Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Pregnancy, childbirth and the postpartum period

Kirsten von Sydow

Introduction

The sexual relations of expectant and young parents are of great medical and psychologic significance - sexual activity during pregnancy might harm the fetus, and pregnancy, birth, and breast-feeding might also impair maternal sexual health. Sexuality can become a problem within the relationship of (expectant) parents, but becoming a mother or a father can also strengthen sexual health and interpersonal relationships.

This chapter will include information on the following: (1) sexual function during pregnancy and the first year postpartum; (2) maternal sexual activity throughout pregnancy; (3) the epidemiology and etiology of sexual problems in both genders during pregnancy and the postpartum period; (4) the diagnosis and treatment options of sexual problems; (5) research implications. This review is founded on a systematic metacontent-analysis of 59 studies on parental sexuality during pregnancy and the postpartum period, published between 1950 and 1996,1 on new reviews,2-5 and on new publications identified through research in medical and psychologic databases and through cross-references. The data presented here refer to only adult (not teenage) pregnancy.

Sexual function during pregnancy and the first year postpartum

Genital physiology and sexual responsiveness

During sexual excitement, genital vasocongestion is intensified in the first and second trimesters of pregnancy (see Chapters 4.1-4.4 and 5.1-5.6 of this volume). In the third trimester, vasocongestion generally is strong and barely influenced by sexual excitement. Lubrication and orgasm are intensified in pregnancy, but climax may sometimes be accompanied by cramps. In the third trimester, vaginal contractions are weaker, and sometimes tonic muscle spasms occur. Postorgasmic contractions usually disappear after about 15 min.1,4

In the first 6-8 weeks postpartum and during breast-feeding, the sexual excitability of mothers is physiologically reduced, the walls of the vagina are thinner, and orgasm is less intense. Breast-feeding women may ejaculate milk during climax. After about 3 months or cessation of breast-feeding, these changes regress. Some women then experience orgasm more intensely than before. On resumption of intercourse, women mostly perceive their vaginal tension as unchanged or tighter. At 3-4 months postpartum, vaginal tension is mostly unchanged, although vaginal tension is slacker in about 20%. At 6-12 months after the birth, sexual responsiveness is reduced in 40-50% of the mothers and in about 20% of the fathers.1

Sexual interest, initiative, and attitudes

Female sexual interest or desire (see Chapters 5.1-5.6) throughout pregnancy remains unchanged or slightly decreased in the first trimester and decreases sharply by the end of the third trimester, but, altogether, it is remarkably variable, especially in the second trimester.5 Male sexual interest remains mostly unchanged until the end of the second trimester, and then decreases sharply. Female interest in tenderness remains unchanged in pregnancy, or increases. The preferred erotic and sexual activities tend to be unchanged throughout pregnancy and after birth, but vaginal stimulation becomes less important in the second and third trimester.1 Compared with the time before pregnancy, female sexual interest is reduced in most cases at 3-4 months postpartum, but subsequently is very variable. It seems that men are more often sexually uninterested postpartum than women.1

In most couples, men show more sexual initiative before, during, and after pregnancy than women.1 Female coital activity during pregnancy and postpartum is sometimes motivated by concerns about the partner (e.g., concern about his sexual satisfaction and faithfulness).1,6

Most pregnant women think that intercourse should be practiced entirely throughout pregnancy (attitudes). If intercourse has to be avoided for medical reasons, they plead for mutual petting, stimulation of the male part (12%), and sexual abstinence (6%) - none for stimulation of the female part. Some African women think that sexual activity during pregnancy might be helpful for mother and baby (e.g. widening the vagina and facilitating labor)1 (see Chapter 16.8).

