Sexual self-efficacy: Affection, sexual communication, and self-acceptance as significant factors related to sexual function on menopausal women in Indonesia

Abstract

Objective

This study aims to analyze the relationship of sexual self-efficacy: affection, sexual communication, and self-acceptance and sexual function on menopausal women in Indonesia.

Method

An analytical, descriptive design with a cross-sectional approach was used in this study. We recruited 360 menopausal women in a suburban area in Depok Indonesia using consecutive sampling method. Measurements were made using the Sexual Self-efficacy Scale for Female Functioning (SSES-F), Female Sexual Function Index (FSFI), and the demographic data questionnaires.

Results

Most of the menopausal women have sexual dysfunction with the average score of FSFI 19.34 and decreased self-efficacy score with the average score of 31.91. There is a significant relationship between sexual self-efficacy: affection, sexual communication, and self-acceptance and sexual function in menopausal women (p-value <0.001).

Conclusion

This study result implies the importance of assessing sexual self-efficacy needs as a part of the sexuality assessment in menopausal women. Therefore, improving sexual self-efficacy is of high importance to address the sexual dysfunction in menopausal women in Indonesia.

Introduction

Menopausal women tend to have a low level of sexual interest and reluctance to engage in sexual activity.¹ In the transition period prior to menopause, the ovaries of women are weakened resulting in hormonal changes which affect physical and psychological health, including women's sexual interest.² Sexual dysfunction is estimated to occur in 22–43% of menopausal women worldwide. The prevalence of sexual dysfunction increases in middle-aged women; 14% of women aged 45–64 years report to have at least one sexual problem while only 21% of women with the sexual problem go to the health care professionals.³

Sexual dysfunction is a common issue among women, and its prevalence is yet increasing. The results from a longitudinal study showed that during the transition into menopause, women experience significant declines of the sexual desire, sexual arousal, orgasm, frequency of sexual activity, and affection, as well as vaginal dryness and dyspareunia.⁴ Therefore, given the magnitude of its implications, menopause is a major women's health problem and a critical period for women entering the middle-age time.^5,6

A low level of sexual desire followed by lower sexual activity also has impacts on the partners. Whereas men hardly get their sexual needs fulfilled through sexual activity, menopausal women also lose sexual arousal and satisfaction in sexual activity. Women may also suffer from vaginal pain due to reduced vaginal elasticity. Such condition may cause menopausal women to avoid sexual activities because of their low self-confidence in sexual ability, which may also lead to a disruption in the husband–wife relationship and communication.¹ In the aging period, the means of sexual expression may change, for example, less coital sexual activity and more sexual touches and other intimacy forms.⁷

Sexual dysfunction, as well as sexual response, can be highly influenced by self-efficacy, non-efficacy and self-esteem of a person.⁸ The ability of the menopausal women to maintain their sexual function depends on their self-efficacy and motivation to be willing and able to fulfill their sexual needs. Thus, maintaining sexual self-efficacy can be a way to improve the quality of sexual relationship among couples.⁹

Studies on menopause, particularly the sexual function of menopausal women, are extensive. Despite the common perception that the period of menopause entails sexual dysfunction and ceasing of sexual activity, there is evidence that supports being sexually active in the menopausal period. In the menopause and post-menopause period, the sexual function including sexual intercourse naturally declines and shifts into a more affectionate sexual relationship such as touch and communication. Women's self-confidence to sustain sexual activity and to alleviate symptoms of sexual dysfunction during menopause can be seen through their sexual self-efficacy. Among Indonesian women, a study on sexual self-efficacy and sexual function in menopausal women is limited. This study, therefore, aimed to identify the relationship between sexual self-efficacy and sexual function among menopausal women in Indonesia.

Methods

Study design

This study was a cross-sectional descriptive, analytical study conducted in an area in Depok, West Java, Indonesia. The sample comprised 360 participants were recruited using a consecutive sampling method. The criteria of inclusion were: menopausal women aged 45–60 years; menstruation had been ceased for minimum a year; living with the husband; having no severe illness or psychological illness. Women receiving hormonal therapy or having a history of hysterectomy were excluded from the study. Depok provincial health office gave access to the population data of women aged 45–60 years residing in Depok. Data were collected in January–July 2018 with the assistance of the community health cadres in Curug, a suburban area in Depok.

The participants filled out the questionnaires while the researcher assisted for any emergent questions or difficulties. Data were then analyzed after going through the editing, coding, processing, and cleaning processes.

