Perceptions of women about sexuality during breastfeeding: an integrative literature review

Elaine Lutz Martins^I; Octavio Muniz da Costa Vargens^II

^INurse Midwife. Master degree student of the Nursing Post-graduate Program, Faculty of Nursing, e Rio de Janeiro State University Brazil. Email: elainelutzmartins@yahoo.com.br
^IINurse Midwife. PhD. Titular professor, Faculty of Nursing, e Rio de Janeiro State University. Brazil. Email: omcvargens@uol.com.br

ABSTRACT: This integrative literature review aimed to identify women’s perceptions of sexuality during breast feeding, focusing on pleasurable sensations. A bibliographical search performed on the LILACS, MEDLINE and PUBMED databases yielded a sample of nine articles. Results were grouped by two main themes: body changes, dual function of the breast and merging of roles during maternity and the influence of breast feeding on female and marital sexuality. It was possible to identify a gap in studies on this theme in that few address female sexuality, in terms of sensations of pleasure, sexual excitement and even orgasm during breast feeding. More research is needed into the subjectivity of female sexuality, so that nursing personnel – and mainly obstetric nurses – can provide input to planning comprehensive care for women, mothers and wet nurses.

Keywords: Sexuality; breastfeeding; women’s health; obstetric nursing.

INTRODUCTION

Sexuality is an important aspect in women’s life, because it involves various bodily and hormonal changes, that occur at each stage of the female reproductive cycle. For example, in the puerperal period sexuality joins several other factors of motherhood, such as breastfeeding, generating perceptions and unexplored feelings and discussed by women, health professionals and society.

Breastfeeding is considered one of the most intimate human contacts, as well as the sexual act and delivery¹. We identified the relationship between the act of breastfeeding with female sexuality, when we understand the meaning of the terminology breastfeeding, which refers to the act of the nursing to breastfeed the infant and the same breastfeed it directly².

Through the understanding of subjectivity involved in the act of breastfeeding, we could associate with female sexuality, because some women experience satisfaction and or intense pleasure during sucking on her breasts¹. This is explained by the release of oxytocin during the act of breastfeeding. This higher concentration of oxytocin may cause pleasure and some women refer to orgasm sensation during breastfeeding. Such sensation can generate a feeling of guilt, especially when the baby is male, because they imagine to be practicing incest. The experience of these feelings is very significant for them, which can lead to the abandonment of breastfeeding (BF)³.

Thus, breastfeeding can bring different sensations and feelings for women when it relates to sexuality, because it is also a social experience that will have different meanings and aspects in every woman's life⁴. During the puerperium, it is socially expected that these women are ready, welcoming and eager to breastfeed. Unfortunately, expectations are focused on the care of the baby, ignoring the feelings, desires and physical and emotional condition of the mother/wet nurse⁵.

It is known that the experience of sexuality during breastfeeding has conditioned sociocultural aspects, psychologically outlined and its approach, sometimes, does not contemplate the various subjectivities that are around woman⁶. For having a professional performance covering fully every woman, it is necessary a vision focusing on the peculiarity of women/mothers/ wet nurses and to understand not only its biological participation in breastfeeding, but also other aspects that surround women's universe⁷, to work on the issue of sexuality during breastfeeding.

In this context, this study allows an overview of works that address women’s sexuality during breastfeeding, and present a reflection about how we approach this issue with women, during nursing care. It is also a relevant contribution in the construction of new knowledge for nursing in women's health. Furthermore, it allows us to plan an integral care, articulating popular and scientific knowledge and experiences, making women protagonist of the roles of being a woman, mother and wet nurse simultaneously.

Thus, the objective of the study was to present, through integrative literature review, a synthesis of the different perceptions of women about sexuality during breastfeeding, focusing on sensations of pleasure.

METHODOLOGY

This is an integrative literature review, which gathered and synthesized in a systematic and orderly manner, the results of research about the issue of sexuality during breastfeeding. For conducting the review was followed the steps: identification of the subject; sampling or literature search; categorization of studies; assessment of studies included in the integrative review; interpretation of results; and synthesis of knowledge evidenced in the analyzed researches⁸.