Sexual activity

Coital activity in pregnancy declines slightly in the first trimester, is variable in the second trimester, and declines sharply in the third trimester. Up to month 7 of pregnancy, most couples practice intercourse; in month 8, about half to three- quarters; and in month 9, around one-third. The last coitus occurs about 1 month before delivery. About 10% of the women abstain from coitus once pregnancy is confirmed. The use of the male superior position declines during pregnancy, while the female superior position (only in the second trimester), the side- by-side position, or the rear entry position are practiced more often. The variability of coital positions generally decreases - during pregnancy. In the second trimester of pregnancy, sexual intercourse occurs about four or five times per month.1,7,8

In Europe and the USA, intercourse is resumed, on average, 6-8 weeks after birth of the child (Nigeria: 16.5 weeks). In month 2 postpartum, 66-94% of the couples practice intercourse; in month 3, 88-95%; in month 7, 95-100%; and in month 13, 97%. Compared with the prepregnancy period, coital frequency is reduced in most couples during the first year after the birth. Data concerning coital activity postpartum are variable due to the variable patterns of breast-feeding and cultural differences. A total of 84-90% of the couples use contraceptives postpartum, mostly birth-control pills or condoms.1,7-9

Nongenital physical tenderness by both partners remains unchanged throughout the first two trimesters of pregnancy and decreases continuously from month 6 of pregnancy until 3 years postpartum. On average, noncoital sexual contact is resumed 3 weeks after having given birth, usually before intercourse is resumed. Anal intercourse during pregnancy is practiced by only a minority (1-13%). The course of most heterosexual activities (e.g., coital activity, French kissing, manual genital stimulation of woman or man) and female masturbation mostly follows a “standard pattern” and is characterized by a decrease throughout pregnancy (especially during the third trimester), and no or very low activity in the first trimester postpartum, followed by a slight increase. During late pregnancy and the first weeks postpartum, fellatio is practiced more often than cunnilingus. The frequency of male masturbation remains stable throughout pregnancy and the postpartum period. Homosexual activities have not yet been researched in this context.1,7,8

Sexual enjoyment and orgasm

Before pregnancy, 76-79% of the women enjoyed intercourse (7-21% not at all), in the first trimester 59%, in the second 75-84%, and in the last 40-41% report enjoyment of sexual intercourse. No data could be found concerning the sexual enjoyment of men during their spouse’s pregnancy. More than half of the women enjoy sexual intimacy with their partner in the first year after having given birth, 18-20% partially, and 24-30% not at all. Data reported by the fathers are comparably alike.1

Before pregnancy, or in women aged 30 years, the cumulative incidence of orgasm is 51-87%, while 10-26% of all women remain nonorgasmic during their entire lives. Several studies have explored female orgasm during pregnancy, but results are contradictory. In the third trimester, 54% of the sexually active women report orgasm with the last coitus.1 The first orgasm after giving birth occurs, on average, after 7 weeks postpartum (range: 2-18 weeks). During the first coitus postpartum, only 20% of the women reach a climax; 3-6 months after childbirth, three-quarters reach orgasm (about as many as before pregnancy). The preferred methods for reaching orgasm mostly remain unchanged. Both genders prefer manual stimulation, oral stimulation, intercourse, and masturbation.1

Erotic aspects of the parent-infant relationship

Touching is necessary for the baby and is considered mostly pleasurable for both baby and mother (no data are available on fathers). The physical contact with the baby can be accompanied by erotic feelings, especially during breast-feeding (Leboyer: “faire l’amour”).1 One-third to one-half of mothers describe breast-feeding as an erotic experience. One-quarter express feelings of guilt due to their sexual excitement. Few women ever reach orgasm during breast-feeding - others stop nursing because of fear of the sexual stimulation.1

Does maternal sexual activity during pregnancy harm the fetus or the mother?