Instruments and measures

The instruments used in this study consisted of a demography questionnaire, the Sexual Self-efficacy Scale for Female Functioning (SSES-F) questionnaire, and the Female Sexual Function Index (FSFI) questionnaire. SSE-F has 37 items divided into eight domains: interpersonal orgasm, interpersonal interest/desire, sensuality, individual arousal, affection, communication, body-acceptance, and refusal. The answers of all questions are in Likert scales. The outcomes of the measurement are assessed from the mean of the total score of all answers.¹⁰ FSFI questionnaire evaluates the basic dimensions of women's sexual function. This 19-item questionnaire comprises six domains: sexual desire, arousal, lubrication, orgasm, sexual satisfaction, and pain during sexual intercourse. Answers from every question in FSFI are scored 0–5.^11,12 The lowest possible total score is 0.2 while the highest is 36.¹¹ Wiegel et al. (2005) reported the FSFI's cutoff point of 26.55 for women sexual dysfunction. Prior studies had confirmed the validity and reliability of this questionnaire.^11,13 FSFI has demonstrated high internal consistency for the total score of FSFI and scores of the six domains with Cronbach alpha of >0.9 for the composite sample and >0.8 for dysfunctional and nondysfunctional samples.¹³ These instruments underwent translation from English to Bahasa Indonesia by an academic language center and validated by an expert panel and a pilot study in 20 participants previous to study.

Analysis

We did a univariate analysis to obtain the general description and distribution of each variable. Afterward, we performed bivariate analyses using Pearson correlation and chi-square tests to identify the relationship between studied variables. We assume that the decrease in sexual self-efficacy score is related to the sexual function score (total score and scores in all domains). The level of significance was set at 0.05.

Ethical consent

Ethical approval was granted by the Institutional Review Board of Faculty of Nursing, Universitas Indonesia (No. 99/UN2.F12.D/HKP.02.04/2018).

Results

More than half of our participants were aged >55 years old (50.6%) and had lower educational status (54.7%). Most participants (96.4%) were housewives of poor families whose monthly family income was lower than the average minimum wage of the region (approximately 246 USD). The majority of the participants (82.2%) were in postmenopausal status. The summary of the demographic characteristics of the participants is presented in Table 1.

Table 1.

The participant characteristics (n = 360).

Characteristics	n	Percent (%)
Age
≤55 years	178	49.4
>55 years	182	50.6
Education
Basic education	197	54.7
Higher education	163	45.3
Occupation
Housewife	347	96.4
Employee	13	3.6
Family income
Lower family income	253	70.6
Higher family income	106	29.4
Menopause status
Menopause	64	17.8
Postmenopause	296	82.2

FSFI and SSE-F tests result yielded the mean total score of 19.34 and 31.91 respectively (Table 2). Table 3 shows the statistically significant relationships of affection, sexual communication, and self-acceptance with the mean total of sexual function (p-value <0.001).

Table 2.

The sexual function (FSFI) and sexual self-efficacy (SSES-F) of the participants (n = 360).

Sexual function domain	Score		Min–max
	Mean	SD
Desire	2.84	0.86	0.6–6.0
Arousal	2.76	1.02	0.0–4.8
Lubrication	3.40	1.36	0.0–6.0
Orgasm	3.31	1.41	0.0–6.0
Satisfaction	3.34	1.38	0.0–6.0
Pain	3.69	1.46	0.0–6.0
Total score	19.34	6.64	0.6–32.1

Sexual self-efficacy domain	Score		Min–max
	Mean	SD
Interpersonal orgasm	33.31	22.97	0–100
Interpersonal interest/desire	35.81	25.7	0–100
Sensuality	30.49	27.03	0–100
Individual arousal	9.8	14.29	0–85
Affection	43.89	26.97	0–100
Communication	36.14	22.17	0–92
Body-acceptance	44.23	24.47	0–100
Refusal	21.65	24.24	0–100
Total score	31.91	16.64	0–81

Table 3.

The relationship between affection, communication, self-acceptance and sexual self-efficacy with sexual function in Indonesian menopausal women (n = 360).

Sexual self-efficacy	Sexual function
	p value
Affection	<0.001
Communication	<0.001
Self-acceptance	<0.001
Total Mean Score	<0.001

Discussion

One of the main findings of this study is that the majority of the menopausal women had sexual dysfunction (total mean score <26.55). This finding shows a bigger incidence of sexual dysfunction in Indonesian women than in Turkish women in prior studies by Özerdoğan et al. (2009) and Kömürcü dan İşbilen (2011).^14,15 Özerdoğan et al. found 68.8% menopausal women aged 40–65 years had sexual dysfunction while Kömürcü dan İşbilen found 57.5% postmenopausal women with sexual dysfunction.^4,16 A study by Yangın et al. (2008) also found a lower rate of sexual dysfunction in menopausal women (65%).¹⁷ Such difference is plausibly related to the characteristics of the Indonesian women participated in the study who have a lower educational background and socioeconomic status. Education and economic status are known to be associated with the prevalence of sexual dysfunction in menopausal women. Participants with the lower educational background are more likely to have sexual dysfunction than those with higher education. Educational background may affect the level of knowledge and anticipation of the women in facing the menopause process. Higher knowledge level is associated with a more positive attitude toward.¹⁸ Other studies also showed a significant relationship between socioeconomic and family status with sexual dysfunction. A review conducted by Nazarpour et al. (2016) suggested that women with higher social, economic status tend to engage in more sexual activities.¹⁹

Studies with a multidimensional assessment of sexual function revealed the extent to which the sexual function aspects are affected by menopause. According to the results of the Massachusetts Women's Health Study, sexual interest, satisfaction, frequency, desire, orgasm, or pain are negatively influenced by menopausal transition.^20,21,3,22 Our study finding supports those previous findings that the decrease of mean of sexual function score mostly occurs in the satisfaction, sexual interest, orgasm, and pain domains. Menopausal women are more likely to have a low satisfaction level during sexual activities. A lower satisfaction may link to the decrease in the sexual interest and frequency of orgasm due to menopausal status.

