depth of her under‐ standing of another person [13].

It was Hochschild who was the first person exposing the importance of emotions in work, however, his work was largely focused on commercial organizations. Emotional work in midwifery is of great importance, however largely unrecognized. Midwives need to work in a sensitive way in order that woman's feelings are acknowledged and responded to. To do this effectively, midwives also need to be aware of their own feelings, as their unrevealed inside conflicts can affect communication and relationship with women [14].

Students learn the emotional work during the study. The senior staff at the clinical placements are usually the role models for them and the perception changes over the educational process [15]. When dealing with problems in sexual area, it is of crucial meaning that midwives learn how to communicate and manage the feelings.

On the surface it could be presumed that midwifery is "on the happy side" of healthcare, and that only positive emotions will usually be felt [14]. But it is not always so. Midwives work also with clients that experience undesired pregnancy, live in an abusive relationship, have problems with conception, decide to end pregnancy etc. In these cases midwives need to support women even with greater emotional awareness.

The word partnership is often used to describe woman-midwife relationship. Some authors even go further and name it "professional friendship" [16]. Relationship between woman and a midwife can vary in its intensity, trust, openness and level of intimacy. This often depends on the level of reciprocity [17] and is closely connected with the way of communicating with each other.

### *2.1.2. Ethics and mode of communication*

**2. Background**

2 Sexology in Midwifery

to woman, but affect the family as a whole.

affects all aspects of her life.

sexually transmitted diseases".

*2.1.1. Empathy and emotional work*

standing of another person [13].

**2.1. Midwifery**

The focus that this chapter deals with, lays in the cross-section of midwifery and sexuality, however these two components is hard to separate completely. The state of the motherhood is obviously bound up with definitions of sexuality. The interlinking with sexual identity, sexual activity and motherhood is very complex tangle to unpick [8]. Midwifery is closely connected with sexuality of a couple; the birth is the take of the period that started with the sexual act. As sexual intercourse is not just the physical act, also pregnancy, birth and processes after the birth cannot be considered only bodily – they are multidimensional in its nature, affecting emotions, social and spiritual aspects of individual. These effects are not limited only

The intercourse, pregnancy, childbirth, breastfeeding and establishment of new relationships after the birth are very intimate milestones of the family life. As Price [9] acknowledges: "The physical changes of woman are linked also to her views of her sexual self". Her changing physical shape reveals that she is recognized by others as a sexual being [10].This process

The midwife that actively enters in the life of the couple/family during these periods must be therefore consciously aware of the emotional value of these periods for the clients. Already in 1975 World Health Organization acknowledged [11]: "Opportunities for the provision of sex information and counselling are particularly likely to arise in services for maternal and child health, family planning, mental health, community health, abortion and sterilization, and

There are many subthemes of midwifery that are closely connected to the management of issues of sexuality, however because of the above reasons, the author exposed the most evident

Empathy is essential for the effective provision of midwifery care [12]. However, in case of dealing with sexuality issues, is even more crucial. It helps midwife not to invade in womens' intimacy. In relating empathy to the therapeutic relationship of a midwife, it is seen to require midwife to be intuitive, with the woman then being able to show the depth of her under‐

It was Hochschild who was the first person exposing the importance of emotions in work, however, his work was largely focused on commercial organizations. Emotional work in midwifery is of great importance, however largely unrecognized. Midwives need to work in a sensitive way in order that woman's feelings are acknowledged and responded to. To do this effectively, midwives also need to be aware of their own feelings, as their unrevealed inside

conflicts can affect communication and relationship with women [14].

connections, such as empathy or emotional work, communication skills and ethics.

The midwife-women relationship is the foundation of the midwifery services says Kirkham [18]. The social context of those involved – their values and believes affect what the two parties bring to their relationship [19]. It is important of being aware of these sometimes unconscious impacts (or even biases), when communicating and acting.

Questions regarding sexuality may be regarded as problematic as they are sensitive and complex, and demand time and expertise [20]. In the study by Wendt et al. [21] health professionals (midwives and doctors) exposed, beside lack of organisational support or communication skills, difficult emotions that complicate the situation when speaking of sexual problems. This reason might restrain midwives and clinicians from raising sexual issues. It is important that woman is treated as a partner in a relationship, so that the solutions to her problems derive from her alone. Therefore active listening is used when discussing things with women [22].