Coital and orgasmic activity during pregnancy have been associated with negative effects on baby health. The mechanisms discussed include: (1) uterine contractions through female orgasm or nipple stimulation, both of which might trigger oxytocin release, or through male orgasm due to prostaglandins in sperm; (2) sexually transmitted infections; (3) “mechanical” stress through intercourse; and (4) emotional or physical stress of mother, which might induce uterine contractions. These studies suffer from small samples and incomplete confounder control. Large and representative studies have observed no overall association between birth complications (perinatal mortality, preterm birth, premature rupture of the membranes, and low birth weight) and either coital activity or orgasmic frequency. Nevertheless, the male superior intercourse position and intercourse practiced by women suffering from certain genital infections are associated with an elevated risk of preterm delivery.1,4,10-16

In healthy women, no significant relationship between frequency of intercourse and genital infections can be found. Pregnant women with sexually transmitted disease-infected partners, partners with extramarital heterosexual or homosexual relationships, and partners injecting drugs should use condoms (see Chapter 7.7). Unfortunately, they usually do not use them.4 Two studies (n =16) associate cunnilingus during pregnancy with the very rare complication of venous air embolism, which might develop if air is blown into the vagina.4,17,18

Sexual problems: epidemiology and etiology

Epidemiology

The fear of harming the baby inhibits about one-quarter to one- half of the expectant mothers and fathers (who are sometimes afraid of hurting their partner as well) from performing sexual intercourse during pregnancy. Dyspareunia (painful intercourse) is experienced by 22-50% of pregnant women (prior to pregnancy: 12%). In the third trimester, a substantial proportion of women are also irritated by orgasmic uterine contractions (6-62%), positional difficulties (12-20%), a perceived lack of attractiveness (4-20%), or worry about the sexual satisfaction of the spouse (35-88%). Data regarding male perceptions have not yet become available for further scientific research.1,19,20

Only 12-14% of both partners report not experiencing sexual problems postpartum. However, 40-64% of the mothers and 19-64% of the fathers are afraid to resume intercourse. A total of 40% of the women report having problems with their first intercourse postpartum. Of those women with problems, 64% subsequently avoid intercourse. More than half of all women experience pain during their first intercourse after birth. At 3 and 6 months postpartum, 41% and 22%, respectively, still suffer from dyspareunia. At 13 months postpartum, 22% are still having problems. A total of 57% of the wives are worried about the sexual satisfaction of their spouses. One-fifth of the couples report problems with contraception or (in breast-feeding mothers) milk leakage. In the long run, the sexual relationship of at least one-third of all couples worsens. Sexual problems are most pronounced 3-4 years postpartum. Yet, one-quarter of all mothers report an intensification of their sexual lives after having given birth.21 Pregnancy and birth lead to short-term weight increase for more than half of all mothers. One year after birth of the child, 7% of the mothers still weigh 5 kg more than before pregnancy. No data are available on female attractiveness postpartum or male attractiveness.1

Women rarely have extramarital relationships during pregnancy and the first months postpartum, but 4-28% of all fathers report starting a new or continuing a pre-existing affair. In West Africa, postnatal marital coital abstinence is associated with increased risk of male extramarital affairs and increased risk of unprotected extramarital sex.1,22,23

Etiology of sexual problems and dysfunctions

It seems obvious that female sexual problems and decline in sexual activity, interest, and enjoyment during pregnancy and the postpartum period are related to the physical processes of pregnancy, delivery, and breast-feeding. But only a part of the observable changes can be attributed to physiologic processes.

The effects of time have already been described. On average, sexual interest and activity decline throughout pregnancy and increase after the birth. Not surprisingly, during pregnancy and the postpartum period, several sexual factors are correlated (e.g., interest and activity).1 Some other influences shall be discussed in more detail.

The effect of parenthood: parents versus childless couples

Few studies compare the sexual situation of (expectant) parents with that of childless couples. Their results are contradictory. Coital activity, tenderness, and sexual satisfaction generally decline with increasing duration of the relationship, possibly independently of parenthood, or even more so in parents.1

Sex/gender

The few results on sex/gender effects during pregnancy and the postpartum period are mixed. It seems that men are sexually more inhibited during pregnancy than women, and that women’s sexual self-acceptance is generally higher. Sexual satisfaction postpartum is identical. During the first 3 years postpartum, women describe a stronger decline in their partner’s tenderness, but they still describe their partners as behaving more tenderly than men perceive their wives’ behavior.1