Symptoms of declining sexual interest and pain during intercourse may affect the relationship and quality of life of the women in peri- and postmenopausal period.³ Several studies also reported the increase of age-related sexual problems as nearly 40% had decreased sexual response and interest. Low sexual interest is associated with other sexual issues such as minimal arousal and orgasm.²³

The majority of the participants in this present study had a low level of sexual belief in doing sexual activities, as indicated in the low mean score of all SSES-F domains. There is a statistically significant relationship between SSES-F score and the sexual function of the menopausal women (p-value <0.001). Most participants perceived that sexuality was none of their priority in the menopausal age. The sexual activity of the menopausal women in Indonesia is mostly done as a duty of the wives for fulfilling the husband's sexual need. This is consistent with the previous study results by Jamali et al. (2016) regarding sexual function and attitude in aging women in Iran which found that 81.5% women experienced sexual dysfunction and 6.2% of the menopausal women believed that they tried to maintain their sexual relationship for the sake of their husbands.²⁴

Our study finds that most of our participants had good sexual belief in the affection domain. The menopausal women in this study were able to nurture the deep affection for their husbands despite lacking physical, sexual relationship. They shifted their sexual expression from coital or physical sexual intercourse into affectionate expressions such as holding hands, hugging, kissing, or talking. Such affectionate expressions are commonly increasing while the couple, as well as the women, aging. Affectionate sexual expressions such as touching, caressing, hugging, kissing, and holding hand may bring romantic feeling and intimacy for the couples.^7,21,25

Another interesting finding of this study is the significant relationship between the communication domain in SSES-F and FSFI. A low level of sexual belief in the communication domain is followed by a low mean score of FSFI. Our participants mentioned that they felt unsure and uncomfortable in communicating their sexual problems such as vaginal dryness and pain during intercourse to their husbands. Our participants also had a lower belief to address they’re lost of sexual interest and were reluctant to ask for sexual stimulation from their husbands. This finding agrees with the results of a previous study in India by Sunila (2014), which found 50% menopausal women had sexual dysfunction; one-third of them quitted sexual intercourse in the past two years, and 76% of them did not seek professional help mostly due to embarrassment to communicate the problems.²⁶ According to Dominguez and Barbagallo (2016), many older women have internalized this misunderstanding and believed that sexuality is an inappropriate concern for them.¹⁸ A study was done by Kaur et al. (2005) about sexual function in menopausal women in Kelantan Malaysia suggested that older women would be “retired sexually” after menopause so that they became less active sexually and were shy to discuss this problem as they saw it as a taboo.²⁷

In this study, we found the decreasing mean score of body acceptance in menopausal women. Physiological changes in women's body shape may affect body image and acceptance. Menopausal women feel uncomfortable with the body changes occurring in the aging and menopause period. Therefore, they also feel uncomfortable to be unclothed in front of their husband. The physiological changes due to menopause contribute to women's negative body Image.²⁸ Changes in appearance may alter the way women view and perceive their body.²⁸

Age-related physical changes often lead to women's low confidence to engage in sexual activity. Our study finding showed a lower level of sexual belief in the body-acceptance aspect. There was a significant relationship between the body-acceptance domain and the sexual function of the menopausal women so that the lower the score of the body-acceptance, the lower the sexual function score in FSFI. Sexual efficacy is also referred to as the self-confidence and self-control in sexual experiences. Women with higher sexual self-efficacy are more likely to have a lower risk of a sexual problem. According to Rowland (2015), positive sexual self-concept, including sexual self-efficacy, is strongly associated with sexual function.^29,30,9

Menopausal women in our study tend to not refuse their husband's request for sexual intercourse. According to the major religious and social norms in Indonesia, women cannot disdain their husband's request to have sexual intercourse. The majority of the Indonesians are muslims whose primary guidance (Al Qur’an) mentions that men are destined to be the leader of the family. In the Islamic tradition of the Prophet Muhammad (sunnah), it is also prescribed that the wives must attend to the husband's call for the sexual activity. “If a man calls his wife to bed, the wife should come to him even though she is at the kitchen” (hadith narrated by Tirmidzi no. 4/387; authentic according to Al-Albani on Shahih At-Targhib: 2/199). The patriarchal culture in Indonesia sets the men in a leading position superior to women and even places women as an object.³¹ Thus, Indonesian women may feel powerless to express their sexual concerns or needs, or refusing sexual activity. This is also the case for menopausal women. In spite of their naturally lower sexual interest and response, the Indonesian menopausal women have no sufficient sexual self-efficacy to refuse to have sexual intercourse with their husband.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgment

This study is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No.: 1860/UN2.R3.1/HKP.05.00/2018.