Abstinence To Excite Sex

• Sexual Abstinence Benefits
• Why Abstinence

Results In this setting, prolonged sexual abstinence intended at promoting child health was the dominant discourse in the period after childbirth. Sexual relations after childbirth involved the control of sexuality for ensuring family health and avoiding the social implications of non-adherence to sexual abstinence norms. Both abstinence and control were emphasised more with regard to women than to men. Although the traditional discourse on prolonged sexual abstinence for protecting child health was reproduced in Ilala, some modern aspects such as the use of condoms and other contraceptives prevailed in the discussion. Conclusion Discourses on sexuality after childbirth are instrumental in reproducing gender-power inequalities, with women being subjected to more restrictions and control than men are. Thus, interventions that create openness in discussing sexual relations and health-related matters after childbirth and mitigate gendered norms suppressing women and perpetuating harmful behaviours are needed. The involvement of males in the interventions would benefit men, women, and children through improving the gender relations that promote family health.

Abigail McElroy writes that abstinence-only sex education is both ineffective and dangerous, and that's why she led the charge to end it in her Pennsylvania school district.

Background Sexuality as the social construct of a biological drive is closely related to gender, another social construct. Men and women are socialised to culturally- specific and socially acceptable ideals of masculinity and femininity , and the period after childbirth is no exception.

Sexuality has long been a subject of secrecy and taboo in Africa. However, the presence of HIV has precipitated the move towards more openness on how sexuality is conceptualised , and gendered norms on sexuality and decision-making have been dismantled -. Prolonged sexual abstinence after childbirth is a socio-cultural practice with health implications and is described in several African countries.

The practice of postpartum abstinence is closely linked to child spacing in Tanzania , Ghana , and the Ivory Coast , with additional connections to lactation and child health in Ghana , the Ivory Coast , and Malawi. In Tanzania, the 2010 demographic and health survey found the median length of postpartum abstinence to be 3.8 months, with 19% of participants in the survey still abstaining at 12–13 months postpartum. This is about half the median length of postpartum abstinence (6.5 months) estimated 20 years earlier and indicates a marked reduction in postpartum abstinence over the years, although the reasons for abstinence are not presented.

Despite the decrease in the length of sexual abstinence postpartum, 50% of first-time mothers worry both over the timing of resuming sex, and how their partner will react to both them and the baby, six weeks after childbirth. Qualitative interviews in the same area reveal that both women and men express concerns over the resumption of sex during the breastfeeding period, with a belief this may negatively affect the health of the baby. In Ghana , Ivory Coast , and Nigeria , there is an increased risk of the spread of HIV and other sexually transmitted infections (STIs) during the breastfeeding period, as men are reported to engage in extramarital sex while their women partners observe abstinence. Such risks and concerns over the possible health implications are also voiced by Tanzanian first-time mothers and fathers. However, different countries and communities, have differing and context-specific explanations for postpartum sexual abstinence and its social and health implications for the family. Thus, a deeper understanding is required about how the parents and community at large perceive sexual relations after childbirth in relation to health as a contribution to reducing the knowledge gap in the study setting.

Traditionally, support after childbirth in Tanzania is provided by family members. However, young populations in urban areas are less likely to receive family support and more likely to experience divergent views from different ethnic groups they encounter, as they attempt to adapt to their new urban settings. Thus, an exploration of this population would provide a deeper understanding of health and other socio-cultural challenges facing first-time parents after childbirth. This study therefore explored discourses on prolonged sexual abstinence after childbirth in relation to family health in low-income suburbs of Dar es Salaam, Tanzania. The description provides a comprehensive picture that can be used as a resource for policy deliberations on how sexual education, postpartum care, contraceptive services, and HIV/STI prevention can be improved.

Study setting This study was undertaken in the low-income suburbs of Ilala, a municipality comprising 637,000 of the 2,487,300 inhabitants that make up the total population of Dar es Salaam. The majority of inhabitants of Illala are internal migrants and represent the multiple cultures and ethnic groups that make up Tanzania. In Ilala, unemployment is high and most young adults are self-employed in petty businesses that are often insufficient to meet basic needs. Hence, Ilala shares the same characteristics as many low-income suburbs in cities of low-income countries: a young, sexually active, and fertile population, poverty, high congestion, poor sanitation, poor health, and insufficient transport system ,. In Tanzania, health care after childbirth focuses on family planning services and the prevention of childhood illnesses. There is no formal health care follow-up for either the woman or her partner after uncomplicated childbirth, which implies that many health concerns during this period are unattended by health professionals. As many as 90% of women in Dar es Salaam deliver in health care facilities: nationally, only 51% of women deliver in health care facilities.

Participants and recruitment Government community leaders, including street leaders, were informed about the aim and procedures of the study and asked to help identify participants. The criteria for selection included being a first-time mother or father who cohabited with their partner and infant of 6 months of age or under, and women and men with experience of supporting first-time parents, such as grandmothers and grandfathers, in-laws, aunts, maternal and paternal parents, and neighbours. Purposive sampling was used to capture variations in perceptions relating to experience and gender. A snowball approach was later used to obtain subsequent participants. The recruitment resulted into eighty-two (82) participants from 29 different ethnic groups. Details on the compositions of the FGDs are found in Table.

Focus group discussions Between August 2009 and January 2010, fourteen FGDs were conducted with 4 to 8 people participating in each FGD. To facilitate group interactions, the participants were allocated to groups based on gender and age : the compositions of the focus groups are presented in Table. A piloted hypothetical scenario was constructed based on previous interview studies with mothers and fathers , and initially read to the groups. The scenario highlighted family health and practices, and sexual and gender relations after childbirth. The first, female, author (CKM) moderated the FGDs with women, and the second, male author (ABP) moderated the FGDs with men. All FGDs were conducted in Kiswahili, which was fluently spoken by all participants. The discussions were audio recorded and field notes were taken.

Sexual Abstinence Benefits

The scenario presented at the beginning of each FGD Neema is a young Chagga ethnic origin woman who is self-employed with a small hair salon in Buguruni. She is married to Peter and they were blessed with their first baby four months ago. Neema’s husband, the young father Peter, is Hehe ethnic origin and a self-employed shopkeeper. He is very excited about their baby and feels guilty for not spending enough time with his new baby and partner. However, he cannot manage, as his family depends on his daily earnings from his small shop.