Sociodemographic and work-related variables

Several sociodemographic variables (e.g., education, nationality, duration of relationship, socioeconomic data) are not significantly or consistently related to sexual variables in pregnancy and postpartum. But marital status, age, religious affiliation, and culture and ethnicity are associated with sexual behavior. More tenderness and sexual activity are found in nonmarital relationships, in younger, less religion-affiliated subjects, and in European and Australian (than US) parents (at least, participants stated this). Older mothers suffer more from dyspareunia.1,7,8

The overall number of hours of employment of both genders is not associated with sexual outcome for wives or husbands, but both genders’ work-role quality is a predictor of sexual outcomes, especially of sexual satisfaction.24

Physical health, reproductive history, and delivery data

The results concerning parity and sexuality during pregnancy and postpartum remain inconsistent. But experienced parents feel more secure about sexual activity postpartum.1

Women who tried to conceive for a longer period of time practice intercourse less frequently during pregnancy and 3 months postpartum. Prior miscarriages have no effect on coital activity or interest throughout pregnancy and postpartum in either spouse. Expectant mothers with few or no pregnancy symptoms and less weight gain practice intercourse more often during and after pregnancy, and are coitally more interested, and their partners are sexually more contented.1

There are no significant correlations between the severity of birth pain and postpartum sexuality.

The degree of perineal trauma is strongly related to postnatal dyspareunia in a dose-response manner (no perineal damage: 11% coital pain; unstitched tears: 15%; stitched tears: 21%; episiotomy: 40%), and it is also associated with sexual behavior postpartum. The highest risk of developing post-birth dyspareunia is found for women with assisted vaginal deliveries (vacuum extractor or forceps); the risk is intermediate for women with spontaneous vaginal deliveries and lowest after cesarean section. Women with cesarean section resume intercourse somewhat earlier than women delivering vaginally.12,792125-28

Postpartum tenderness between the spouses declines most if mothers suffered from birth complications and their deliveries were prolonged.1

The spouse’s presence at birth seems to have no effect on subsequent coital activity or female sexual enjoyment.1

Several postpartum health factors (estrogen and prolactin status, time of cessation of lochial loss, and time of resumption of menstruation) are not related to sexual variables. Female sexual interest, but not activity, is related to testosterone levels. Kegel exercises of the vaginal muscles help to regain vaginal tonicity. Maternal fatigue (which is equally strong in employed women and in homemakers) is related to a postnatal lack of coital interest.1,9,24,29 Potential influences of male physical and mental health factors have not yet been researched.1

Psychologic health and biography

Mental symptoms (depressed mood or emotional lability) during pregnancy and the postpartum period are negatively related to sexual interest, enjoyment, coital activity, and the perceived - tenderness of the partner (see Chapters 3.1-3.4). Depressed women experience more sexual problems postpartum. Psychotherapy experiences are associated with heightened female sexual interest and enjoyment during pregnancy.1,9,29,30

Nonreproductive biographic factors have been neglected in research up to now, although strong evidence exists that interindividual and intercouple variability in sexual variables is high during the entire transition to parenthood, as in any other phase of the life cycle. Several studies reveal a remarkable intraindividual/intracouple constancy as well: the relative levels of sexual interest and activity of individual women remain constant from the time before pregnancy up to 1 year postpartum. Pregnant women and their partners reporting a good childhood (and current) relationship with their fathers (and possibly with their mothers as well) experience less decline in coital interest and activity than those with a childhood (and current) relationship exclusively focused on their mothers. If a woman reported sexual aversion before pregnancy, her coital interest declines more sharply in the first trimester. Prepregnancy sexuality is positively correlated with coital activity during pregnancy and postpartum. Prebirth dyspareunia is related to postbirth dyspareunia1,21,31 (see Chapter 6.5).

