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Unconsummated marriage in the Arab Islamic world: Tunisian experience
Sexologies (2013) 22, e71—e76
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ORIGINAL ARTICLE
Unconsummated marriage in the Arab Islamic world: Tunisian experience夽 M. Nabil Mhiri (MD) a, W. Smaoui (MD) a, M. Bouassida (MD) a,∗, K. Chabchoub (MD) a, J. Masmoudi (MD) b, M. Hadjslimen (MD) a, N. Chaieb (MD) a, N. Rebai (MD) a, S. Masmoudi (MD) a, A. Bahloul (MD) a a b
Urology department, Habib Bourguiba academic medical center, Majida Boulila avenue, 3026 Sfax, Tunisia Psychiatry department, Hedi Chaker academic medical center, 3029 Sfax, Tunisia
Available online 27 March 2013
KEYWORDS Unconsummated marriage; Couples; Erectile dysfunction; Premature ejaculation; Vaginismus; Sex therapy
Summary Objective. — To identify the clinical features of unconsummated marriage (UCM) amongst couples, the etiological factors, the therapeutic approaches and to clarify the different evolutive aspects. Patients and methods. — In this retrospective study, the files of 80 consecutive couples followed for UCM between 2000 and 2010 at our andrology consultation were reviewed. Results. — The mean age of the husbands was 36 years (22—82 years), that of the brides was 28 years (17—57 years). The average length of marriage was 14 months (range 3 months—7 years). Couples had little knowledge of sexology. The sexual dysfunctions noted were: erectile dysfunction in 40% of cases, premature ejaculation in 5%, a combination of premature ejaculation with erectile dysfunction and decreased libido in 15%, vaginismus in 12.5% and the associated causes (erectile dysfunction with vaginismus) in 27.5%. The first-line treatment was based on a sexological approach consisting of sex education and sex therapy, associated in some cases with oral drugs and as second-line treatment, sometimes intracavernous injections. After a mean follow-up of 5 months (range 1—15 months), the outcomes of treatment were: good prognosis with consummation of marriage in 57 cases (71.25%), failure with UCM in 18 cases (22.25%) and not known in five cases (6.25%). Conclusion. — UCM is quite frequent in the Arab Islamic world. The best treatment is prevention based on sexual education of youngsters and treatment of sexual dysfunctions for people who consult before marriage. © 2013 Elsevier Masson SAS. All rights reserved.
DOI of original article:http://dx.doi.org/10.1016/j.sexol.2013.02.003. La version en franc ¸ais de cet article, publiée dans l’édition imprimée de la revue, est disponible en ligne : doi : 10.1016/j.sexol. 2013.02.003. ∗ Corresponding author. E-mail address: [email protected] (M. Bouassida). 夽
1158-1360/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.sexol.2013.02.004
e72
M. Nabil Mhiri et al.
Introduction
Clinical and paraclinical data
Marriage is the only legitimated form of sexuality in the Arab Islamic world. In some societies, a marriage ceremony is always expected to include consummation which must take place on the wedding night or during the succeeding few days. In some rural areas, some confirmation is expected for the families involved that coitus has occurred and that the bride was a virgin (Zargooshi, 2000). Any delay in the consummation of marriage (CM) can be a source of suffering in the couple and the family environment, creating a social emergency. Unconsummated marriage (UCM) is defined as the failure at all attempts of vaginal coitus that a faithful couple, married or not, might have tried in vain, for at least 3 consecutive months of night-time cohabitation (Waynberg, 1994). UCM is a common medical and social problem facing medical practitioners in conservative communities. It accounts for up to 17% of visits to sexual health clinics (Badran et al., 2006). And yet little is known about the causes of UCM in our region; the present work aims to define the main contributing factors, the therapeutic approaches and to clarify the different evolutive aspects.
All patients underwent a complete physical examination that focused on external genitalia and secondary sexual characteristics. For the biological assessment, a standard workup was performed with a dosage of fasting blood glucose, serum creatinine, lipid profile, complete blood count and liver function tests were routinely carried out. Serum testosterone and prolactin tests were carried out whenever indicated (cases with affected sexual desire, hypogonadal features, older age, gynecomastia or small testicular size). Penile color doppler flow study was carried out in six cases. After this initial evaluation, the nature of the problem and different management options were discussed with the patient or the couple: sexological interview of the couple based on sexual education (anatomy of genital organs and importance of preliminaries) with sex therapy, oral drug or intracavernous injections (ICIs).