To guide this study, the research question was formulated: which are the perceptions of women about sexuality during breastfeeding?

The literature search was performed in electronic databases such as Latin American and Caribbean Literature on Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) and Public Medline (PUBMED). It was used the following keywords and words, and their respective combinations in the English language: breastfeeding or maternal suckling and sexuality, breastfeeding or maternal suckling and sexual arousal, oxytocin and breastfeeding or maternal suckling, orgasm and breastfeeding or maternal suckling.

The survey of the studies took place in the period September-December 2012. To select them, the inclusion criteria were: articles of original research related to the topic, available online in its entirety; and in English, Portuguese or Spanish languages. The exclusion criteria were: articles without abstracts in the database or incomplete and do not answer the research question.

From the conducted search, we found 356 studies in three databases (12 in LILACS, 139 in MEDLINE, and 205 in PUBMED), of which eight were repeated in the databases; 94 had incomplete summaries; 218 did not respond to the theme; six were not from original research; 21 were unavailable online in full. Finally, the search identified nine articles for analysis^9-17.

The results were discussed in light of the speciality literature^1-7,18-26.

RESULTS AND DISCUSSION

After exhaustive reading of the selected studies, it was possible to identify search results. Of the nine articles included in the integrative review, it was noted that nursing has three publications, the medical field has two studies, psychology one. In other three studies were unable to identify the area. Concerning to the origin of the studies, three are from the United States, two from Scotland and one, respectively, from Brazil, South Korea, Canada and UK.

As regard to the publication period, the works examined covered the period from 1989 to 2010.
For the year, two were published in 2005, two in 2000 and one study for each year in 2010, 2006, 2004, 1997 and 1986. Regarding the type of research design, it was evidenced a qualitative study and the other ones with quantitative approach.

The examined scientific production, published in the period 1986-2004, are shown in Figure 1.

The articles published in the period 2005-2010 are shown in Figure 2.

Moreover, the analysis of texts allowed the identification of two thematics groups: body changes, dual function of breast and fusion of roles during maternity and breastfeeding influence on sexuality of woman and couple, which will be addressed below.

Body changes, dual function of breast and fusion of roles during maternity

Women's perceptions regarding breastfeeding and sexuality begin in lived experience of motherhood, because in this period the majority of the changes occur in their sexualidade¹⁶, influenced by physical, emotional, social, psychological and hormonal changes.

The bodily changes and the shape of the breasts were evidenced in the perceptions of women about sexuality during breastfeeding, they were seen as positive or not. Some women reported changes in breast shape as a barrier between breastfeeding and sexuality¹⁷, as the changes in size, shape and sensitivity, due to the amount of milk, are perceived as negative^11,16.

Women who give a negative meaning to changes in self-image end up feeling uncomfortable. For them, these bodily changes restrict and intimidate the intra and interpersonal attitudes and relationships, interfering with their sexuality, more explicitly in the sexual exercise with their partner¹⁶. Some feelings as dissatisfaction and shame of their own body, do not feel comfortable with their partner, and negatively influence the couple's sex life⁴.

Other bodily changes are also perceived as flaccid abdomen without the presence of the baby, as well as its own weight above normal¹⁶. It is known that these body changes are physiology normal of a woman in the puerperal period, however, is often not naturally understood and just negatively affect the female sexuality, for example, the self-image and self-esteem are affected.

These perceptions are linked to the ideology of the biological body, because women feel uncomfortable with their bodies, which affects self-esteem, self-image, sexuality, and even the relationship with their partners⁴.

It is noticed that the female breast is much valued in Brazilian culture as in U.S. Thus, some women like the changes related to volume and firmness of the breasts, in the period of lactation, feeling attractive and sexy. Also, there is the assumption of breast prosthesis implant after weaning, to maintain this ideal image of breasts¹.

Regarding to the function of breasts, is realize that breastfeeding is prioritized over other functions performed by the female breast. Studies indicate that infant feeding is more significant than the female sexual functioning¹⁷, plus a sum of good feelings and wishes involving lactation and make women strengthen and prioritize breastfeeding over other functions performed by the female breast^16,18. Thus, the female breast is seen by women and society as a source of food for their children and not as an eroticized body, leaving aside female sexuality, its feelings and pleasure.