As this was their first baby, they were not sure how to take care of the cord and how Neema’s hygiene and nutritional status should be maintained. Neema was also worried because she had vaginal discharge a few days after delivery. Neema’s mother-in-law applied hot water compressions, but Neema complained that it was very hot and uncomfortable.

Neema is breastfeeding exclusively, as advised by the midwives. However, the baby has been crying, especially at night. They do not sleep much and feel stressed. Neema and Peter suspect that the baby is not getting enough breast milk and they are wondering whether they should start her with light porridge.

Peter wants them to resume sex, but Neema maintains they should abstain until the child has stopped breastfeeding i.e. One to two years. They had a big argument, where Peter slapped her because she refused him sex.

Neema worries Peter might not abstain and be unfaithful. Data analysis The FGDs were transcribed in Kiswahili and translated to English before analysis. One FGD with mothers was not possible to analyse due to poor sound quality. The first author listened to all recordings and compared them with transcripts in both languages to ensure the quality of data transformation. The transcripts were analysed by discourse analysis.

‘Discourse analysis deliberately systematizes different ways of talking so that we can understand them better’ page 5. After reading the text for general understanding, a closer and detailed analysis identified all relevant statements referring to prolonged sexual abstinence after childbirth.

These were later sorted into different categories as they were reviewed. The analysis included the determination of which people were being referred to, which people gained or lost from the utilisation of certain aspects in the discourse from the health and gender perspectives, and the connections between discourses. Ethical issues Ethical approval for this study was granted by the Senate Research and Publications Committee of the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. Permission was granted by the office of Municipal Director, Ilala Municipality. The Regional Ethical Review Board of Uppsala University, Uppsala, Sweden, conducted a consultative review.

Oral information on the aim and procedures of the study was provided in Kiswahili to all potential participants. Verbal consent was obtained, and participants were reassured of confidentiality. Participants were asked to reveal only what they felt comfortable sharing with others, as investigators could not guarantee confidentiality among participants. Participants were free to leave the discussions or decline to answer any question at any point, without being required to give reasons. No participant left, but some remained silent during parts of the discussions. Kubemenda The dominant discourse on sexual abstinence after childbirth was about the importance of abstaining from sexual intercourse in order to protect the baby from getting kubemenda. Kubemenda was described as a phenomenon in which a child has poor growth and development, and ill health resulting from the parents’ non-adherence to sexual abstinence.

A child affected by kubemenda could be recognized as it presented with different symptoms, the most prominent ones being frequent diarrhoea, malnutrition, abnormal thinness, poor growth, weak upper and lower limbs, generalised body weakness or paralysis. Less prominent symptoms included shiny cheeks, swollen limbs, and convulsions. The possibility that kubemenda did not exist as a childhood condition related to the parents’ non-adherence to sexual abstinence was not mentioned in any FGD. This implied a strong belief in the existence of this phenomenon. P: As you know when a woman is taking care of the child, she is not supposed to have sex with her husband because the child’s health will deteriorate; sometimes the child might get convulsions. FGD 3 – Mothers. Constructions of ‘kubemenda’ There were several ways of explaining why kubemenda appears.

It was often described as occurring when the mother had sexual intercourse during the breastfeeding period. Another reason was that the woman conceived during the breastfeeding period. In addition, kubemenda could occur because one of the couple had extramarital sex. Interestingly, some participants described men’s extramarital sex as a way of protecting the child from kubemenda.

Three constructs on the mechanisms causing kubemenda were revealed: heat or sweat produced during sexual intercourse; sperm entering and contaminating breast milk; and, touching the baby without washing the body properly after having sexual intercourse. P: When the mother washes herself after having sex and then breastfeeds the child, there is no problem. However, when you ejaculate inside and leave out the sperm in the vagina it seems the semen passes, we do not know where. We are not on a doctor’s level of understanding.

However, later on, when the child breastfeeds, the semen enters the breast milk they all say “breasts of the mother” eeh! FGD 2 –Fathers. Meanings attached to sexual abstinence In this discourse, sexual abstinence was given several meanings, ranging from total abstinence from sex for both parents, to occasional or less frequent sex, to the woman abstaining while the man has sex with another woman. Maintaining prolonged sexual abstinence during the period after childbirth was delineated as problematic, and at times, unrealistic and against human nature. P: So the issue of abstaining sex. He can say okay to it, but practicing it while in the battlefield, staying in the same room with his wife where they used to make love. It will be a little bit of a problem.

FGD 1 - SP Males. The child can continue to breastfeed and you can continue to have sex with your husband. However, not every day, you can arrange to have sex once a week so that you do not endanger cause kubemenda the child. FGD 8 – Mothers. There were variations on the exact period the couple should abstain from sex to ensure child’s health, ranging from 40 days to two and half years.

Generally, the child’s growth and development indicated when sex could be resumed, such as when the child had been weaned or was able to crawl and walk. M: How long should it take before they can have sex normally? P1: They have to wait until the child is able to walk and has been weaned. M: `So, until the child is able to walk, does this mean a year? Until the child stops breastfeeding and is able to walk. P4: Others advise until the child is 6 months, others two years, but mostly two years and a half. FGD 3 – Mothers The child’s health (and whether it presented with kubemenda or not) was a proxy for recognising the couple’s non-adherence to the norm of sexual abstinence.

A child with kubemenda was not socially acceptable, and the social consequences of kubemenda for the couple included gossiping about their misbehaviour, shame, and social stigma. Therefore, avoiding kubemenda was important for maintaining family integrity and meeting social expectations in relation to sexuality and family health after childbirth.

Strategies for preventing ‘kubemenda’ Several strategies for preventing kubemenda were outlined. These included the use of withdrawal and modern contraceptives, especially condoms that prevented sperm from reaching and poisoning breast milk, washing the body after sex to prevent dirt from sweat from contaminating the child, traditional herbs, and sleeping in separate beds or a temporary separation.