Partnership variables (including attractiveness)

Relationship satisfaction is related to sexual satisfaction during pregnancy in both genders and to (female) postbirth sexual interest. In men, marital quality is also associated with coital activity and tenderness during pregnancy and postpartum.29,32 Marital conflict at the beginning of pregnancy is not related to female coital activity or enjoyment during and after pregnancy. Pregnant women’s attractiveness (self and partner evaluation) correlates positively to coital activity and sexual enjoyment, and negatively to coital pain. Mothers who trust their method of contraception experience a higher degree of sexual adjustment, but there is no effect on men.1

Not only do partnership variables influence sexual behavior, but the reverse is true as well: sexual activity and enjoyment throughout pregnancy are associated with subsequent (higher) evaluations of relationship stability, tenderness, and communication at 4 months and 3 years postpartum.1,33

Attributes of the infant, breast-feeding, and parent-child relationship

Whether a pregnancy is planned or not is not related to coital activity during pregnancy and postpartum; results concerning the (negative) effects on sexual interest in women during pregnancy are mixed, yet there is no effect on men or on postpartum women. Feelings about the pregnancy are not related to coital activity, but to sexual interest and enjoyment. Worry that the fetus could be hurt during intercourse is related to decreased interest in men.1

Babies’ birth weight, size, and Apgar score are not related to mothers’ coital activity. The baby’s gender has no influence on postpartum coital activity, sexual interest, or enjoyment in women, but it seems that mothers of male babies practice intercourse less often during pregnancy and are perceived by their partners as less tender during the postpartum months than mothers of female babies. Marital tenderness decreases most in mothers with a rigid and overprotective relationship with their babies.1

Breast-feeding (at months 1-4 postpartum) is accompanied by reduced coital activity, reduced sexual desire, and reduced sexual satisfaction in women and their male partners. Longtime breast-feeding mothers resume intercourse at a later time, are slightly less sexually interested, suffer more often from coital pain, and enjoy intercourse to a lesser degree. The cessation of breast-feeding has a positive effect on sexual activity, but no effect on sexual responsiveness or orgasm. The negative impact of breast-feeding on maternal (and paternal) sexuality results from changes in mothers’ hormone status, which influences desire and lubrication, and to the changed “meaning” of the breasts (nutritional versus sexual) for both partners.1792134

Diagnosis of sexual problems and dysfunctions, and their prevention and treatment

Gynecologic/obstetric intervention and advice

The use of episiotomy should be further reduced and strongly restricted to specified fetal-maternal indications, because it is strongly related to postbirth dyspareunia - more so than spontaneous perineal tears.1,27

Although the majority of gynecologists report that they spontaneously talk about sexuality to their pregnant patients, two-thirds of all women in various industrialized countries do not remember their gynecologist talking to them about sexuality in pregnancy. A total of 76% of the women who had not discussed these issues with their doctors felt they should have been discussed. Of those who talked to their doctor about sexuality in pregnancy, 49% raised this issue first, with 34% feeling uncomfortable in bringing up the topic themselves. A total of 45% of the young Israeli mothers rated the information about sex during pregnancy given by their physician or the hospital staff as insufficient. Women who do not dare to ask their gynecologist sexual questions during pregnancy more often experience intensification of their sexual feelings than women who dare, because doctors often give restrictive advice (such as coital abstinence for certain periods). Alternative coital positions or alternatives to intercourse (such as mutual hand stimulation) are very rarely mentioned by doctors. None of the doctors mentioned that sex could improve during pregnancy. Yet, only 8-10% of women stopped intercourse completely after medical advice to abstain.1,4,19,35

Intercourse and/or orgasm should be avoided by expectant mothers who suffer from such pregnancy complications as bleeding, abdominal pains, ruptured membranes, premature dilation of the cervix, or heightened risk of premature labor, placenta previa, placental insufficiency, incompetent cervix, and - possibly - twin pregnancy.4 Infection by sexually transmitted disease,4 including human immunodeficiency virus, can lead to miscarriage or stillbirth, or otherwise harm the embryo/fetus. But there is no reason to “forbid” sex to the majority of healthy, pregnant women and their partners in general, not even in the last weeks before birth.1