Patients and methods Between 2000 and 2010, the files of 80 consecutive couples followed for UCM at our andrology consultation were reviewed and patients were recruited with their informed consent.
Inclusion criteria All couples or partners who consult for UCM after at least 3 months of night-time cohabitation were included.
Exclusion criteria Couples consulting for sexual dysfunction as a result of marital discord and those who had failure of vaginal coitus for a period less than 3 months. Different items were studied.
Psychosocial data Age of partners, length of marriage, the pattern of consultation (UCM or infertility), degree of family pressure on the couple, degree of emotional ties between the couple, assessment of knowledge in sexology and genital anatomy, assessment of the degree of socio-cultural conformism of each partner, previous use of traditional healers, review of the person’s educational, family and religious background. Moreover, gender identity, sexual orientation and sexual behavior (desires, fantasies, autoeroticism, current and previous interpersonal sexual activity, same sex relations, rejection experience, sexual abuse and body image) were carefully explored, as were the mode of consultation and the quality of the referring physician.
Results A total of 160 consecutive patients complaining of UCM were retrospectively included in the study. All patients were of Tunisian nationality. The mean age of male partners was 36 years (22—82 years), and of brides 28 years (17—57 years) (Table 1). Fifty percent of the patients were from rural regions, and the rest from urban areas. The most common reason for consultation of patients was the inability to consummate the marriage observed in 65 couples (81.25%), in the other cases, the UCM associated with infertility or infertility alone with a desire to have children were noted in 11 cases (13.75%) and four cases (5%) respectively. Regarding the mode of presentation, the couple consulted together in 54 cases (67.5%), the male partner alone in 22 cases (27.5%) and male partner and relatives in four cases (5%). The average length of marriage was 14 months (range 3 months—7 years). It was noted that 40% of couples (32 cases) had consulted between the third and sixth month after marriage, 25% (20 cases) between the seventh and 12th month, 22.5% (18 cases) between the 13th and 24th month, and 12.5% (10 cases) beyond the 24th month after marriage. Twenty six couples (32.5%) had visited traditional healers before medical consultation.
Table 1 distribution of patients according to gender and age brackets. Age (years)
Husbands Number
< 25 25—30 31—40 > 40
2 22 44 12
Total
80
Brides Percentage 2.5 27.5 55 15 100
Number 8 44 18 10 80
Percentage 10 55 22.5 12.5 100
Unconsummated marriage in the Arab Islamic world: Tunisian experience Table 2 Etiologic factors causing the unconsummated marriage. Etiology
Number
Erectile dysfunction (ED) alone Premature ejaculation (PE) alone ED ± PE ± libido Vaginismus alone Associated etiologies (couple)
32 4 12 10 22
Total
80
Percentage 40 5 15 12.5 27.5 100
About the marital status of the male partners, 90% were at their first marriage. Concerning the cultural level, 25% of husbands had primary education only, 60% secondary school and 15% university studies. History analysis of patients revealed several underlying conditions, but only among the male partners, namely diabetes in eight cases (10%), smoking in 32 cases (40%) and alcohol in four cases (5%). We tried to have subjective information on the sexual history of each patient and found that most of the male partners had very limited knowledge about the anatomy of the external genitalia, the prelude and manipulation of the female sex. Thus, no sexual experience was noted in 44 male partners and only 10 men had a previous history of successful intercourse. Physical examination had revealed mild hypotrophy of the testes in five cases (6%), marked obesity in four cases (5%), unilateral inguinal hernia in three cases (3.75%), moderate bilateral gynecomastia in two cases (2.5%). Biologically, the dosage of serum testosterone was performed in 10 cases (12.5%) with a low rate in one case, the determination of serum prolactin levels achieved in two cases (2.5%) was normal, dyslipidemia was found in three cases (3.75%) and diabetes in eight cases (10%). Penile color doppler flow study was carried out in six cases (7.5%) and had shown an occlusive arterial model in two cases. Regarding the sexuality of the male partners, spontaneous erections were normal in 64 cases (80%), low rigidity in 14 cases (17.5%) and none in two cases (2.5%). Libido was normal in 71 cases (88%) and low in nine cases (12%). Premature ejaculation was noted in 14 cases (17.5%) and retrograde ejaculation in two cases (2.5%). Shallow intercourse was found in 80 cases (100%). As for the married women, 78% of brides were at their first marriage. Sexual history had shown no previous sexual experience and their knowledge of sexology was very low. Their attitudes with their husbands were varied: active and cooperative in 28 cases (35%), passive in six cases (7.5%), frustrated/retracted in 12 cases(15%), virginal behavior in 20 cases (25%) and unknown in 14 cases (17.5%). The etiological factors underlying the UCM are illustrated in Table 2. Erectile dysfunction was the main cause of UCM noted in 66 cases (82.5%). Vaginismus was the second etiology observed in 32 cases (40%). Severe premature ejaculation occurring during foreplay or during attempts at penetration was the third etiology noted in 16 cases (20%). Combined etiologies within the couple have been found in 22 cases (27.5%) as erectile dysfunction associated with vaginismus. The sexual dysfunction among male partners
Table 3
e73 Results related to marriage length.
