INTRODUCTION:

Sexual health is the ability to express one’s sexuality free from the risk of sexually transmitted infections (STIs), unwanted pregnancy, coercion, violence, and discrimination. It means being able to have an informed, enjoyable, and safe sex life, based on a positive approach to sexual expression and mutual respect in sexual relations. It is positively enriching, includes pleasure, and enhances self-determination, communication, and relationships¹

Scientific study in the area of sexuality in India is scant and if studied they have focused on male sexual disorders.²²Little is known about the prevalence of sexual dysfunction in people attending their general practice and such problems are rarely recognized by doctors.²

The first study in India which systematically enquired into female sexuality among married young women in North India reported that more than half of the sample (58%) admitted having inhibition or anxiety while performing sexual activity.

A total of 17% participants encountered one or more difficulties during sexual activities in the form of headache (10%), difficulty in reaching orgasms (9%) painful intercourse (7%) lack of vaginal lubrication (5%), bleeding after intercourse and vaginal infection (2%). Some attributed these problems due to spouses health problems (4%) and conflict with spouse (4%)³.

Apart from the above disorders of sexual functioning the young women may encounter problems related to engaging in sexual relationship with their partner like abuse and unsafe sex predisposing to the risk of acquiring HIV.

UNDP/UNFPA / WHO investigated areas of sexual and reproductive health care of young people, including adolescents (aged 10.19 years) and youth (aged 15.24 years)in 20 countries . In every setting, sexual activity begins during adolescence among many young people. Much of this activity is risky. Contraceptive use is often erratic and unwanted pregnancy and unsafe abortions are observed in many settings. Sexual relations may be forced. There are wide gender-based differences in sexual conduct, and in the ability to negotiate sexual activity and contraceptive use. Despite this, relatively few young people think they are at risk of disease or unwanted pregnancy. Awareness of safe sex practices seems to be superficial, and misinformation regarding the risks and consequences of unsafe sex is wide- spread⁴.A study examined the partner abuse and HIV risk among 2058 sexually active young adult women. Young, sexually active women experiencing no abuse in their relationships were more likely to consistently use condoms in the past 12 months than with their abused counterparts. A casual pathway may exist between prior abuse, current abuse and HIV risk⁵.

A study that explored the sexual coercion and abuse among 146 women with a severe mental illness in NIMHANS, India revealed the following findings. Sexual coercion was reported by 30% involving threatened or actual physical force and the most commonly identified perpetrator was the woman's husband or intimate partner (15 percent), or a person in a position of authority in their community (10 percent). Women with a history of abuse were more likely to report HIV-related sexual behavior (P .001). In contrast to the 30 percent of women who reported sexual coercion during interviews, only 3.5 percent of the medical records contained this information. Increased screening and reporting are indicated, as are sexual abuse prevention and treatment programs.⁶

Keeping in view of the above mentioned facts and non availability of data from young women in slums a study on the sexual health problems of young women is warranted.

Aim:

To identify the sexual health problems of young women in slums

MATERIALS AND METHODS:

The study was a cross sectional survey of 155 healthy young women residing in 5 different slums .The participants were selected from the general population using stratified sampling technique if fulfilled the following inclusion criteria.

Inclusion criteria

Age between 15-24 years

Married and staying continuously with the spouse for at least two months .

Instrument A self report instrument was developed and modified from Brief index of sexual functioning for women ⁽⁷⁾. It has 13 items scored on a 3point scale (0-2).

Data collection procedure

The tool was administered after getting the informed consent from each participant. The participants were interviewed in a convenient place. Confidentiality and anonymity were ensured.

RESULTS:

1. Demographic Characteristics

More than 50% of young women were below 19 years of age. Nearly 80% of them were Hindus and unemployed. Three fourth of the subjects were living in slums for more than 10 years. Only 30% of the subjects had completed a higher secondary education. Partner of the married (60%) and father of the unmarried were the key decision makers for medical expenses. About occupation, 73.55% of married women were home makers, the rest involved in jobs like coolie, supportive jobs in private companies, small scale industries, corporate cleaning work etc. The socioeconomic status of the subjects revealed that only a small proportion of women (7.74%) were having a family income above Rs.5000

Partner’s Characteristics: Nearly 60% of their partners were Coolie workers. Nearly 35% of their partners were using alcohol and 25% were consuming tobacco.

Sexual health problems of young women:

Frequency and Percentage Distribution of Married Women According to Severity of Sexual Problems (N=155)

Table-1:

Variable	f	%
*I. Sexual Problems*
Present	52	33.55
Absent	103	66.45
*II. Severity of Problem (n=52)*
Severe	0	0
Moderate	0	0
Mild	52	100

Table 1 depicts that only 1/3^rd (33.35%) had sexual problems and out of those reported none had moderate or severe sexual problems.