As language, also actions, when dealing with delicate situations, which those connected to sexuality certainly are, must be tactful, sensitive and ethically sound. Attending women in childbirth is highly intimate and some procedures are very intrusive (for example vaginal examinations); midwives need to perform them with sensitivity and empathy. Especially when dealing with delicate sexuality issues (such as pregnancy after sexual abuse or similar), midwives must bear in mind that their actions and words affect women deeply.

Being ethically aware is a necessary step towards being an autonomous practitioner [23]. Believes and values of professionals and clients that interact are very different and derive from their broader social context, culture and past experiences. Therefore the solutions to same problems may vary, but there need to be clear ethical boundaries that must not be crossed.

### **2.2. Sexology**

Sexology defined by Oxford dictionary [24], is "the study of human sexual life or relation‐ ships". On the Kinsey Institute website [25] sexology is defined in much more detail: "Sexology is the systematic study of human sexuality. It encompasses all aspects of sexuality, including attempting to characterise 'normal sexuality' and its variants, including paraphilias. Modern sexology is a multidisciplinary field which uses the techniques of fields including biology, medicine, psychology, statistics, epidemiology, pedagogics, sociology, anthropology, and sometimes criminology to bear on its subject. It studies human sexual development and the development of sexual relationships as well as the mechanics of sexual intercourse and sexual malfunction. It also documents the sexuality of special groups, such as handicapped, children, and elderly, and studies sexual pathologies such as sex addiction and child sexual abuse. Sexology is considered descriptive, not prescriptive: it attempts to document reality, not to prescribe what behaviour is suitable, ethical, or moral. Sexology has often been the subject of controversy between supporters of sexology, those who believe that sexology pries into matters held sacrosanct, and those who philosophically object to its claims of objectivity and empiricism".

The concept of sexology as a science in Europe was first proposed in 1907 by the Berlin dermatologist Iwan Bloch. His ideas were quickly embraced by interested colleagues in the same city, especially Magnus Hirschfeld, who in 1908 edited the Journal of Sexology, in 1913 co-founded the Medical Society for Sexology and Eugenics, in 1919 the Institute for Sexology in Berlin and organized the first international conference on sexology in 1921 in Berlin. Both Bloch and Hirschfeld believed that the traditional medical approach to sexual questions was too narrow and had to be broadened. Only a combination of methods taken from the natural and social sciences could do justice to the complex bio-psycho-social phenomenon of human sexual behavior [26]. The very important document that set the scene of sexology in the area of health was WHO document introduced in 1975 [11].

### *2.2.1. Sexual health and midwifery*

It took several ages until the claim that all health professionals should have some basic scientific knowledge about human sex behaviour. It derived from the document on definition and promotion of sexual health by the World Health Organization [11]. That is to say, physicians and psychotherapists, nurses, hospital administrators, marriage and family counsellors, family planning officials, community health workers and even epidemiologists should receive at least some sexological training. But this enterprise is still marginalized in universities [26]. There is also an obvious shortage of interested teachers who can devote the necessary time to acquiring sufficient knowledge and skill in dealing with human sexuality to organize and lead educa‐ tional programmes in this area [11].

Sexuality is essential to health and contributes to quality of life, personal development and well-being. Positive sexual experiences promote health when they generate a feeling of security [27]. Nursing and midwifery council [2] sees the role of the midwife in individual counselling, solving the sexual problems like advising women regarding the contraception (also appropri‐ ate for woman that breastfeeds), dealing with loss of libido (for example in the postpartum), giving advice regarding sexuality during pregnancy, solving the problems with discomfort of the perineum after the birth or even dyspareunia, dealing with problems of changed body image during pregnancy etc. One aspect of the midwifery care can be also advising about natural methods of family planning [28].

When women attend health-care services, there are opportunities to create a dialogue aimed at promoting their sexual health [29]. But often health professionals believe that they have insufficient education, feel poorly prepared and therefore they do not discuss sexual issues with their patients [30]. However women expect them to – in a study by Wendt et al. [31], a majority of young women approved of being asked about sexuality by midwife or clinician, because they trusted them [21]. Sexology training programs, whether academic or professional, must therefore be included in the basic study of health professionals, to improve attitudes as well as to impart knowledge [26].