Results Marriage length
CM
UCM
Not known
3—6 months 7—12 months 13—24 months > 2 years
26 14 13 4
6 3 3 6
0 3 2 0
Total
57
18
5
CM: consummation of marriage; UCM: unconsummated marriage.
had psychogenic causes in 66 cases (82.5%) and an organic etiology in 14 cases (17.5%). For the female partners, all cases of vaginismus had a psychogenic origin. The first-line treatment was based on a sexological interview of the couple which consists of sex education and sex therapy. The latter includes personalized sessions with the couple or one of two partners whose main purpose was listening to the patient, dedramatization of the situation, provision of psychological support and sex education which provides knowledge about anatomy of the genitalia and the importance of preliminaries. In parallel, a facilitator treatment of erectile dysfunction was prescribed as vasodilatator drugs (yohimbine) and vitamins. Treatment of premature ejaculation requires sex therapy (the squeeze technique and ‘‘stop and go’’ method), paroxetine or chlomipramine. In the case of vaginismus, treatment was based on sex therapy in which the woman explores her body, associated with behavioral therapy and oral drugs (tranquilisers, muscle relaxants). As second line treatment, cases in which erectile dysfunction persists, phosphodiesterase type V inhibitors (PDEV Inh) were prescribed alone in 22 cases, ICI of PGE1 alone in 24 cases, PDEV Inh then ICI in two cases and finally, ICI then PDEV Inh in eight cases. Indeed, ICIs were fully realized in 34 cases with different rhythm according to each patient: inferior or equal to two ICI in 17 cases, three ICI in five cases, four ICI in five cases, and self ICI in seven cases. The second line treatment for the female partner was based on gynecological assessment in 50% of cases and extended sex therapy (2—15 months) in 12 cases to treat vaginismus. After a mean follow-up of 5 months (range 1—15 months), the outcomes of treatment were as follows (Table 3): • good prognosis with CM in 57 cases (71.25%); • failure with UCM in 18 cases (22.25%); • not known in five cases (6.25%). Analysis of 57 successful cases showed that the CM was related to: sex therapy as first line treatment in 10 cases, PDEV Inh in 18 cases, ICI in 23 cases, and vaginismus treatment in six cases.
e74 The 18 failed cases were related to a predominant vaginismus noted in four cases, major erectile dysfunction in six cases and mixed etiologies of the couple in eight cases. The outcome was either divorce in eight cases or a stable relationship in 10 cases.
Discussion UCM is a common medical and social problem facing medical practitioners in conservative communities. It accounts for up to 17% of visits to sexual health clinics (El-Meliegy, 2004). Furthermore, social and cultural constraints exert extrapressure on the couple to consummate their marriage soon after the ceremony, on the wedding night. This is particularly evident in conservative societies where there is lack of sex education, sexual prohibition and misconception about genitalia along with unrealistic expectations (Kaplan and Sadock, 1995) In societies in which there is ample opportunity for premarital coitus, UCM is extremely rare (Zargooshi, 2000). Causes of UCM vary widely in the literature. Classically, performance anxiety is considered to be the major etiological factor (Reckless and Geiger, 1978; Ghanem et al., 1998). Source of performance anxiety were represented by lack of sex education, sexual prohibition, overly stressed by parents or society, psychological problems, penis envy, phobia of penetration, passive aggressive personality of the bride, immaturity in both partners, distorted concepts about genitalia, over-dependence on primary families, and problems in sexual identification and/or orientation (Kaplan and Sadock, 1995; Duddle, 1997), fear of sexual failure, request for sexual performance, fear of being rejected by the partner, the couple’s urge to consummate marriage on the wedding night, living in the same house with the family and a lengthy, noisy wedding ceremony. Unreasonable expectations, traumatic early sexual experiences, restricted foreplay, impaired self-image and poor communication, all contributed to performance anxiety (Zargooshi, 2000; Badran et al., 2006; Duddle, 1977). In patients with a history of successful