In the temporary separation situation, the woman and the child would move to her parents or in-laws until the child had grown sufficiently to allow the parents to resume sex. Separation was also a way of avoiding social shame, as disputes about sexual resumption were easily overheard in the neighbourhoods. Masturbation surfaced as a male strategy for preventing kubemenda, although when this point was probed, some male participants appeared uncomfortable discussing it. If all other strategies failed, divorce was mentioned as an option.

You may decide to leave your husband in order to rescue your child. M: So, you stay with your parents? You go back home to the parents to take care of your child because you are having trouble with your husband every night and people neighbours keep on listening to you all laugh. FGD 4 - SP Females. Gendered expectations on abstinence In the discourse on prolonged sexual abstinence after childbirth, there were gender differences in relation to the control of sexual desire, with men and women being positioned differently. Men were mainly described as weak, with little ability for controlling their sexual urge, and thus could not be expected to abstain from sex for a prolonged period. Extramarital sex was often portrayed as normal conduct for men.

P1: In reality, there is no man who can endure abstinence! There is none! M: There is no man who can abstain from sex? P1: There is no one who can wait until you are through with breastfeeding the child. P2: For one year and a half! FGD 3 – Mothers P: But, at the moment, in Dar es Salaam, there are many women.

So, one may decide not to have sex with his wife so that he will not endanger his child. So, he has an extramarital affair instead. He thinks that if he has an affair it gives him relief. FGD 5 – Fathers The father’s extramarital affairs were depicted as acts of responsibility towards the baby, as this protected the baby from kubemenda. The women were expected to adhere to the norms of abstinence more than the men were. The women were mainly positioned as being strong in controlling their sexual urge and were expected to be able to abstain from sex for longer periods.

P: women can abstain very well if they will not think of that sex and you just go back to normal, mmh. You may think that I am lying, but that is how I live since I was four months pregnant until now. So, if I was able to abstain for that long, why should I fail? Note that I have a four-month-old child! FGD 3 – Mothers In contrast to men, if women decided to have extramarital affairs to fulfil their sexual needs, they were considered deviant or promiscuous. P4: Those men and women who are unsettled having more than one sexual partner can get HIV/AIDS. But, there are other prostitute women.

They have a husband at home but still have extramarital relationships while they know that there is this disease. FGD 4 - SP Females The possibility of women’s sexual urge inducing them to seduce their partner into having sex, despite their intention to adhere to the norm of abstinence, was also expressed. P: You see someone with a baby and wearing more than ten strings of waist beads beads are believed to attract a man, for whom are you wearing those beads while you have a baby? What do those beads signify? That you love him!

Now, when the husband sees you will he not get erect after seeing those beads? FGD 7 - SP Females The women’s main described worry was losing their partners to other women, and contracting HIV and other STIs. This was emphasised in the discussion about men being the main source of HIV in families if they engaged in extramarital sex during this period. P: When he decides to go for extramarital affairs, he will love two things; that is the woman and AIDS.

Apart from AIDS, there are other minor diseases. And when he comes back to his wife, he can be carrying anything to his house. FGD 6 - SP Females. Women’s conflicting roles and men’s authority Although men were described as weak in controlling their sexual desire, they were also depicted as controlling over women, and could force them to have sex against their will, even when the women wanted to uphold the sexual abstinence norm.

As a result, women were sometimes described as ‘giving in’ to men’s sexual advances in order to protect their marriage, avoid divorce, or family violence, such as battering and rape. Furthermore, women were depicted as constrained in this subjective position, as they struggled to fulfil social expectations both as mothers and as wives. Some men were said to punish women who denied them sex by not providing economic support, which would force the women into having sex against their will. P3: When you go to bed, you might be arguing and there will be no peace.

You might ask for money and he tells you ‘I don’t have’ while you see it money and he might not give you. Several Ps: He will not give you! FGD 4- SP Females Throughout the discourse, the mother was accorded responsibility for ensuring the growth and safety of the baby, whereas, the father was depicted as the financial provider for the family. Strong women and good mothers were portrayed as being firm and abiding by the sexual abstinence norm to protect the health of the baby, maintain family integrity, and avoid shame.

Consequently, women who decided to resume sex prematurely were considered irresponsible mothers. In this subjective position, the woman was blamed if the child became affected by kubemenda. P: The strict person there, who nurtures, is the mother.

The father does not raise the child, man! The father does it raise the child from the outside by having extramarital affairs, if he wants his child to be with him survive. FGD 9 - SP Males Women often described pretending to be unaware of, or disregarding, their partners having other sexual partners as a strategy for achieving the normative construct of a good and submissive mother and wife. P: But if you see a man is having an affair you just leave do not trouble him alone and take care of the baby. The most important thing is that you are getting money for spending at home and you are eating.

You should not trouble him. You should concentrate on your business and you take good care of the baby. FGD 6 - SP Females. A part of traditional discourse Sexual abstinence after childbirth was described as part of an old tradition to which both men and women should adhere in order to prevent kubemenda and the associated social shame.

P: In those times when we were breastfeeding, you would not think of that sex and we didn’t have time for that. We made sure the child is able to walk first and then we started having sexual intercourse.

FGD 4 - SP Females Men’s difficulty in abstaining from sex for longer periods was described as true. Even in the olden days, extramarital affairs were part of the traditional discourse. P: I have given birth to ten children.

But, I could not stay for two years taking care of the baby without being together having sex with my husband. He would run away from me, he would have another woman.

FGD 7- SP Females The discussions revealed the discourse on prolonged sexual abstinence after childbirth appeared to originate from traditional societies where men could have several wives. However, polygamy in the traditional form was not often described as an alternative in Ilala. P: People at that time were obedient. Even us, we were obedient but our youth today are not obedient. Therefore, there is no way out; you have to advise him ‘Eeh my son, you see, things are difficult!

If I could, I would marry you to a second wife. You are a man; I would get you a second wife. I know a woman can abstain but a man cannot.

So, what I am saying is that you must comply with doctor’s advice on condom use. Nowadays, there are condoms, you can have sex with your wife and the child will not be affected. So I advise you that go and take condoms have sex with your wife as you were doing before’. FGD 1 - SP Males The participants highlighted how traditional discourses have been transferred from one generation to another through traditional rituals. Just before childbirth, elders shared their experiences and knowledge on sexuality and sexual abstinence after childbirth to the expectant mothers and fathers. This reproduction of old traditions was described as a continuous process, where young parents were given advice and guidance deemed necessary at any time after childbirth.