In a survey within Brazilian and French women, was investigated the dualism of maternal and erotic breast, which shows the existence of prohibition to touch the maternal breast, called by the author as taboo of mother's breast. Still, in this study, it was possible to reveal the existence of several cases in which the idea of dividing the body is perceived as a horizontal division, between the lower half, sexual, and the upper half, maternal and reserved only for the feeding function¹⁹.

Another study conducted in the city of Rio de Janeiro, with 20 breastfeeding women, the breast was comprehended solely as maternal structure, being in contrast with the current society, where the cult of the perfect and eroticized breast is more ascendant⁶.

In addition, the function played by breast exclusively in feeding function interferes negatively in the conjugal sexuality, because some women report satisfaction in breastfeeding, as well as the intense physical contact with their son, sufficient and able to overlap the sexual and emotional needs with the partner⁶.

Another factor found in the results was that women do not perceive as a barrier between sexuality and breastfeeding, breastfeeding in public environments¹⁷, leaving aside prejudices, taboos and beliefs, confirming their opinions about the primary function of the breast as a food source. However, this opinion does not always prevail, depending on personal history and culture of each woman.

In a study of literature review that aimed at identifying the feeding practices in the first year of life, identified problems for maintenance of BF among teenage mothers, since one of the main factors mentioned by them was the embarrassment to breastfeed in public. This report is unusual in Brazil, as this negative perception depends on the culture of each social group²⁰.

Moreover, the new condition of being a mother/ wet nurse and woman/wife, both brings conditions of different forms of acting in the world. Given this fusion of roles and responsibilities, some women seek alternatives to reconcile sexuality and breastfeeding, added with the symbolic and concrete presence of the child, which could satisfactorily enjoy the pleasures favored by sexual exercise and by motherhood¹⁶.

In this perspective, both maximum expressions of their experience in the role of being a mother and wife are configured as source of emotions and sensations perceived as positive or not about the aspect of sexuality during breastfeeding¹⁶.

It is known that becoming a mother is a ritual of passage and a involves the woman in a  reorganization of their various roles. This adjustment period is considered complex, because bio-psychosocial changes occur, these changes are attributed to new meanings that can interfere to their adjustment to motherhood⁴.

Some negative factors are perceived in this phase to adapt to new roles and responsibilities, which end up interfering with female sexuality and marriage. Among these factors affecting marital sexuality, are the baby care, exhaustion of domestic chores and lack of time that are considered as a sexual demotivation. Therefore, to reconcile between the role of woman/wife and mother role is a difficult task, which is not always satisfactorily⁶.

Still, the act of breastfeeding can generate personal conflicts and in relational environment, due to an ambivalence of feelings²¹, since it is considered as one more activity among the many that women have to play by overloading tehm²².

Another factor is the value assigned to the prioritization of the baby care by familiars and as the mothers, which overshadows attention to women demonstrations in front of their bodies^{4, 22}, also creating the expectation that women assume the role of mother immediately and without difficulties⁴. Besides the exclusive dedication of the mother to the baby being perceived by men as rejection, because now the companion have low priority¹⁹.

Thus, this period of women’s life should not be neglected, but valued, in order to minimize the factors with negative influence on their perceptions and feelings during maternity.

Influence of breastfeeding on sexuality of woman and couple

Some negative feelings between the association of breastfeeding and sexual relationship of a couple are pointed out in some studies. These associate lactation with dyspareunia, at three months postpartum, but at six months the pain is no longer reported^12,15.

Moreover, breastfeeding is considered an important factor in the late recovery of the sexual relationship of the couple, and the main reasons for this postponement and lack of interest are, fatigue and fear of pain¹⁴. Other studies confirm that women who breastfeed are more likely experiencing the loss of interest in sex relationship than those using artificial feeding^9,10, but this effect did not persist long-term¹⁰.

A study that described the influence of BF on women's sexuality showed that the decreased desire, frequency and duration of sexual intercourse, as well as dyspareunia and vaginal lubrication changes were present in most of the reports of the mothers⁶.