intercourse during a previous relationship (e.g., previous marriage), the novelty of the sexual partner, in addition to other factors, may precipitate the failure (Badran et al., 2006). In the series of Zargooshi (Zargooshi, 2000), the lack of knowledge about sexual functioning in rural regions of Iran results in many misconceptions. In fact, 44% of the rural patients believed that they were ‘locked’ and to be ‘opened’, they had visited traditional healers before seeking medical help. Variations in the incidence of different etiological factors in the reported studies may reflect variations in patient selection or study methodology. Moreover, it may provide evidence for the influence of cultural and social elements on human sexuality (Badran et al., 2006; Duddle, 1977). There are many forms of couple therapy available for the management of relationship problems in those with sexual disorders (Crowe, 2004). For erectile problems, these include ‘teasing’ the erection, by letting it abate and re-establish itself, followed by non-demanding containment in the vagina. Sexual
M. Nabil Mhiri et al. intercourse may follow later in therapy but it is always sensible to start any interaction with sensate focus and to go ahead with intercourse only if both partners feel confident. This approach may be combined with medication (Crowe, 2004). Indeed, facilitator treatment of erection was prescribed per os at the first consultation. ICIs were prescribed at the first or second line depending on the social emergency of UCM and where the couple lived in the family circle (Zargooshi, 2000; Delavierre, 2004; Staerman and Malgrange, 2004). The response rate to ICIs was high (range 80 to 100%) for patients with causes other than vascular (Zargooshi, 2000). Regarding premature ejaculation, its incidence varies from one series to another: 3.1% (Badran, 2006), 8.3% (Addar, 2004) and 23% (Zargooshi, 2000). In our study, its incidence was 20%. Therapeutic approaches for premature ejaculation were based on cognitive and behavioral pacing strategies, and the involvement of the partner in the therapy as the ‘stop—start’ or ‘squeeze’ technique. This involves first attempting to control the ejaculation in self-stimulation, and later in mutual masturbation and intercourse. Other pharmacological treatments may be used such as antidepressants, PDEV inhibitor, and ICIs. (Crowe, 2004; Metz and Pryor, 2000). Regarding the problem of vaginismus, this is one of the most common psychosomatic disorders amongst the female partners precluding the intravaginal deposition of sperm. It was reported to be the reason for UCM in 20% to 67% of cases and leads to dyspareunia, infertility and sexual dysfunction in either partner with secondary erectile dysfunction in the male partner (Jindal Umesh and Jindal, 2010; Ozdemir et al., 2008; Dogan and Dogan, 2008). The incidence rate of vaginismus varies from 2% in the general population to 47% in sex therapy clinics (Jindal Umesh and Jindal, 2010). In our study, we recorded a rate of vaginismus of 40%. Vaginismus was defined as an involuntary spasm of the pelvic floor muscles surrounding the outer third of the vagina, especially the perineal muscles and the levator ani muscles (Cherng-Jye, 2004; Masters and Johnson, 1970; Kaplan, 1974). In severe cases of vaginismus, the adductors of the thighs, the rectus abdominis, and the gluteus muscles may also contract involuntarily as opposed to the rhythmic contraction during orgasm. Increased muscle tension that precludes vaginal entry may cause sexual pain (Eserda˘ g et al., 2011). This reflex and spastic contraction is triggered by imagined or anticipated attempts at vaginal penetration or during the act of intromission or coitus (Cherng-Jye, 2004). Vaginismus can be global, in which case the woman is unable to place anything inside her vagina, or situational, in which case she can use a tampon and tolerate a pelvic examination but cannot have intercourse (Ghazizadeh and Nikzad, 2004). The severest form of classical vaginismus makes penetration virtually impossible, causes a severe burning pain, and leads to UCM (Graziottin et al., 2009). The condition may be primary (present from the first attempt at penetration) or secondary (following physical or psychological trauma, infection, menopausal change, or pelvic pathology) (Caplan, 1988).