Many gynecologists seem to be uncertain about sexual advice with regard to potential pregnancy problems. Nearly all agree on the necessity of avoidance of intercourse during and after bleeding, but there is no such agreement on the question of how much bleeding should lead to how many days or weeks of coital abstinence. Similarly, recommendations vary with regard to the sexual consequences of premature contractions. Some doctors do not even give restrictive advice when seemingly necessary (e.g., incompetent cervix or vaginal infection). There is a lack of medical knowledge regarding the management of pregnancy complications, especially concerning the question of what conditions allow the ban on intercourse to be reversed, as when vaginal bleeding has stopped. Medical textbooks do not specify this.4,19 Uncertainty and lack of training in couple/sexual counseling might be one reason that doctors avoid this topic altogether. Discussions concerning sexual questions are not included in the routine antenatal care. If they occur, the male partner is usually not included.1,4

Postbirth maternal and child health services in Europe and the USA focus more on the child than the mother. Health professionals do not always show the awareness, knowledge, and skills to deal with postnatal sexual problems.25 Postbirth medical advice on sexuality usually focuses only on contraception, which is discussed in 76% of the 6-week postnatal checks - but the topics of intercourse, perineal problems, pain, and sexual interest are not mentioned and not recognized in the great majority of postnatal checks.25 In total, 22% of young mothers seek medical advice for perineal or coital problems; 8% of these feel that they have not received adequate help. Three-quarters who need help actively seek it - one-quarter dare not do so.Many couples wish to receive more information about bodily changes and sexuality postpartum, and 30% report that sexual counseling might have been helpful.1

Practical recommendations concerning medical advice about sexuality during pregnancy and postpartum should include the following:1,4

 Offer the chance to talk about the current emotional, marital, and sexual situation and signal that the doctor is open to the information needs of the patient and her partner (e.g., could sexual intercourse during pregnancy harm the baby?). Postpartum sexuality is more than contraception! Open questions about sexual interest, behavior, and potential problems with coital pain or incontinence can be helpful.

 Give information about the variability of female and male sexuality and the normality of fluctuations during the transition to parenthood. Erotic feelings evoked by breastfeeding can be mentioned and their normality articulated. Young mothers have to be informed that vaginal dryness and/or loss of libido may be associated with breast-feeding and that use of lubricants might help.

 Acknowledge patients’ and partners’ fears and uncertainties and respect their inner limitations. The aim is not a maximum of sexual activity, but a sexual life that allows both partners, and - from the medical and the parental point of view - the baby, a form of contentedness. This also includes the option of sexual abstinence.

 Give technical advice concerning the range of sexual options during pregnancy and postpartum: tenderness, noncoital sexual activities (e.g., manual and oral stimulation, masturbation) and alternative coital positions (female superior, rear entry/“spoon”, use of pillows).

 Instruct the patient in self-help (postbirth self-inspection of vulva with a hand mirror and insertion of a finger to test for healing; vaginal muscle toning/Kegel-exercises).

 Show sensitivity regarding sexual and nonsexual domestic violence. At least 2-8% of pregnant women have had a history of sexual abuse during childhood or adulthood. This can lead to mental as well as gynecologic and obstetric problems, but it does not affect pregnancy outcome.36,37 But health-care providers often seem rather oblivious to this problem.38

Health-care policy and prevention

At the final 6-8-week postnatal checkup, only about half of all new mothers have resumed sexual intercourse. Women’s sexual health problems extend well into the first postnatal year and sometimes even longer.1,25,26 Consequently, a 6-month postbirth checkup including questions about sexuality (Did you already resume intercourse? How did it feel? Do you have any perineal problems?) and other taboo topics (Do you have any problems with incontinence?) would help to identify the full range of problems women may experience after childbirth.