Despite very clear role of the midwife in dealing with sexual issues, midwifery textbooks usually present only certain aspects of sexuality, such as contraception or intimacy during pregnancy and childbirth [28, 32]. The question is, where midwifery students learn the skills and approaches to address the issue of sexual health. Health-profession students commonly state that conversation about sexuality with patients makes them uncomfortable [33]. The author identified that this field of midwifery is largely neglected, however very important for women, therefore she decided to include the subject of Sexology into the undergraduate study programme of midwifery.

### **2.3. Midwifery study programme and sexology**

**2.2. Sexology**

4 Sexology in Midwifery

empiricism".

Sexology defined by Oxford dictionary [24], is "the study of human sexual life or relation‐ ships". On the Kinsey Institute website [25] sexology is defined in much more detail: "Sexology is the systematic study of human sexuality. It encompasses all aspects of sexuality, including attempting to characterise 'normal sexuality' and its variants, including paraphilias. Modern sexology is a multidisciplinary field which uses the techniques of fields including biology, medicine, psychology, statistics, epidemiology, pedagogics, sociology, anthropology, and sometimes criminology to bear on its subject. It studies human sexual development and the development of sexual relationships as well as the mechanics of sexual intercourse and sexual malfunction. It also documents the sexuality of special groups, such as handicapped, children, and elderly, and studies sexual pathologies such as sex addiction and child sexual abuse. Sexology is considered descriptive, not prescriptive: it attempts to document reality, not to prescribe what behaviour is suitable, ethical, or moral. Sexology has often been the subject of controversy between supporters of sexology, those who believe that sexology pries into matters held sacrosanct, and those who philosophically object to its claims of objectivity and

The concept of sexology as a science in Europe was first proposed in 1907 by the Berlin dermatologist Iwan Bloch. His ideas were quickly embraced by interested colleagues in the same city, especially Magnus Hirschfeld, who in 1908 edited the Journal of Sexology, in 1913 co-founded the Medical Society for Sexology and Eugenics, in 1919 the Institute for Sexology in Berlin and organized the first international conference on sexology in 1921 in Berlin. Both Bloch and Hirschfeld believed that the traditional medical approach to sexual questions was too narrow and had to be broadened. Only a combination of methods taken from the natural and social sciences could do justice to the complex bio-psycho-social phenomenon of human sexual behavior [26]. The very important document that set the scene of sexology in the area

It took several ages until the claim that all health professionals should have some basic scientific knowledge about human sex behaviour. It derived from the document on definition and promotion of sexual health by the World Health Organization [11]. That is to say, physicians and psychotherapists, nurses, hospital administrators, marriage and family counsellors, family planning officials, community health workers and even epidemiologists should receive at least some sexological training. But this enterprise is still marginalized in universities [26]. There is also an obvious shortage of interested teachers who can devote the necessary time to acquiring sufficient knowledge and skill in dealing with human sexuality to organize and lead educa‐

Sexuality is essential to health and contributes to quality of life, personal development and well-being. Positive sexual experiences promote health when they generate a feeling of security [27]. Nursing and midwifery council [2] sees the role of the midwife in individual counselling, solving the sexual problems like advising women regarding the contraception (also appropri‐ ate for woman that breastfeeds), dealing with loss of libido (for example in the postpartum),

of health was WHO document introduced in 1975 [11].

*2.2.1. Sexual health and midwifery*

tional programmes in this area [11].

In 2004 midwifery education in Slovenia faced great changes. With Slovenia entering EU, changes of curriculum had to be made to address all midwives' competencies, according to the European directives [34]. Within the implementation of the undergraduate study pro‐ gramme that is delivered at the Faculty of Health sciences in Ljubljana (the only midwifery programme in Slovenia), also new subject was added to the curriculum, called Sexology in midwifery. It was composed of 20 hours of lectures and was allocated in the last (third year) of the midwifery study. It was a compulsory subject [35].

With the changes of the programme in 2007, due to the Bologna reform, subject Sexology in midwifery expanded to 15 hours of lectures and 30 hours of seminars. It was still allocated in the last (third) year of the programme, however it was not mandatory anymore [36].

The content and the aim of the subject stayed the same; however the expansion enabled to discuss the themes more in depth and the use of different forms of study provided the possibility to use other teaching methods, not just lecturing.

The contents of the study are:


The goal of the subject is that students get an insight into own standpoints and attitudes regarding certain sexual issues and through the discussion identify own barriers, prejudices and hindrances for open communication about this matter with women.