Unconsummated marriage in the Arab Islamic world: Tunisian experience Various etiologic factors have been postulated as an important causes of vaginismus: misinformation, ignorance and guilt about sexuality (Ellison, 1968), fear of pain, experiencing or witnessing sexual trauma or sexual violation, background of religious orthodoxy and cultural taboos, organic pathology, personality, parents’ relationship and the father—daughter relationship, male partner’s personality, male partner’s sexual dysfunction and the couple’s relationship (Reissing et al., 1999). Ideally, a multidisciplinary approach for sexual pain is recommended. Psychological issues as well as interpersonal issues should be first addressed early on with psychotherapy. Involvement of the partner in the treatment should be encouraged but remains the decision of the woman (Crowley et al., 2006). The first step of treatment was based on education to correct any misinformation about sexual functioning and the genitals, perception of the vagina, and relaxation training to reduce anxiety for slacking the vaginal muscles (Pourhosein and Bahrami Ehsan, 2011). Different techniques can be used: cognitive behavioral therapy, vulvar and vaginal desensitization, building of a positive attitude toward sex and stepwise tolerance of intravaginal insertion of fingers and objects like a transvaginal ultrasound probe or a speculum (Jindal Umesh and Jindal, 2010) or by hypnotherapy (Pourhosein and Bahrami Ehsan, 2011) which was quite effective to diminish anxiety and phobia, resolve fear and facilitate relaxation and loosening of the muscles (Eserda˘ g et al., 2011). In refractory cases of vaginismus when conventional therapies have failed, local injection of botulinum toxin can be considered (Ghazizadeh and Nikzad, 2004). This technique has been receiving increasing attention since it was first described in a 1997 case report by Brin and Vapnek (1997). In a controlled study by Shafik and ElSibai (2000), all the women given Botox were able to have intercourse, none required reinjection, and there was no recurrence or complication during the follow-up period. However, therapy with botulinum toxin should be considered experimental and ideally administered as part of clinical trials.
Conclusion UCM is quite frequent in the Arab Islamic world. The identification of its etiological factors may be essential for the proper management to achieve a successful outcome. There are many forms of couple therapy available for the management of relationship problems including those with sexual disorders. The best treatment is prevention based on sexual education of youngsters and treatment of sexual dysfunctions for people who consult before marriage.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
e75
References Addar MH. The unconsummated marriage: causes and management. Clin Exp Obstet Gynecol 2004;31:279—81. Badran W, Moamen N, Fahmy I, El-Karaksy A, Abdel-Nasser TM, Ghanem H. Etiological factors of unconsummated marriage. Int J Impot Res 2006;18:458—63. Brin MF, Vapnek JM. Treatment of vaginismus with botulinum toxin injections. Lancet 1997;349:252—3. Caplan HW. An effective clinical approach to vaginismus-putting the patient in charge. West J Med 1988;149:769—70. Cherng-Jye J. The pathophysiology and etiology of vaginismus. Taiwanese J Obstet Gynecol 2004;43(1):10—5. Crowe M. Couple relationship problems, individual psychological problems and sexual disorders. Psychiatry 2004;3(2):8—10. Crowley T, Richardson D, Goldmeier D. Recommendations for the management of vaginismus: BASHH Special Interest Group for sexual dysfunction. Int J STD AIDS 2006;17:14—8. Delavierre D. Modalités de prescription des injections intracaverneuses. Andrologie 2004;14(3):354—6. Dogan S, Dogan M. The frequency of sexual dysfunction in male partners of women with vaginismus in a Turkish sample. Int J Impot Res 2008;20:218—21. Duddle M. Biological factors in unconsummated marriage. J Psychosom Res 1997;21:161—6. Duddle M. Etiological factors in the unconsummated marriage. J Psychosom Res 1977;21:157—60. El-Meliegy A. A retrospective study of 418 patients with honeymoon impotence in an andrology clinic in Jeddah, Saudi Arabia. Eur J Sexol 2004;13:1—4. Ellison C. Psychosomatic factors in the unconsummated marriage. J Psychosom Res 1968;12:61—5. glul E, Akarsul S, Micozkadio˘ glui S. TreatEserda˘ g S, Zülfikaro˘ ment Outcome of 460 women with vaginismus. Eur J Surg Sci 2011;2(3):73—9. Ghanem H, Sherif T, AbdEl-Gawad T, Assad T. Short term use of intracavernous vasoactive drugs in the treatment of persistent psychogenic erectile dysfunction. Int J Impot Res 1998;10:211—4. Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory vaginismus. Am Coll Obstet Gynecol 2004;104(5):922—5. Graziottin A, Serafinib A, Palacios S. Aetiology, diagnostic algorithms and prognosis of female sexual dysfunction. Maturitas 2009;63:128—34. Jindal Umesh N, Jindal S. Use by gynecologists of a modified sensate focus technique to treat vaginismus causing infertility. Fertil Steril 2010;94(6):2393—5. Kaplan HS. The new sex therapy. New York: Brunner-Routledge; 1974. Kaplan H, Sadock BJ. Normal human sexuality and sexual and gender identity disorders. In: Kaplan HI, Sadock BJ, editors. Comprehensive textbook of psychiatry. Baltimore: Williams & Wilkins; 1995. p. 1295—360. Masters WH, Johnson VE. Human sexual inadequacy. Boston: Little, Brown; 1970. Metz ME, Pryor JL. Premature ejaculation: a psychophysiological approach for assessment and management. J Sex Marital Ther 2000;26:293—320. Ozdemir O, Simsek F, Ozkardes S, Incesu C, Karakoc B. The unconsummated marriage: its frequency and clinical characteristics in a sexual dysfunction clinic. J Sex Marital Ther 2008;34:368—79. Pourhosein R, Bahrami Ehsan Z. Using hypnosis in a case of vaginismus: a case report. Procedia Soc Behav Sci 2011;15: 3886—9. Reckless J, Geiger N. Impotence as a practical problem. In: LoPiccolo L, LoPiccolo J, editors. Handbook of sex therapy. New York: Plenum Press; 1978. p. 305.