Corroborating this finding, a study that investigated the levels of sexual interest and response from breastfeeding women, identified in reports less pleasure in orgasm, less frequency and need of more stimulation to achieve it, than women who did not breastfeed²³. Adding to that, the hormonal influence is directly linked to negative interference of breastfeeding on the sexual relationship of a couple, because it can cause sexual complications, such as decreased vaginal lubrication¹¹.

This phenomenon is explained by the reduced level of estrogen and progesterone and prolactin increase during the BF²⁴, since estrogen promotes sexual receptivity, whereas prolactin required for milk production, functions as an inhibitor¹⁹. It is concluded that low levels of sex steroids may contribute to decreased sexual interest and to the lack or decreased vaginal lubrication²⁵.

Another hormonal influence is the presence and action of oxytocin in the act of breastfeeding as in the sexual intercourse¹. Leaking breast milk may occur when some women are sexually stimulated, but this milk ejection during intercourse was perceived as neutral¹¹. However this situation, sometimes is understood by women as embarrassing or discouraging during sex.

In a survey, six women were surveyed about how they dealt with sexuality and bodily changes in the postpartum period, noting that some of them reported discomfort with the presence of breast milk during sex. Unlike their colleagues who do not care about the presence of maternal milk and want to touch them and try it⁴.

Some strategies are used to minimize this discomfort and embarrassment during sexual intercourse, as the use of bra, diapers and protectors⁶, besides the inhibition of sexual stimulation of the breasts and nipples in women with sensitive breasts²⁶. However, if the milk ejection occurs, some women report that interrupt the sexual act due to the memory of their son, because they understand that it is hungry, that they are wasting the milk or being ashamed and find an unpleasant situation for the companion⁶.

Opposed to the negative aspects of breastfeeding about sexuality, lactation can offer feelings of pleasure and sexual arousal during breastfeeding in some wet nurses. It was evident that the sensations of suction caused excitement in some women during the act of breastfeeding, however, was not for most of the mothers¹¹.

Moreover, natural compounds obtained from lactating women and babies, during breastfeeding, increased sexual motivation of other women, measures with sexual desire and fantasies. This increase in sexual motivation was different in women with a regular sexual partner, but women who did not have a regular partner had more fantasies¹³.

Unfortunately, we live in a society where prevails a repressive culture, because some women can not accept the fact that suckling at the breast, performed during breastfeeding, may cause them a similar feeling to that experienced by women during an orgasm during sex with their partner¹. However, there are women who break this taboo of maternal incest, revealing their pleasurable sensations with the baby sucking the breast, and experience similar sensations to sexual pleasure⁶.

To experience breastfeeding and sexuality simultaneously, requires physiological and scientific knowledge, and also historical, social, psychological and cultural aspects of women, because the perceptions and meanings can be different for every woman, according to his uniqueness. Therefore, it is concluded from this study that women's perceptions about sexuality during breastfeeding refers to the bodily changes, the function performed by the breast, the fusion of roles during maternity, hormonal influences on marital sexuality, as well as on female sexuality, through pleasurable sensations as individual perception of each woman.

However, from these found results, it is noticed that there is a gap in research about the subject, since most studies are of quantitative approach, prioritizing marital sexuality, thus minimizing female sexuality, with their subjectivity, their perceptions, desires and pleasurable sensations during breastfeeding.

Therefore, it is necessary to develop and improve research involving women's perceptions about female sexuality during breastfeeding, seeking to identify the knowledge of the issue in society and to recognize the culture surrounding women's perceptions. Thus, nursing professionals, especially nurse midwives, will present subsidies to plan an integral women's health, mother and wet nurse.

REFERENCES

1. Abuchaim ESV. Experiencing breasfeeding and sexuality in motherhood: separanting yourself between motherhood and being a woman [tese de doutorado]. São Paulo: Universidade de São Paulo; 2005.

2. Carvalho MR, Tavares LAM. Breastfeeding: scientific bases. 3a ed. Rio de Janeiro: Guanabara Koogan; 2010.

3. Febrasgo. Federação Brasileira das Associações de Ginecologia e Obstetrícia. Guidelines Manual: breastfeeding. São Paulo: Ponto; 2006.

