I visited a woman in her late 30s at her house, as part of data collection for a study. She lived in a lower-middle-class household with her husband who had a job that kept him very busy while the woman stayed at home. The study was around couples dealing with infertility, and the primary respondents were women. I introduced myself to this woman and briefed her about the study. After obtaining her consent, I took out my interview schedule to start the interview. The first section of the schedule had a few screening questions. These were to discern whether or not couples who did not have a child at the time of the survey were actively attempting pregnancy. The first question was, “Are you and your husband currently trying to get pregnant?”
After I asked the question, there was a lingering silence from my respondent. This was expected because the topic of enquiry was very difficult for women to talk about. Since I did not get a reply, I repeated the question, thinking that my respondent had not understood the question clearly. Then, she looked at me pensively and replied, “No”. I entered the response and just as I was moving to the next question, she said, “We do not have sexual relations”. I thought it was just a passing phase and asked her more about it. What she narrated to me was heart-breaking. She got married at the age of 17, and it’s been 20 years since she has been married. She feels her life has no meaning and that a child would at least give her a reason to live. After marriage, they had consulted a male infertility specialist since the husband had erectile dysfunction. In addition to erectile dysfunction, her husband was diagnosed with azoospermia (no sperm in the ejaculate). The doctor had told her that since she was young, she could consider re-marriage if she wanted to have a child. She also added that her husband had said that if she wanted to go, he was ready to leave her, and she could go elsewhere and be happy.
She said to me, “I am from a very poor family and if I left so soon after marriage and went back to my home, there would be nothing for me there. Here, at least I get food to eat and clothes to wear. So I stayed in this marriage.” They had tried In Vitro Fertilisation (IVF) with donor sperm once but it was not successful. She added that her husband does not come to the hospital, “If we have to do it again, he has to come and consent but I don’t think he is interested. I cannot even discuss these things because he gets hurt and tells me if I want to leave then I am free to do so.”
She went on to tell me that her husband does not recognise the pain that she experiences because he goes out to work and forgets these things. “I sit at home and it is upsetting for me. I am telling someone all these feelings for the first time.”
I found this particular narrative important because, as someone researching infertility, I have heard women discuss how sex has become a routine affair for them. Infertility treatments require that couples have sexual intercourse on particular days, as advised by their treating physicians. Women who are on ovulation induction treatment are advised to have sex on days when they are given ovulation trigger shots (Human chorionic gonadotrophin – hCG injections). Women in my study have told me that they do not feel particularly inclined to have sex on certain days due to the hormones and also pain due to the injections, as the injections are either given subcutaneously in the lower abdomen or intramuscularly in the buttocks. They have reported that they were unable to even sit properly, due to pain, after the injection. Nevertheless, they have sex in order to get pregnant. Engaging in intercourse has become a process where the desired outcome, i.e., pregnancy, is the only thing they look forward to.
We see women who say that they have to have sex when they are not emotionally or physically inclined to do so to those who are unable to have sexual intercourse due to their partner’s sexual dysfunction. These narratives are a few among the spectrum of female sexual experiences, where women are limited by various factors like lack of power, privilege, autonomy and agency from enjoying a satisfying sexual relationship An accompanying infertility diagnosis adds another layer to this experience. Most women are powerless in the situation they are in, because they are bound by the obligation to reproduce. Many don’t have the agency to talk openly about sex and pleasure within the patriarchal set-up they are part of, such as my respondents. The woman I spoke with voiced her feelings for the first time to someone because she was asked that particular question. This woman’s sexuality lies at the intersection of gender, class, and her partner’s condition.
The gender identity of women, intersecting with social, cultural and gender norms, leads to a non-recognition of their sexual rights. The consequences of this are manifold including violence, marital rape, sexually transmitted infections, unwanted pregnancy, abortions, depression, and an unsatisfying sexual life. We are often taught that in marriage, the man is entitled to sexual pleasure while the role of the woman is to be a passive provider of this sexual pleasure to her husband. Women are taught by gender norms to ignore their sexuality, and any departure from this is subjected to moral condemnation and those who speak openly about their sexual needs and pleasure are vulnerable to being shamed. Hence, they are often forced to remain silent and live their lives in constant agony rather than being able to experience a fulfilling sexual life. Female sexuality and pleasure are often dismissed. They are either rushed into orgasm or if not, they are forced to fake it, which is considered more acceptable than speaking up.
When the man has a sexual dysfunction, the woman is expected to protect her husband from the stigma surrounding it. Therefore, women have to let go of sexual pleasure in their life and silently endure it. These issues relating to sexual needs are not recognised in routine clinical practice (if not specifically mentioned), especially in infertility treatment where sex is an important step to attaining pregnancy. In routine clinical encounters, couples are given blanket advice to have sex during the fertile period. In that space sex only becomes a means for procreation. Most women do not open up about the issues related to their sexual life to their doctors, because they are not sure whether or not they are allowed to talk about these issues at all. It is also important to note that most women choose to keep quiet and accept their circumstance. Internalised patriarchy plays a major role in them having to remain silent, compounded by their life circumstances and lack of resources to negotiate a fulfilling sexual life.
A friend, who is a head and neck surgeon, recounted to me once about a female patient he saw in the OPD (Out Patient Department). The woman came with the complaint of headache to him and, in routine clinical examination and history, he did not final anything significant. He added that the OPD is usually very busy and they do not get the time to have very detailed conversations with the patients. The patient was advised to take analgesics and to come for a review if the pain persisted. He said that the woman came to the OPD again with the same complaint, and even after further investigations no underlying pathology could be identified. On the day she visited again, the OPD had not been crowded, and he took some time to talk to her. That is when the woman opened up to the doctor regarding her life. He identified that the patient and her husband did not have sexual relations and that caused much distress to her. The doctor immediately referred her to a specialist in sexual medicine. He added that the woman never visited the OPD again, but we do not know whether she visited the sexologist or not.
Mostly, in our routine clinical practice, these cases get ignored as stress headaches or psychosomatic symptoms because a woman’s sexual needs are not considered real or important. We need to recognise the importance of talking about female sexuality and the sexual needs of women, and equipping our medical caregivers to be sensitive to such issues. An important first step towards this is to develop and implement a comprehensive sexual health course in the medical curriculum. This can help medical professionals in recognising and addressing sexual health issues without a moralistic or judgmental attitude.
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