e76 Reissing ED, Binik YM, Khalife S. Does vaginismus exist? A critical review of the literature. J Nerv Ment Dis 1999;187:261—74. Shafik A, El-Sibai O. Vaginismus: results of treatment with botulin toxin. J Obstet Gynaecol 2000;20:300—2. Staerman F, Malgrange D. Treatment of erectile dysfunction. EMC Med 2004;1(4):276—80.
M. Nabil Mhiri et al. Waynberg J. Guide pratique de sexologie médicale. Paris: SIMEP; 1994, p. 93—9. Zargooshi J. Unconsummated marriage: clarification of aetiology; treatment with intracorporeal injection. BJU Int 2000;86: 75—9.
Disponible en ligne sur
www.sciencedirect.com
ORIGINAL ARTICLE
Unconsummated marriage in the Arab Islamic world: Tunisian experience夽 M. Nabil Mhiri (MD) a, W. Smaoui (MD) a, M. Bouassida (MD) a,∗, K. Chabchoub (MD) a, J. Masmoudi (MD) b, M. Hadjslimen (MD) a, N. Chaieb (MD) a, N. Rebai (MD) a, S. Masmoudi (MD) a, A. Bahloul (MD) a a b
Urology department, Habib Bourguiba academic medical center, Majida Boulila avenue, 3026 Sfax, Tunisia Psychiatry department, Hedi Chaker academic medical center, 3029 Sfax, Tunisia
Available online 27 March 2013
KEYWORDS Unconsummated marriage; Couples; Erectile dysfunction; Premature ejaculation; Vaginismus; Sex therapy
Summary Objective. — To identify the clinical features of unconsummated marriage (UCM) amongst couples, the etiological factors, the therapeutic approaches and to clarify the different evolutive aspects. Patients and methods. — In this retrospective study, the files of 80 consecutive couples followed for UCM between 2000 and 2010 at our andrology consultation were reviewed. Results. — The mean age of the husbands was 36 years (22—82 years), that of the brides was 28 years (17—57 years). The average length of marriage was 14 months (range 3 months—7 years). Couples had little knowledge of sexology. The sexual dysfunctions noted were: erectile dysfunction in 40% of cases, premature ejaculation in 5%, a combination of premature ejaculation with erectile dysfunction and decreased libido in 15%, vaginismus in 12.5% and the associated causes (erectile dysfunction with vaginismus) in 27.5%. The first-line treatment was based on a sexological approach consisting of sex education and sex therapy, associated in some cases with oral drugs and as second-line treatment, sometimes intracavernous injections. After a mean follow-up of 5 months (range 1—15 months), the outcomes of treatment were: good prognosis with consummation of marriage in 57 cases (71.25%), failure with UCM in 18 cases (22.25%) and not known in five cases (6.25%). Conclusion. — UCM is quite frequent in the Arab Islamic world. The best treatment is prevention based on sexual education of youngsters and treatment of sexual dysfunctions for people who consult before marriage. © 2013 Elsevier Masson SAS. All rights reserved.