Similar support is still being offered to parents in Ilala. Modern discourse enabling people to sidestep the restrictions The practice of prolonged sexual abstinence after childbirth was repeatedly expressed as outdated. Both young and old participants described young couples as violating the sexual abstinence norms, thus, putting the infants at risk for kubemenda. P1: No, we do not wait, to say the truth. (Laughter) M: Eeeh, so what do you do? P1: You discuss with your husband and do what you know and then you keep quiet. When you go to your parents, they might ask ‘what has happened to the child’, but you know the secret and you keep it in your hearts (laughs).

FGD 8 - Mothers Traditional aspects such as abstinence and kubemenda were present simultaneously with modern aspects such as contraceptives, HIV, and the use of health care services. Young couples were depicted as different from those of previous generations, as they had better knowledge of sexuality issues and of how to protect themselves against pregnancy, HIV, and other STIs. Access to condoms and other modern contraceptives was considered advantageous for young couples, and as acceptable strategies for avoiding kubemenda. Weak position of the public health care services The public health services were not discussed much in the FGDs.

However, health care providers could be consulted for treating a child affected by kubemenda or for providing counselling on contraceptives, HIV, and other STIs. Despite representing the medical discourse, health care workers were sometimes described as conveyors of the traditions of prolonged sexual abstinence and kubemenda.

P: Maybe if you go there at health facility, the nurses will tell you that now that you are taking care of the babies, do not sleep with your husband every day. There is hot water, boil some water, you go and sponge yourself two or three times, after that, you will not have the desire for Athuman a fictive man’s name They say this several times. FGD 6 - SP Females Furthermore, modern couples were said to consult elders for advice in resolving marital conflicts, discussing the timing of resuming sex, treating an affected child, and facilitating temporary separation of the couple to ensure prolonged sexual abstinence. Discussion The present study provided a detailed analysis of the discourses on prolonged sexual abstinence after childbirth in a low-income Tanzanian suburb.

The dominant and socially desirable discourse in this study setting delineated sexual abstinence as a means of protecting the infant from a perceived illness called kubemenda. As a dominant discourse , this limited what people could say.

Stereotypic gender relations, with male dominance and female submission, were normative and depicted as essential for controlling sexuality to ensure family health and avoid the social implications of non-adherence to sexual abstinence. The medical discourse with aspects such as contraceptives, HIV, and the use of health care services, was less prominent. Other co-existing and conflicting discourses delineated abstinence as being against natural human sexuality, and resulting in practices that could endanger family relationships and health.

This is especially problematic in the era of HIV/AIDS. Nevertheless, modern discourses were interspersed among traditional ones. The promotion of child health through birth spacing is the main reason for observing abstinence in Tanzania , Ghana , Ivory Coast , and Nigeria. In the present study however, abstinence was observed mainly to avoid kubemenda. The viewpoint that condoms prevent pregnancy but could not always protect the child from kubemenda supports this argument.

However, as reported from Malawi , the participants in the present study often referred to modern couples as having the possibility to use condoms and other modern contraceptives to protect the child and/or avoid further pregnancy. The variety of explanations of how kubemenda occurred and was prevented could possibly be explained by the multitude of ethnic and cultural backgrounds among the population in Ilala and the FGDs. However, in all the FGDs, there appeared to be genuine worry about resuming sex after childbirth, although opinions on the duration of abstinence differed. The low usage of modern contraceptives among married women, 34% in Tanzania and 30% of women in the reproductive age in Dar es Salaam , is problematic. The reluctance to use contraceptives could possibly reflect parents’ fear of sexual resumption that might result in a new pregnancy sooner than desired, in addition to having little awareness of, and poor access to, contraceptive methods. In contrast, in other instances, condoms were also described as an acceptable strategy for avoiding kubemenda during the postpartum period. This is because condoms were believed to prevent sperm from possible poisoning breast milk.

The higher awareness and acceptability of condoms compared to other modern contraceptives seen in the present study results indicate the importance of raising awareness of and improving access to a variety of contraceptive methods to enable informed choice among men and women. There are no medical reasons for refraining from vaginal intercourse after childbirth once the woman’s discharge has ceased and any wounds have healed , which generally happens 4–6 weeks after delivery.

Establishing this knowledge in communities could facilitate women’s and men’s informed choices on the timing of the resumption of sex postpartum. Health workers have a responsibility for providing this knowledge, particularly to first-time parents, and information and the provision of modern contraceptives have the potential to diminish tensions related to sexuality after childbirth. Prolonged sexual abstinence of up to two and a half years was described as being the predominant behaviour in both the olden days and at present, suggesting a reiteration of the discourse across generations, and illustrating the role of discourse in the production and reproduction of social practices in societies. However, these results should be interpreted with caution, as what people say in a group discussion does not necessarily accord with how they behave in real life. In a group discussion, the expression of views is likely to adhere to socially acceptable norms in a particular social context, and this is supported by findings from the Tanzania health survey , where the median length of postpartum abstinence was only 3.8 months.

An imbalance in the power relations between men and women in sexual relationships was highlighted, and this corroborated other work on dominant male sexuality ,. Men were accorded more power and fewer restrictions on sexual matters than were women, who were burdened with more responsibilities and blamed if expectations were not met. The differences in the way men and women were positioned in relation to sexuality illustrated ‘ power determines whose pleasure is given priority and when, how, and with whom sex takes place’ , page 2. As men were presumed ‘weak’ and having an uncontrollable sexual desire, they were privileged to continued sex life, whereas, women were restrained from the possibility of enjoying and meeting their sexual needs. This reflected the traditional feminine and masculine stereotypes prevalent both in Tanzania and globally.

These concepts encourage, perpetuate, and normalise infidelity in men, and reproduce gender inequalities with negative implications for family health, such as contraction of STIs and family breakups. Nevertheless, these stereotypic ideas require cautious consideration, as other, less prominent, patterns were highlighted. Quantitative studies are needed to explore the distribution of these perceptions and practices in the broader study population.