Table-2: Percentage Distribution of Married Women According to the Problems in Sexual Relationship with their Partner (N=155)

Items Related to Problems in Sexual Relationship	Often		Occasionally		Never
Items Related to Problems in Sexual Relationship	f	%	f	%	f	%
Satisfied with the relationship with their partner	141	91	8	5.2	6	3.9
Head ache after sex	2	1.3	7	4.5	146	94.2
Unable to reach orgasm	2	1.3	7	4.5	146	94.2
Pain during sex	2	1.3	15	9.7	138	89
Bleeding after sex	--	--	2	1.3	153	98.7
Infection of genitalia	2	1.3	2	1.3	151	97.4
Disinterest towards sexual life	4	2.6	12	7.7	139	89.7
Anxiety during sex	3	1.9	9	5.8	143	92.3
Sex without consent	2	1.3	8	5.2	145	93.5
Sexual humiliation	--	--	5	3.2	150	96.8
Using unwanted mode of sex	3	1.9	2	1.3	150	96.8
Has a doubting partner	3	1.9	1	0.6	151	97.4
Sickness limiting sexual contact	3	1.9	12	7.7	140	90.3

Only 1.3% had expressed that problems like headache, unable to reach orgasm, infection in genitalia, sexual violence, pain were present often either during or after sex. 1.9% of women expressed that their partner had humiliated or used unwanted mode of sex or doubted them. 2.6% had disinterest towards sexual life often as table -2

Few subjects came out with their problems such as:

“Husband doubts me, does not respect me at all. We always fight with each other. So we don’t have relationship.” “My husband was working abroad. He revealed to me that he once had sexual relationship with a foreigner. Till now we don’t have an offspring. But he keeps me happy.” On the whole, women did not experience severe sexual problems. The reasons that can be attributed may be underreporting, being in early marital life or having inhibitions to express themselves.

But the results of the study conducted among 1664 married young women in Gujarat, India revealed that 12% of married women experienced unwanted sex frequently; 32% experienced occasionally which is more than the present study findings³. Even in the study carried out in Nigeria 15% had forced sexual intercourse⁸

In Asian Studies there is under reporting of sexual dysfunction by females which may be because they are young age groups. Self reports about sexual dysfunction, especially face to face interviews are subject to under reporting bias arising from concerns of social stigmatization, low emphasis on female sexual satisfaction, poor attitude toward health care professionals which require further evaluation in future studies³.

LIMITATION:

The present study is a preliminary effort to understand the sexual health problems of young women. Being a younger age group a few percentage of the sample only reported about sexual health problems. Neither were they interested in undergoing a clinical examination. Many cultural factors could have had an impact on the study findings .Future studies should explore the sexual health knowledge, attitude, behaviour, disorders and HIV risk of this population.

NURSING IMPLICATIONS:

The Nurses as a Role Model

The nurse’s attitudes, biases and prejudices regarding sexuality are readily transmitted to patients through his or her actions, manner of speech, avoidance of certain circumstances, and types of discussion. The level of knowledge a nurse has about sexual issues can inhibit or promote discussions of sexual health.

Text Box: NURSING GOALS
• Feel comfortable as a sexual being
• Develop self awareness regarding sexual topics
• Develop communication skills that promote discussion of sexual concerns with patients
• Identify patients with problems related to sexuality and intervene competently and comfortably to meet these needs
• Practice responsible sexual expression

The PLISSIt model for sexual health intervention⁹

This model offers four levels of sexual health counselling; it encourages nurses to intervene at the level at which they feel comfortable. The four levels are described as follows :

- Give Permission (P). Convey to the client or relatives that you are willing to discuss sexual thoughts and feelings.

- Offer Limited Information (LI) on the implications of, for example, being pregnant, having cancer or being prescribed a particular medication.

- Make Specific Suggestions (SS) Provide specific instructions that facilitate positive sexual functioning, such as coital positions for women with arthritis.

Provide Intensive Therapy (IT) Clients needing this type of approach should be referred to nurses with advanced knowledge of sex therapy, or to specialist therapist.

Nursing education

 The promotion of sexual health is a legitimate role for the nurse.. Unfortunately, the exploration of sexual health in many nursing education programmes is frequently inadequate. Teachers of nursing are often unprepared and unskilled in promoting learning experiences focused on human sexuality and sexual health and HIV/STI risk.¹

 During the exploratory discussion, try to elicit information about key issues in order to assist the client to perceive and determine his or her risk for STIs, including: Number (and gender) of sexual partners currently and in the past, Knowledge of partner’s sexual practices and other partners, Condom use, History of STIs/ infections and Sexual practices and behaviors⁹.