DOI of original article:http://dx.doi.org/10.1016/j.sexol.2013.02.003. La version en franc ¸ais de cet article, publiée dans l’édition imprimée de la revue, est disponible en ligne : doi : 10.1016/j.sexol. 2013.02.003. ∗ Corresponding author. E-mail address: [email protected] (M. Bouassida). 夽
1158-1360/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.sexol.2013.02.004
e72
M. Nabil Mhiri et al.
Introduction
Clinical and paraclinical data
Marriage is the only legitimated form of sexuality in the Arab Islamic world. In some societies, a marriage ceremony is always expected to include consummation which must take place on the wedding night or during the succeeding few days. In some rural areas, some confirmation is expected for the families involved that coitus has occurred and that the bride was a virgin (Zargooshi, 2000). Any delay in the consummation of marriage (CM) can be a source of suffering in the couple and the family environment, creating a social emergency. Unconsummated marriage (UCM) is defined as the failure at all attempts of vaginal coitus that a faithful couple, married or not, might have tried in vain, for at least 3 consecutive months of night-time cohabitation (Waynberg, 1994). UCM is a common medical and social problem facing medical practitioners in conservative communities. It accounts for up to 17% of visits to sexual health clinics (Badran et al., 2006). And yet little is known about the causes of UCM in our region; the present work aims to define the main contributing factors, the therapeutic approaches and to clarify the different evolutive aspects.
All patients underwent a complete physical examination that focused on external genitalia and secondary sexual characteristics. For the biological assessment, a standard workup was performed with a dosage of fasting blood glucose, serum creatinine, lipid profile, complete blood count and liver function tests were routinely carried out. Serum testosterone and prolactin tests were carried out whenever indicated (cases with affected sexual desire, hypogonadal features, older age, gynecomastia or small testicular size). Penile color doppler flow study was carried out in six cases. After this initial evaluation, the nature of the problem and different management options were discussed with the patient or the couple: sexological interview of the couple based on sexual education (anatomy of genital organs and importance of preliminaries) with sex therapy, oral drug or intracavernous injections (ICIs).
Patients and methods Between 2000 and 2010, the files of 80 consecutive couples followed for UCM at our andrology consultation were reviewed and patients were recruited with their informed consent.
Inclusion criteria All couples or partners who consult for UCM after at least 3 months of night-time cohabitation were included.
Exclusion criteria Couples consulting for sexual dysfunction as a result of marital discord and those who had failure of vaginal coitus for a period less than 3 months. Different items were studied.
Psychosocial data Age of partners, length of marriage, the pattern of consultation (UCM or infertility), degree of family pressure on the couple, degree of emotional ties between the couple, assessment of knowledge in sexology and genital anatomy, assessment of the degree of socio-cultural conformism of each partner, previous use of traditional healers, review of the person’s educational, family and religious background. Moreover, gender identity, sexual orientation and sexual behavior (desires, fantasies, autoeroticism, current and previous interpersonal sexual activity, same sex relations, rejection experience, sexual abuse and body image) were carefully explored, as were the mode of consultation and the quality of the referring physician.
Results A total of 160 consecutive patients complaining of UCM were retrospectively included in the study. All patients were of Tunisian nationality. The mean age of male partners was 36 years (22—82 years), and of brides 28 years (17—57 years) (Table 1). Fifty percent of the patients were from rural regions, and the rest from urban areas. The most common reason for consultation of patients was the inability to consummate the marriage observed in 65 couples (81.25%), in the other cases, the UCM associated with infertility or infertility alone with a desire to have children were noted in 11 cases (13.75%) and four cases (5%) respectively. Regarding the mode of presentation, the couple consulted together in 54 cases (67.5%), the male partner alone in 22 cases (27.5%) and male partner and relatives in four cases (5%). The average length of marriage was 14 months (range 3 months—7 years). It was noted that 40% of couples (32 cases) had consulted between the third and sixth month after marriage, 25% (20 cases) between the seventh and 12th month, 22.5% (18 cases) between the 13th and 24th month, and 12.5% (10 cases) beyond the 24th month after marriage. Twenty six couples (32.5%) had visited traditional healers before medical consultation.