At first the only method used was lecture, but later it become evident that students appreciate also debate, projects and benefit from role playing. At first the subject had an exam at the end of the course. But since the main aim of the subject was never testing theoretical knowledge of the students, the subject is now assessed on the basis of students' work within the project/ seminar and involvement in the discussion.

Since undergraduate study programme of midwifery is going to be implemented again in 2015, there was a need to evaluate the subject in order to decide, whether to still include it into the future 4-year curriculum.

### **3. Methodology and research design**

With the aim of evaluating the form, content, methods and employability of knowledge and skills gained through the realization of the subject Sexology in Midwifery, which is included in the undergraduate midwifery study programme, the quantitative research method was used. For the administration of the questionnaire, author used web survey, using EnKlikAn‐ keta [37], the tool that provides the option of transmission of the data into the SPSS programme.

### **3.1. Research tool**

The research tool was questionnaire, developed especially for the study that evaluated all aspects of the curriculum. Questionnaire was not pilot tested, however it was discussed over with methodologist and was given to two academic colleagues to fulfil and define vague questions.

Questionnaire was composed of 16 questions: 11 closed questions, 3 semi-closed questions (with the possibility "other") and 2 open ended questions. The first two questions ("Did you study midwifery" and "Did you attend subject Sexology in midwifery") were selective – if participants answered them no, they were not able to answer all the other questions. In questions regarding the general satisfaction with the subject, satisfaction with contents and teaching methods, author used Likert scale. Participants had to answer all the questions, otherwise they were not allowed to move to the next question in the survey.

### **3.2. Participants, sampling**

**•** perceptions of sexuality in postmodern society;

**•** sexuality in different periods of woman's life;

seminar and involvement in the discussion.

**3. Methodology and research design**

future 4-year curriculum.

**3.1. Research tool**

questions.

**•** sexuality during pregnancy, birth and puerperium; **•** women's sexual problems and midwifery care [36].

**•** sexuality in art;

6 Sexology in Midwifery

**•** individual aspects and prejudices regarding sexual issues;

**•** midwives role, approach and communication regarding sexual issues;

and hindrances for open communication about this matter with women.

The goal of the subject is that students get an insight into own standpoints and attitudes regarding certain sexual issues and through the discussion identify own barriers, prejudices

At first the only method used was lecture, but later it become evident that students appreciate also debate, projects and benefit from role playing. At first the subject had an exam at the end of the course. But since the main aim of the subject was never testing theoretical knowledge of the students, the subject is now assessed on the basis of students' work within the project/

Since undergraduate study programme of midwifery is going to be implemented again in 2015, there was a need to evaluate the subject in order to decide, whether to still include it into the

With the aim of evaluating the form, content, methods and employability of knowledge and skills gained through the realization of the subject Sexology in Midwifery, which is included in the undergraduate midwifery study programme, the quantitative research method was used. For the administration of the questionnaire, author used web survey, using EnKlikAn‐ keta [37], the tool that provides the option of transmission of the data into the SPSS programme.

The research tool was questionnaire, developed especially for the study that evaluated all aspects of the curriculum. Questionnaire was not pilot tested, however it was discussed over with methodologist and was given to two academic colleagues to fulfil and define vague

Questionnaire was composed of 16 questions: 11 closed questions, 3 semi-closed questions (with the possibility "other") and 2 open ended questions. The first two questions ("Did you study midwifery" and "Did you attend subject Sexology in midwifery") were selective – if

**•** interconnections among love, sexuality, partnership, parenthood;

The approach was total population sampling [38] - the sample included all generations of graduates of midwifery study programme, from the year, when Sexology was introduced in the study programme, till June 2014. It consisted of 174 participants. 3 mails returned with the notification that e-mail address is not active anymore, so final number of participants included in the study was 171.

### **3.3. Data collection, ethical considerations and analysis**

Participants were approached through the alumni club list; the request with the link to the web survey was sent to them via e-mail address. The web survey was available online from 19th of June, till 20th of July 2014.

When graduates were approached, they were ensured confidentiality. It was stressed for several times (in the mail and in the introduction letter of the survey) that their cooperation is voluntary. In order to ensure participants confidentiality, we did not ask about the gender (since only few graduates in midwifery are males and would feel exposed) and the year of attendance in the subject, so it is impossible to track participants from their answers.

Data from the survey were analysed with SPSS (version 20) programme. Basic descriptive statistic measures were calculated for this paper, to get the general insight into the participants' views on the subject. Some of the results of the study are presented below.