Furthermore, females participated in upholding male dominance discourses, a factor that has been previously described , indicating how deeply these ideas are embedded in the participants’ culture and, as such, are regarded as normative. Whereas men were positioned as ‘weak’ in abstaining from sex, women were expected to curb the problem by providing sex to avoid risking HIV/STIs, and to protect their marriage, even if this happens against their will. Women in this position lacked the right to decide when to have sex (‘ lack of bedroom power’ ) page 167.

Female submission to male sexual dominance is a social expectation. However, in Ilala, this problem was compounded by women’s economic dependence, as they were expected to disregard their partners’ infidelity so as not to be deprived of basic needs such as food.

Thus, achieving equal gender-power relations is unrealistic if women are not economically empowered. Obtaining positive relationships among couples and practices that promote family health requires economically independent women and general sexuality education covering gender dimensions, in which maternal and child health services are important stakeholders. Different moral standards related to sexual activity after childbirth were used to determine who were good mothers and women and good fathers and men, a fact that supported previous findings ,.

For instance, women having extramarital sex were labelled as deviant and irresponsible, whereas, for men, the same behaviour was socially tolerable and even expected. Similar differences in moral standards in this area are described by mothers and fathers : Haram suggests ‘deviant’ women might be tired of repression, and find ways of expressing and meeting their sexual urge by adopting positions to take control of their lives. This could be an alternative interpretation of the findings in the present study. Sexuality as a socially constructed phenomenon can be controlled and channelled in directions where it does least harm.

The tensions in the discourse in the present study indicated a possible opening for introducing interventions aimed at promoting family health after childbirth. Interventions in the form of dialogue between couples, community members in general, and health care providers would create a forum for discussing different discourses, the tensions created, and their relation to various practices that are important for family health after childbirth. Further, the dialogue would act as a forum for the provision of health information and discussion on gendered norms relating to sexuality during the childbearing period. Increasing the awareness of gendered feminine and masculine notions that can compromise the health of the families is important for enabling couples to make informed choices in relation to sexuality, and for creating opportunities for health workers to reflect on their own perspectives and uncertainties as part of both the traditional and medical discourses. The discourses indicated a strong link between perceptions on sexual behaviour and ideas about the qualities that make a good parent.

This could be an asset and a motivating factor for change towards promoting healthier lifestyles during the childbearing period. Change could be promoted by creating awareness of how previous discourses that might have supported health in other times and settings could now lead to ill health, due to changed circumstances, such as the abandonment of organised polygamy and the high prevalence of HIV; and of new possibilities, such as condoms, oral contraceptives and increased knowledge about sexual relations.

One of the challenges would be discussing and questioning the perceived direct link between sexual activity and ill health in infants, in the face of the strong popular belief in kubemenda. The existence of discourses contradicting the dominant discourse of abstinence could be used to motivate discussions and interventions for influencing a positive change towards healthy behaviour.

To understand both sexual relations after childbirth and the tension resulting from conflicting discourses in connection to kubemenda and sexuality, participants relied on traditional discourses, and only partly on medical discourses. However, this depended on specific contexts and individual situations and preferences.

In accordance with previous studies on mothers and fathers , if the worries outlined in the discourses were not addressed, they could have negative health implications for both the baby and the parents. The increased risk of contracting HIV/STIs in the case of multiple sex partners was considered a threat, as was disagreements between the couple over sexual abstinence. Furthermore, common childhood illnesses might be confused with kubemenda, implying the child might be denied health care and taken to traditional healers instead. In the worst scenario, parents might decide to stop breastfeeding prematurely to be able to have sex, contrary to professional advice. However, participants in the present study did not describe this as an option. Premature mixed feeding or weaning increases the risk of diarrhoea, infections, malnutrition, and slow development in infants , which could be interpreted as kubemenda from a layman’s perspective. Although emotional health problems were not explored or mentioned in the FGDs, these problems, especially depression, are internationally described as frequent among women and men, in general, and during the postpartum period in particular -.

From the results of the present study, the worries, relational problems, violence, and ill health indicate a possibility of the development of emotional problems. There are few studies on emotional health after childbirth in Tanzania , and further studies are thus needed to explore the frequency and character of depression among parents during the childbearing years. Currently in Tanzania, the health care system pays little attention to maternal or family health after childbirth, including sexual matters. In the present study, health workers were said to be active in reinforcing traditional discourses, which implies a lack of expertise on sexual matters after childbirth. Health care providers should inform, and discuss sex resumption and related problems after childbirth, with the parents. Midwives and other health care providers are in a better position to intervene if provided the opportunity, in the form of guidelines, content and skills, for sexual education after childbirth. A crucial contribution would be putting the Tanzanian national policy for postpartum health care visits into practice.

Descriptions of the participants’ characteristics, setting, along with some illustrative quotes, were provided to help in the assessment of the transferability of the results from the present study to other contexts. One limitation of this study was the design, which did not allow ethnic differences to be discerned, although 29 ethnics groups, out of about 130 existing in Tanzania, were represented, and the FGD groups comprised a mixture of participants with different ethnic backgrounds.

Furthermore, the study did not include first-time parents with higher educational levels and higher socioeconomic status. Their inclusion could have generated different perspectives. Conclusion Prolonged sexual abstinence after childbirth for protecting the infant’s health and avoiding kubemenda was the dominant and socially desirable discourse in this study setting. The medical discourse with aspects such as contraceptives, HIV, and the use of health care services was less prominent. Prolonged sexual abstinence after childbirth was managed through controlling sexuality to ensure both family health and the avoidance of social implications resulting from non-adherence to sexual abstinence. Discourses on sexuality after childbirth are vehicles in the reproduction of gender-power inequalities, where women are subjected to more restrictions and control than men are. Interventions that create both openness in discussing sexual relations and health-related matters after childbirth and mitigate gendered norms suppressing women and perpetuating harmful behaviours are needed.

The involvement of males in the interventions would benefit men, women, and children through improving gender relations that promote family health. Authors’ contributions CKM was involved in the conceptualisation and design of the study, fieldwork coordination, data collection, data analysis and interpretation, and manuscript drafting; ABP was involved in the conceptualisation and design of the study, data collection, data interpretation, and critically revising the manuscript.

