The approach to sexuality is little taken care of during a medical care process, either because of the professionals’ fear of invading an intimate space or because of the patient’s taboos . This aspect gains weight when we talk about gynecological surgery, which directly affects the reproductive organs and related to female sexuality.
The reproductive psychiatry aims to hormonal changes that vulnerable women can trigger a number of psychiatric disorders premenstrual , perinatal and perimenopausal. And more and more studies appear that indicate that the decrease in sexual activity in those who have undergone gynecological interventions is not related to an organic disability, but to emotional and psychological components closely linked to the organs that represent sexuality.
“It is very necessary that health professionals support these women beyond medical aspects, regarding quality of life, their fears, the perception of mutilation and the restart of sexual life, ” explains midwife Francisca Postigo, technician at the General Directorate of Sanitary Assistance of the Murcian Health Service and expert in affective / sexuality programs.
What surgeries can affect sexuality
The most frequent gynecological surgery is hysterectomy (removal of the uterus ), which affects an invisible organ related to sexuality, unlike the breasts, which are visible and represent a sexual identification for women above other aspects of their body. .
“The evidence says that hysterectomy makes the uterus visible, something that until now was not seen, even in women with menopausal or perimenopausal age who have already satisfied their maternal desire and do not want to have more children.” And despite this, many women describe this intervention with feelings of loss , or a feeling of incapacity that they did not have before. “They have emptied me” or “they left me hollow” , is how they describe the absence of something that had a place in their body, something they would never say if their gallbladder or kidney were removed. And it is that the emotional experience is linked to the surgical act to the point that women with a diagnosis of infertility prior to surgery assume the lack of a uterus as a disappearance of femininity .
The effect that these interventions have on a woman depends as much on the type of surgery and the organs that it involves, as on the vital moment of that person. Hysterectomy can involve removal of the ovaries (ovariectomy if it is double, or oophorectomy if it only affects one of them), which induces menopause. In such a case, in premenopausal women the effects of the intervention may be vaginal dryness or pain in penetration , while in menopausal women, no new symptoms usually appear.
Conization – removing a cone-shaped fragment from the cervix – is a minor intervention to diagnose cancer or precancerous lesions that affects less anatomically, but can also inhibit sexual desire in women who feel life-threatening. “In reality, this fear also occurs after childbirth , when the woman anticipates consequences that do not have to happen and the fear of a painful relationship takes away sexual desire,” added Postigo.
Other interventions that do have a visible result are mastectomies after breast cancer . Giving up one or both breasts, even a portion, does affect the perception of women as being erotic, by losing an important symbol of their femininity . This expert believes that when a woman receives chemotherapy treatment, she can feel death danger and therefore sexuality is no longer a priority . “After the mastectomy, the woman may not recognize a body that no longer responds to the aesthetic and erotic ideal, adding the fear that giving up sexual relations may imply abandoning her partner” And adds that once the breasts have been rebuilt, the woman can feel that they are “not hers” and avoid sexual activity.
Not all gynecological interventions negatively affect sexuality. In many cases surgery will improve the quality of life because it removes symptoms that hinder sex or because there are no more unexpected pregnancies. “What for some is a mutilation, for others it is a liberation, and for that reason the biography of the woman is what marks the path to follow to be able to advise her,” insists this health technician, appealing to the essential communication between the partner to find solutions.
Where to get help
Francisca Postigo stresses that a direct professional approach is required before surgery , informing the patient of how it will affect her sexual life and also after the intervention, to explore how she feels about the changes. “It must be done from an active approach, although there are no clinical guidelines or a specific healthcare circuit. These are disorders that are addressed only if the patient asks, but rarely does the initiative come from the healthcare professional, ”she warns, recommending that questions about possible changes perceived by women be included in the postoperative protocol. and the need for help. “Professionals have to glimpse occasions to know what difficulties these women are going through, knowing that when the subject is approached they feel very relieved”, Postigo argues.
In fact, most cases are resolved only with an examination that confirms that there is no physical disorder that prevents a restart of sexual life normally, although sometimes the fears of the recently operated woman must be explored, even the fears that they do not. They have a real basis, as a possible scar pain in intercourse. “Only when it affects the concept of self-esteem or her self-concept as a woman will psychological support be required so that she can rewrite her biography herself from the absence of that part of her femininity.”
The expert assures that most of the time there are simple pharmacological solutions for the physical disorder, such as vaginal lubrication . And when there are real difficulties (for example, adhesions to the vaginal wall due to radiotherapy), a readaptation of sexual life will be recommended , which could involve discovering erogenous zones far from genitalia .
In the public health system there is no healthcare circuit that protocols this post-surgical care for women, so the professional task must be reinvented in each case . “We include it in the Comprehensive Plan for Women’s Care (PIAM) in the Region of Murcia and in all nursing plans, but when it comes to truth, both professionals and patients have the same taboos on sexuality and death Francisca Postigo acknowledges.
Something that proves essential is that women have information prior to the intervention and also later, during the postoperative admission and in subsequent medical check-ups. There are many opportunities for the team (nurse, surgeon, gynecologist, midwife) to listen to that patient and indicate therapy. Postigo insists that they go to their trusted professional, preferably the midwives, because they receive training in this regard and attend postpartum reviews. “The interview has a therapeutic power in itself, because the expression of the problem is part of the solution,” he says, indicating that midwives will refer to the gynecologist when there is a physical difficulty for sexual intercourse, or to mental health if what exists is theneed to mourn and accept reality .
“There is a whole bio-psycho-social framework that surrounds women and that favors their recovery or hinders them,” according to Alfonso Gil, an expert psychiatrist in psychosomatic gynecology and perinatal mental health, who had previously practiced as a gynecologist. “The dogma that I learned myself is that the non-pregnant uterus is inactive and I reported this to women. On one occasion I told them that they no longer needed it if they were not going to have more children, but I was wrong . ”
As a psychiatrist, Gil now defends that the scar on the body or the excision of an organ leaves a mark on the brain and its connections . It alludes to recent studies that invite further research on the contribution of the uterus to the female phenotype, including the effects of hysterectomy on brain and endocrine aging, which would help decipher the impact of gynecological surgeries. “The results demonstrate that the non-pregnant uterus is not inactive and suggests that there is an ovary-uterus-brain system that is disrupted when the reproductive tract is disrupted, leading to disturbances in brain function.”
And as the feeling of loss triggers an “unauthorized” grief in women, this psychiatrist emphasizes the importance of validating and authorizing the emotions that can be generated, as well as promoting parting rituals. Gil concludes with the need to “clarify and adjust the expectations of health professionals and affected women in order to plan care and time off work, according to the adaptability of each patient.”