4. Salim NR, Araújo NM, Gualda DMR. Body and sexuality: puerperas’ experiences. Rev Latino-Am Enfermagem. 2010; 18(4): 08 telas.

5. Monteiro JCS, Gomes FA, Nakano AMS. Breastfeeding and female breast: an analysis under the perspective of sexuality and reproductive rights. Texto contexto – enferm. 2006; 15:146-50.

6. Marques DM, Lemos A. Sexuality and breastfeeding: woman/mother’s dilemmas. Rev enferm UFPE on line. 2010; 4: 622-30.

7. Marques DM, Pereira AL. Breastfeeding: always a benefit, not always a pleasure. Ciênc cuid Saúde. 2010; 9: 214-9.

8. Pompeo DA, Rossi LA, Galvão CM. Integrative literature review: the initial step in the validation process of nursing diagnoses. Acta Paul Enferm. 2009; 22: 434-8.

9. Alder EM, Cook A, Davidson D, West C, Bancroft J. Hormones, mood and sexuality in lactating women. Br J Psychiatry. 1986; 148: 74-9.

10. Glazener CM. Sexual function after childbirth: women's experiences, persistent morbidity and lack of professional recognition. BJOG. 1997; 104: 330-5.

11. Avery MD, Duckett L, Frantzich CR. The experience of sexuality during breastfeeding among primiparous women. Journal of Midwifery & Women’s Health. 2000; 45: 227-37.

12. Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I. Women’s sexual health after childbirth. BJOG. 2000; 107:186-95.

13. Spencer NA, McClintocka MK, Sellergrena SA, Bullivanta S, Jacoba S, Mennella JA. Social chemosignals from breastfeeding women increase sexual motivation.  Horm Behav. 2004; 46: 362-70.

14. Rowland M, Foxcroft L, Hopman WM, Patel R. Breastfeeding and sexuality immediately post partum.  Can Fam Physician. 2005; 51: 1366-7.

15. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J. 2005; 16: 263-7.

16. Abuchaim ESV, Silva IA. Experiencing breasfeeding and sexuality in motherhood: separanting yourself between motherhood and being a woman. Ciênc cuid Saúde. 2006; 5: 220-8.

17. Ahn Y, Sohn M, Yoo E. Breast functions perceived by korean mothers: infant nutrition and female sexuality. West J Nurs Res. 2010; 32(3): 363- 78.

18. Florencio A, Van der Sand ICP, Cabral FB, Colomé ICS, Girardon-Perlini NMO. Sexuality and breastfeeding: concepts and approaches of primary health care nurses. Rev esc enferm USP. 2012; 46: 1320-6.

19. Sandre-Pereira G. Breastfeeding and Sexuality. Estudos Feministas. 2003; 11: 467-91.

20. Lima APE, Javorski M, Vasconcelos MGL. Eating habits in the first year of life. Rev Bras Enferm. 2011; 64: 912-18.

21. Barros CS, Queiroz PP, Javorski M, Vasconcelos MGL, Vasconcelos EMR, Pontes CM. Meanings of the experience of breastfeeding among nurses in maternal and child healthcare. Rev  enferm UERJ. 2012; 20: 802-7.

22. Nakano AMS. Breastfeeding experiences in a group of women: the limits of “the body for the child” and “the body for oneself”. Cad Saúde Pública. 2003; 19(sup.2): 355-63.

23. Alves MGC. Factors that influence women's sexuality after childbirth [dissertação de mestrado]. Lisboa (Pt): Universidade de Lisboa; 2008.

24. Silva AI, Figueiredo B. Sexuality during pregnancy and after childbirth. Psiquiatria Clínica. 2005; 25: 253-64.

25. Vettorazzi J,Marques F, Hentschel H, Ramos JGL, Martins-Costa SH, Badalotti M. Sexuality and the postpartum period: a literature review. Rev HCPA. 2012; 32: 473-9.

26. Alder EM. Sexual behaviour in pregnancy, after childbirth and during breast-feeding. Baillière’s Clinical Obstetrics and Gynaecology. 1989; 3: 805-21.