ED and KC were involved in the conceptualisation and design of the study and critically revising the manuscript. PO was involved in the conceptualisation and design of the study, data analysis and interpretation, and the critical revision of the manuscript. All authors have read and approved the final manuscript.

Introduction The sexuality of young people is a continuous fascination to the popular imagination as well as in sexuality research. The fascination contains a mixture of anxiety and nostalgia that clouds the self-evident observation that each adult – over a sexual lifetime spanning 50 years or more – extends the sexual adolescent that emerged with puberty. However, connecting the sexuality of early adolescence with elements of adult sexuality is difficult, despite a huge literature on adolescent sexuality. The sexuality of adolescents is not only seen as immature, but as being qualitatively distinct from the sexuality of adults.

Exploration of the motivational and functional components of sexuality critical to understanding of adult sexuality – sexual desire, sexual arousal, and sexual function – is almost entirely missing. As a result, critical lacunae exist in understanding the continuum of sexuality development through the lifespan. The purpose of this review, then, is to summarize research on the pubertal antecedents of four hallmarks of adult sexuality: sexual desire; sexual arousal; sexual behaviors; and, sexual function. Only adolescents’ sexual behaviors receive significant research attention, with an almost obsessive interest in the timing and behavioral content of young people’s sexual experience. Linking adolescent and adult sexuality An immediately obvious question is whether “adolescent” and “adult” sexualities are distinct and discontinuous developmental entities. Much of psychological, medical, and epidemiological research cleanly demarcates adolescent and adult sexuality, with many elements of sexual experience assumed to be inappropriate for adolescents and preserved for adults.

From this perspective, sexual experiences such as coitus are seen as fundamentally transformative, marking an irreversible status boundary between adolescence and adulthood. The broad social, cultural, and religious investments in the meanings of words like ‘virgin’ is an example of this perspective.

Because sexuality is seen as a domain requiring adult maturity to experience and express, adolescent sexuality is portrayed – even in ostensibly objective research – as tentative, experimental, confused, inept, and innately dangerous. Indeed, a substantial research literature addresses adolescent sexuality as an expression of “risk-taking” requiring broad social efforts to suppress or control. The control of adolescent sexuality seems to be the point of much of the debate over the content of American sex education which is often skewed toward abstinence, pregnancy, and STI, with little or no mention of masturbation, sexual pleasure or orgasm (;; ) An alternative view (one taken in this review) is that the essential elements of adult sexuality are identifiable in early adolescence and are relatively continuous through the sexual lifespan. Key elements of sexual anatomy are fixed during puberty.

Changes in sexuality from earlier to later adulthood leave this anatomy essentially intact. The hormonal underpinnings of sexuality also remain relatively intact from puberty through late adulthood. Although the subjective interpretations of the experiences of sexuality almost certainly change over the life-course, physiologic components such as sexual arousal and orgasm do not. The foundations for linkage of adolescent and adult sexuality are depicted in.

The model shows (in modified form) four domains of the sexual response cycle – sexual desire, sexual arousal, sexual function, and sexual behaviors that are well-developed in adult sexuality research. Evidence supports both linear and circular organization of these elements adults but their inter-relationships are virtually unexplored within the sexual lives of adolescents. These are aspects of adolescent sexuality open to new research within existing ethical and regulatory bounds that do in fact separate adolescent from adult sexuality.

Sexual Desire Clinical emphasis on desire in association with adult sexual dysfunctions suggests potential value in exploration of the ontogeny of desire during puberty and early adolescence. Sexual desire is a difficult concept to pin down, even for adults. Desire is a motivational state that generates increased attention to sexual stimuli, and variable subjective and physiologic arousal.

The distinction of sexual desire and sexual arousal is not clear and it may be that such distinctions are misleading. Recognition and expression of desire may be a central element in development of sexual self-efficacy during adolescence, especially among adolescent women. However, desire as a motivational state develops in concert with increased capacity for self-regulation of other appetitive behaviors.

Tolman refers to this developmental tension of sexual motivation and sexual control – from the social-psychological perspective of a feminist scholar – as ‘dilemmas of desire’. From a neural development perspective, this may map to increased reactivity to social stimuli associated with pubertal changes in sensitivity to gonadal steroids in key brain areas (; ). Because the elements of sexual desire in adolescence are incompletely delineated, three aspects of desire especially relevant to sexual development during adolescence are discussed: sexual cognitions, objectified desire by others, and objectified desire for others. The discussion of adolescent sexual behaviors (as reflections of adolescent sexuality) is extended beyond the usual review of coitus to address other partnered behaviors as well as masturbation and abstinence. Sexual Cognitions Cognitive markers of sexual desire emerge during early puberty, including identifiable sexual thoughts and sexual attractions.

About 25% of young adults report “thinking a lot about sex” as 11–12 year olds (both boys and girls). Based on reports of fourth- and fifth grade (ages 9–11 years) American boys and girls, 16% reported self-relevant sexual thoughts. In a sample of Spanish boys and girls, about 6% of 9–10 year old boys reported sexual fantasies, increasing to 66% among 13–14 year olds.

Among girls, 15% of 13–14 year olds reported fantasies, with none reported by 9–10 and 11–12 year olds. Prospective studies suggest that sexual cognitions become evident over a short period of time, perhaps as little as 3 months. If expressed interest in sex is a marker of sexual desire, less than 2% of 9–10 year old boys express an interest in having sexual intercourse, but this proportion is 12% among 13–14 year olds. This proportion is 2% or less for girls. Adult men have more frequent sexual cognitions than women, but these differences may be small and more related to erotophilia and this sort of study has not been done in adolescents.

The hormonal and neural organizational basis for the emergence of sexual cognitions is unclear. Affective brain centers – for example, the nucleus accumbens and amygdala – play key roles in social information processing brain networks that are extensively reorganized during puberty These brain regions have large populations of gonadal steroid receptors and are linked to changes in sexual behavior (; ). Total testosterone modestly correlates (r=0.28) to sexual fantasies in pubertal boys, but does not predict fantasies in models that include onset of spontaneous nocturnal ejaculations and age. Testosterone is also associated with frequency of sexual thoughts in young women. Testosterone – presumably acting through androgen receptors in the limbic system and other brain areas – likely is also associated with changes in social information processing associated with romantic and sexual cognitions (; ). Other evidence of sexual cognitions among younger adolescents comes from research focused on sexual abstinence.