 There is a global need for: adolescent- and youth-friendly sexual and reproductive health services; counselling on sexuality, pregnancy, post-abortion issues and family planning; and sex education programmes that are age-appropriate and sensitively imparted.

Nurses Role in Research

Research Recommendations

 Investigate the gender roles and life skills that affect the health situation of young women

 Explore the issues of sexual coercion concerning both married and unmarried youth

 Investigate young people's access to health care, and the constraints they face in the pursuit of good health^.

STRATEGIES AND RECOMMENDATION

1. Programmatic Recommendations

 Build life skills among youth

 Address gender disparities

 Raise awareness of sexual force and coercion, and equip youth to counter them

 Dispel myths and misconceptions

 Provide information through media acceptable to youth

 Involve parents in communicating information on safe sex behaviour

 Involve youth in programmes aimed at imparting information and developing educational strategies

Promote access to confidential and private sexual and reproductivhealthcareservice

2. Promote Sexual Health

Successful promotion of sexual health requires a comprehensive programme of activities, encompassing the health and education sectors, as well as the broader political, economic and legal domains World²

3. Integrating Sexual Health into Primary Health Care Services

Strategies to integrate aspects of sexual health into MCH services include:

è Provision of voluntary and confidential counselling and testing for HIV

è Education about HIV prevention, condom use and prevention of STIs, prevention of mother-to-child transmission of HIV infection.

The Required Skills Recommended For Nurses Are Shown In Figure – 1.

COGNITIVE SKILLS

Strong Knowledge base on

 Human sexuality, myths, anatomy, physiology

 Factors affecting

 Integrate knowledge into nursing care

 Identify patients with problems related to sexuality

INTERPERSONAL SKILLS

 To establish trusting relationship, and build rapport

 Demonstrate non judgmental attitude respect for dignity

 Counselling skills

 Motivate coping behaviors

NURSE

TECHNICAL SKILLS

 Assessment skills for interviewing concern about sexuality

 Ability to adapt techniques for patients with problems affecting sexual health

 Seek help when necessary

ETHICAL AND LEGAL SKILLS

 Commitment to safety and quality Strong sense of accountability

 Commitment to patient advocacy

 Familiarity with agency policy

 Practice in an ethically and legally defendable manner.

Figure-1

CONCLUSION:

The study findings showed that the young women in slums are a vulnerable group and they experience sexual health risks to some extent. Availability of youth friendly reproductive and sexual health services would help in alleviating the myths and inhibition associated in expressing their problems.

REFERENCES:

1. Engender Health. Sexuality and Sexual Health online Mini course 2005. (http ://www.engenderhealth.org/pubs/index.html)

2. Mercer CH, et al. Sexual function problems and help seeking behaviour in Britain: BMJ 2003; 327: pp.426–427. [Online] Available from: http://www.bmj. com/cgi/content/ full/ 327/ 7412/426. (Accessed on 20^th Jun. 2009).

3. Avasthi A, Kaur R, Prakash O, Banergee A, Kumar L & Kulhara P. Sexual behaviour of married young women. A preliminary study from North India. Indian Journal of Community Medicine, 2008; 333 (3): pp.163-166.

4. Ann Denise Brown et al., Sexual relations among young people in developing countries evidence from WHO case studies, Department of reproductive Health and Reports, WHO, Geneva, 1998 (www.who.org)

5. Teitelman AM, Ratcliffe SJ, Dichtder ME & Sullivan CM. Recent and past intimate partner abuse and HIV risk among young women. Jobstet Gynec. Neonatal Nurs. Mar-Apr 2008; 37(2): pp.219-27.

6. Chandra, P.S, Carrey, M.P, Carry, K.B, Shalinianand, A. & Thomas. T. Sexual coercion and abuse among women with a severe mental illness in India. Compr. Psychiatry. 2005 May – June; 44(3) : 2005 – 212.

7. Rosen R et al. The female sexual function index. A multidimensional self report instrument for the assessment of female sexual function. Journal of Sex & Marital Therapy, 2000; 26: pp.191-208

8. WHO. Sexually Transmitted Infections, Reproductive Tract Infections, a guide to Essential Practice, 2005; Department of Reproductive Health Research, WHO

9. Avasthi A, Kaur R, Prakash O, Banergee A, Kumar L & Kulhara P. Sexual behaviour of married young women. A preliminary study from North India. Indian Journal of Community Medicine, 2008; 333 (3): pp.163-166

Received on 13.08.2012 Modified on 20.09.2012

Asian J. Nur. Edu. and Research 2(4): Oct-Dec. 2012; Page 197-201

The PLISSIt model for sexual health intervention9