A new prenatal program designed to decrease the potentially negative effects of parenthood on the quality of marital relationships has positive effects on postpartum satisfaction with the sexual aspects of marriage compared with a traditional prenatal education program.39

Counseling, psychotherapy, and prevention

If sexual problems persist after gynecologic treatment has been successfully completed (e.g., coital pain from episiotomy scars) and the woman has terminated breast-feeding, a closer look at the psychologic situation and the relationship of both partners becomes inevitable. It is helpful if doctors or midwives can assess the psychosocial and sexual situation of the patient as well as the medical side, and that they know mental health professionals to whom they can refer patients for marital counseling or psychotherapy. Not least is this in the interest of the newborn baby, whose life will be more burdened if its parents have an unhappy relationship or divorce.

Research implications

The following research implications are concluded:1

 Research still is split into a medical branch and a social sciences branch. Therefore, scientists should take more notice of the publications of both branches.

 Sampling: more studies including male partners and more studies focusing on representative samples are needed.

 Designs: prospective studies going beyond month 3 to the years 1, 3, 5, or 10 postpartum are lacking. Comparisons with childless couples are scarce.

 Sexual dimensions researched: more descriptive research is needed about noncoital sexual activities (e.g., tenderness, masturbation, sexual initiative, and sexual agency) and the subjective sexual experience of women and men (e.g. enjoyment, orgasm).40

 Validity and reliability: reports on participation rates, dropouts, cross-method reliability, intraspouse reliability with regard to sexual activity,7,8 nonresponse rates for certain questions, the management of terminological problems in questionnaire studies (e.g. participants who do not understand the word “orgasm”), or attributes of the interviewer (gender!) are almost nonexistent.1,8,41

 Data analysis: because coital activity is not the best measure of female sexual interest,1 more analyses of the relationships between sexual interest, masturbation, enjoyment, or orgasm and biographic data, data about the marital relationship, physical and mental health data, physiologic data (e.g. episiotomy, hormonal status, vaginal tonicity postpartum), and sex/gender effects are needed.

 In most studies, the theoretic background is unexplained; some studies ignore central psychosocial context variables (e.g. marital conflicts, cultural norms about motherhood) and biographic conditions (e.g. sexuality before pregnancy). Research should be theoretically guided, as by the developmental psychology of the life span.

Important medical questions about the risks of sexual activities in expectant mothers have been answered. Therefore, one might ask whether more research is really needed. The answer is yes, because sexuality is the most vulnerable area of the relationships of young parents, the majority of couples have sexual problems immediately postpartum, and at least one-third of couples develop serious, long-lasting, psychosexual disturbances after the birth of their first baby. More research is needed - research focusing on both partners’ psychosexual and social adaptation to parenthood, which generally takes much longer than the physical adaptation to motherhood, and on the complex interplay of physical, psychologic, and relational factors.

An important new question arises from the relatively recent trend that fathers in industrialized countries are strongly expected to be present and participate in their children’s birth. What are the implications of this drastic historic change for fathers’ mental health, mothers’ birth experience, their relationship as a couple, and their subsequent sexual relationship? Another emerging research topic is the implications of the increase in assisted parenthood (e.g. the sexuality of mothers expecting twins, in vitro fertilization pregnancies, etc.).

Because sexuality still is a taboo topic, it is methodologically difficult to research. Therefore, research pluralism is needed. We need psychologic in-depth explorations of complex emotional and sexual issues and their longitudinal development with selected samples (the majority are not willing to participate in such studies), as well as large, representative medical and health studies which gather some partnership and sexual data.1

In summary, sex is of little relevance to most new, breastfeeding mothers during the first 3 months postpartum, since adaptation to motherhood takes up their entire energy and involves profound psychosocial and hormonal changes and a lack of sleep. Male sexual activity is also reduced throughout this phase of life, but to a lesser degree. While this seems to be universal, there is remarkable variation in female and male sexual behavior during all other periods of time researched here, namely, during the entire course of pregnancy and months 4-12 postpartum. On average, all heterosexual activities tend to decline throughout pregnancy and reach a point near zero in the immediate postpartum period, and then slowly start to increase again.

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