Attitudes and behavioral intentions around sexual abstinence and other sexual behaviors appear early in adolescence (; ), often expressed in concert with cognitions about sexuality and sexual behavior. Younger adolescents define abstinence as a normal element of a continuum that uses “developmental readiness” as a standard for motivated decisions about shifting from sexually abstinent activity to sexual activity. Many adolescents’ definitions of abstinence include masturbation as well as partnered sexual interactions (; ). Stronger attitudes about abstinence are associated with increased likelihood of abstinence over time, and high levels of intentions to engage in sexual activity are associated with increased levels of sexual activity.

This suggests that adolescents’ sexual cognitions reflect choices about sexual behavior, and supports conceptualizing abstinence as a sexual behavior. Others as objects of desire A hallmark of sexuality development is awareness of sexual interest in other people. This emergent awareness may originate in neuro-endocrine changes of adrenarche and pubarche (;;; ). About 25% of parents of 10–12 year olds report substantial interest in other sex people by their children The common cultural nostalgia about adolescent sexuality is often linked to “crushes,” referring to unreciprocated attraction, feelings and fantasies for another.

Crush is originally slang but a more technical term does not seem to be in contemporary usage. Emotionally intense or quasi-romantic crushes may be an early manifestation of the objectification of others that is not explicitly sexual but is part of the development of the partnered substrates of sexuality. Among 511 American 6 th, 7 th, and 8 th graders, 56% reported at least one current crush, with larger proportions of girls (61%) than boys (48%). The self as an object of desire The complementary aspect of desire for others is the “desire to be desired” and the perception that one is desired. Structural and functional brain changes associated with puberty fundamentally transform the network of brain regions involved in understanding others through perceptions of their underlying mental states (; ). The interpersonally obvious signs puberty – linear growth, increased weight, facial hair development, breast development – contribute to attractiveness to others and are temporally accompanied by increased bodily self-awareness during early adolescence.

Objectification associated with increased body dissatisfaction, especially with advanced pubertal development, is especially characteristic of girls. Girls’ with more advanced puberty have both lower body image satisfaction and higher depression scores, but those with platonic rather than romantic involvement with boys have greater body image satisfaction. Objectification occurs in social and cultural frameworks as well as by potential romantic and sexual partners.

Sexualized images of women and girls are prevalent in mainstream media, with some evidence linking objectification to sexual behavior outcomes such as earlier age at first coitus (;; ). Body satisfaction and body self-esteem, both general and in association with genitals and sexual contexts, are associated with better sexual function among older adolescents and adults (;;; ). Attractiveness – especially facial attractiveness – is an important element in the formation of the dyadic relationships that structure adolescents’ partnered sexual interactions. Substantial attention is given to attractiveness and body image characteristically associated with adolescent development with visual cues especially important aspects of arousal in men. In terms of facial cues, adolescents prefer symmetric, more feminine faces in both males and females, and this preference increases with both age and stage of pubertal development. Adolescents’ judgments of facial attractiveness are less concordant than adults, but more concordant than attractiveness judgments of children.

It unclear how these changes are influenced by continued brain development, by experience, or by interplay of both. Genital appearance is intrinsic to both clinical and social understanding of the sexual meaning of puberty. Despite wide variation in normal appearance, media images of genitals – especially of women – suggest movement to a standard of beauty of a hairless vulva with thin, non-protruding labia (, ). Large proportions (up to 70%) of both adult and adolescent women report partial or complete removal of pubic hair (; ). This emerging standard of “normal” appears to be associated with increased requests for genital cosmetic surgery among young women. Sexual Arousal The hormonal, neuropsychological, interpersonal, and physiologic attributes of adult sexual arousal likely are capacitated during puberty and early adolescence.

However, direct evidence is lacking for the timing and pace for sexual arousal development. Detailed self-report instruments, experimental erotic stimulus-response paradigms, sensitive genital monitoring technology, and various neuroimaging techniques – extensively used in studies of sexual arousal in adults – are unlikely to find application to the study of early adolescents, although there is little evidence of potential harm in such participation. Thus, systematic, developmentally-structured research – however limited – into pubertal and early adolescent sexuality requires cautious integration of information drawn from a variety of limited sources.

One place to begin is with understanding of young adolescents’ awareness of sexual arousal, their interpretation of arousal, and their response to arousal. Arousal awareness, interpretation, and response Most data about awareness of feelings of sexual arousal draw from retrospective reports of young adults.

The word ‘arousal’ is absent in these studies, so the cited data refer to ‘excitement’ or similar words. Sexual stimulation in solitary activities was 24.5% for young men and 6.6% for young women, reporting on memories from 11–12 years of age. Remembered sexual excitement in partnered activities at ages 6–10 was 5.3% of young men and 2.1% of young women. By ages 11–12 years, these proportions were 10.5% and 5.7% for men and women, respectively.

Based on these data, however, we do not know if arousal refers to erection in boys and vaginal lubrication in girls. A review of six published diary-based studies of a single cohort of adolescent women showed that greater sexual interest on a given day was associated with sexual activity on that day, whether the behavior was first lifetime coitus, coitus, fellatio, cunnilingus, anal intercourse, or coitus during menses. This shows that young women’s sexual behavior often matches levels of sexual interest reported on the same day.

Sexual arousal summarizes the complex psychological and physiologic activation associated with sexual stimuli. Many models of adult sexual response assume that sexual desire generates sexual arousal but these models may be less accurate reflections of the link between desire and behavior for women. Our cultural mythology (exemplified in the phrase “raging hormones”) suggests that adolescence is a time of innate, hormonally-mediated sexual arousal. Contemporary neuropsychological data supplements this perspective, suggesting a developmental imbalance in dual brain systems associated with sensation-seeking and behavioral control. An important limitation of direct self-report of sexual arousal by early adolescents is knowing how inquiries about sexual experiences are interpreted (; ). Among 8- and 9-year old children, almost half (14/31) could not label ‘exciting’ body parts on a drawing.

It is possible that genital response is not necessarily sexual at all. Spontaneous nocturnal ejaculations occur without explicit genital stimulation, with an average age of onset of 12.5 years, but are only modestly correlated with testosterone levels. Exercise-induced orgasm – in the absence of sexual arousal or direct genital stimulation – is relatively common in adult women, many of whom report onset during early adolescence. As a response to that publication, we have received a number of communications from men reporting similar experience of exercise and orgasm, often with first experiences in early adolescence (unpublished data). Abstinence Abstinence is often defined as refraining from oral, vaginal, and anal partnered sexual behaviors. However, no single definition exists for what is and is not abstinence and a range of sexual interactions such as kissing and mutual genital touching are included in many young people’s definitions of abstinence (; ).

Young adolescents’ sexual abstinence is distinct from the sexual abstinence of younger children (; ). This distinction is based on emergence of conscious sexual identities, motivations and desires during early and middle adolescence. These emerging identities, motivations and desires manifest in various non-coital sexual behaviors that reflect decisions to avoid coitus , suspend sexual activities after a sexual initiation or delaying first coitus until a perception of ‘right time’ and ‘right person’. Framing abstinence as a behavior chosen within the context of sexual motivations and desires creates a developmentally appropriate framework for adolescent sexuality, separated from social, cultural and religious issues of chastity, virginity and non-virginity. Partnered Sex Partnered sexual behaviors become prominent during mid- and late adolescence. These behaviors include sexual kissing, breast and genital touching, partnered masturbation, fellatio, cunnilingus, penile-vaginal intercourse, and penile-anal intercourse. Other partnered behaviors such as sexual exchange via electronic media (e.g., phone sex, “sexting”), and shared viewing of sexually explicit media also emerge during this time.

The essential element of this aspect of adolescent sexuality is the sexual dyad. The nature and content of the dyadic relationship defines a substantial perspective on social attitudes, motivations, and outcomes (e.g., STI, pregnancy) of adolescents’ sexual relations. A substantial body of literature addresses these issues among adolescents with different-sex partners, but fewer data pertain to sexual behaviors within same-sex dyads. Pubertal changes in testosterone are a causal factor in the timing of sexual initiation and the frequency of sexual activity among adolescent males.

In young women, testosterone is correlated with increases in sexual interest and sexual activity. When adolescents are grouped by pubertal timing (defined as “early,” “average,” and “late maturers”), early maturing boys were youngest to report dating and to have sexual intercourse, followed by average and late maturers. Among girls, late maturers were slower to date and have sexual intercourse, but early maturers showed no difference from average maturers.

Age of maturation was significantly lower for those reporting all heterosexual behaviors for both sexes. Sexual Function Subjective aspects of sex acts are clearly important elements of adults’ sex but are virtually unaddressed in the research literature about adolescent sexuality, sexual behavior, and sexual consequences. Adolescents identify pleasure as an important motivation for sex, although young women place less emphasis on pleasure than young men. Research on sexual pleasure among adolescents largely addresses perceptions of the effects of condom (or contraceptive) use on pleasure. Even young adolescent men without coital experience mention interference with pleasure as a negative aspect of condom use. Sexual pleasure has also emerged – because of the potential lubricating qualities of vaginal microbicides – as an important element of microbicide acceptability, even for young women.

No data obtained from adolescents less than age 18 years of age address physiologic or psychological correlates of orgasm. The average age of retrospectively-reported first orgasm is 13 years and 17 years of age for men and women, respectively.

These data refer in part to orgasm from masturbation but demonstrate that the capacity for orgasm is present in adolescence. About 10% of adolescent women report orgasm with first heterosexual coitus. Among 18–24 year old Swedish women, 26% reported that first orgasm occurred in association with penile-vaginal intercourse, and an additional 25% from cunnilingus or partner masturbation. In a national Australian survey, 84% of 16–19 year old men, and 52% of women reported an orgasm at their most recent sexual encounter.

General individual characteristics – autonomy, general self-esteem, and empathy – are related to sexual health outcomes like frequency of orgasm, and liking to give/receive oral-genital sex. Taken together, these recent research findings suggest that maturation, sexual learning and experience are associated with generally positive changes in sexual health through adolescence into young adulthood. One aspect of the subjective experience of partnered sex is pain, especially among young women.

Pain is often mentioned (both as an expectation and an experience) in association with first coitus. However, a substantial proportion (about 53%) of young women ages 14–17 years report some degree of pain with most recent penile-vaginal intercourse (JD Fortenberry, unpublished data), and remains prevalent (about 33% of women) even with increasing age and coital experience. Young women continue to have coitus for a variety of reasons including being perceptive of their partner’s sexual needs, and because coitus is considered to be an affirmation of being a normal woman, irrespective of pain or discomfort (; ).

Conclusion No other period of the lifespan is sexuality at such a period of developmental change. While elements of sexuality and sexual interest are observable in children, the reorganization of the hormonal, anatomic, and neuropsychological substrates of sex during early adolescence is profound. Likewise, adolescence brings into play detailed and complex rules governing sexual display, sexual interaction, mating, and reproduction.

Why Abstinence

A major objective of this review is to enlarge a perspective on adolescent sexuality to incorporate elements such as sexual desire, sexual arousal, and sexual function, as well as sexual behaviors. Insights from better understanding of these diverse aspects of sexuality provide a foundation for better understanding of healthy adolescent sexuality development. These insights may also give basis to a perspective of the continuities in sexuality development over the lifespan. As ‘sexual health’ becomes a more relevant defining paradigm within public health, we may better understanding approaches to supporting healthy sexual experience while minimizing the adverse consequences of sexual trauma, unplanned pregnancy, and sexually transmitted infections.

By making the linkage of adolescent to adult sexuality, I am not suggesting that adolescence is a perfect mirror of the adult. Among other issues, many of the tools of contemporary research are unlikely to be useful in the study of adolescent sexuality.

For example, laboratory-based studies of sexual arousal – using visual erotic stimuli – are unlikely to be conducted with adolescent research partipants in the foreseeable future. However, thoughtful use of existing and new research should provide a strong empirical basis from which public policy, public health practice and clinical services can be developed that will enhance adolescent health and well-being while preventing disease and adverse consequences.