Table 1 distribution of patients according to gender and age brackets. Age (years)
Husbands Number
< 25 25—30 31—40 > 40
2 22 44 12
Total
80
Brides Percentage 2.5 27.5 55 15 100
Number 8 44 18 10 80
Percentage 10 55 22.5 12.5 100
Unconsummated marriage in the Arab Islamic world: Tunisian experience Table 2 Etiologic factors causing the unconsummated marriage. Etiology
Number
Erectile dysfunction (ED) alone Premature ejaculation (PE) alone ED ± PE ± libido Vaginismus alone Associated etiologies (couple)
32 4 12 10 22
Total
80
Percentage 40 5 15 12.5 27.5 100
About the marital status of the male partners, 90% were at their first marriage. Concerning the cultural level, 25% of husbands had primary education only, 60% secondary school and 15% university studies. History analysis of patients revealed several underlying conditions, but only among the male partners, namely diabetes in eight cases (10%), smoking in 32 cases (40%) and alcohol in four cases (5%). We tried to have subjective information on the sexual history of each patient and found that most of the male partners had very limited knowledge about the anatomy of the external genitalia, the prelude and manipulation of the female sex. Thus, no sexual experience was noted in 44 male partners and only 10 men had a previous history of successful intercourse. Physical examination had revealed mild hypotrophy of the testes in five cases (6%), marked obesity in four cases (5%), unilateral inguinal hernia in three cases (3.75%), moderate bilateral gynecomastia in two cases (2.5%). Biologically, the dosage of serum testosterone was performed in 10 cases (12.5%) with a low rate in one case, the determination of serum prolactin levels achieved in two cases (2.5%) was normal, dyslipidemia was found in three cases (3.75%) and diabetes in eight cases (10%). Penile color doppler flow study was carried out in six cases (7.5%) and had shown an occlusive arterial model in two cases. Regarding the sexuality of the male partners, spontaneous erections were normal in 64 cases (80%), low rigidity in 14 cases (17.5%) and none in two cases (2.5%). Libido was normal in 71 cases (88%) and low in nine cases (12%). Premature ejaculation was noted in 14 cases (17.5%) and retrograde ejaculation in two cases (2.5%). Shallow intercourse was found in 80 cases (100%). As for the married women, 78% of brides were at their first marriage. Sexual history had shown no previous sexual experience and their knowledge of sexology was very low. Their attitudes with their husbands were varied: active and cooperative in 28 cases (35%), passive in six cases (7.5%), frustrated/retracted in 12 cases(15%), virginal behavior in 20 cases (25%) and unknown in 14 cases (17.5%). The etiological factors underlying the UCM are illustrated in Table 2. Erectile dysfunction was the main cause of UCM noted in 66 cases (82.5%). Vaginismus was the second etiology observed in 32 cases (40%). Severe premature ejaculation occurring during foreplay or during attempts at penetration was the third etiology noted in 16 cases (20%). Combined etiologies within the couple have been found in 22 cases (27.5%) as erectile dysfunction associated with vaginismus. The sexual dysfunction among male partners
Table 3
e73 Results related to marriage length.
Results Marriage length
CM
UCM
Not known
3—6 months 7—12 months 13—24 months > 2 years
26 14 13 4
6 3 3 6
0 3 2 0
Total
57
18
5
CM: consummation of marriage; UCM: unconsummated marriage.
had psychogenic causes in 66 cases (82.5%) and an organic etiology in 14 cases (17.5%). For the female partners, all cases of vaginismus had a psychogenic origin. The first-line treatment was based on a sexological interview of the couple which consists of sex education and sex therapy. The latter includes personalized sessions with the couple or one of two partners whose main purpose was listening to the patient, dedramatization of the situation, provision of psychological support and sex education which provides knowledge about anatomy of the genitalia and the importance of preliminaries. In parallel, a facilitator treatment of erectile dysfunction was prescribed as vasodilatator drugs (yohimbine) and vitamins. Treatment of premature ejaculation requires sex therapy (the squeeze technique and ‘‘stop and go’’ method), paroxetine or chlomipramine. In the case of vaginismus, treatment was based on sex therapy in which the woman explores her body, associated with behavioral therapy and oral drugs (tranquilisers, muscle relaxants). As second line treatment, cases in which erectile dysfunction persists, phosphodiesterase type V inhibitors (PDEV Inh) were prescribed alone in 22 cases, ICI of PGE1 alone in 24 cases, PDEV Inh then ICI in two cases and finally, ICI then PDEV Inh in eight cases. Indeed, ICIs were fully realized in 34 cases with different rhythm according to each patient: inferior or equal to two ICI in 17 cases, three ICI in five cases, four ICI in five cases, and self ICI in seven cases. The second line treatment for the female partner was based on gynecological assessment in 50% of cases and extended sex therapy (2—15 months) in 12 cases to treat vaginismus. After a mean follow-up of 5 months (range 1—15 months), the outcomes of treatment were as follows (Table 3): • good prognosis with CM in 57 cases (71.25%); • failure with UCM in 18 cases (22.25%); • not known in five cases (6.25%). Analysis of 57 successful cases showed that the CM was related to: sex therapy as first line treatment in 10 cases, PDEV Inh in 18 cases, ICI in 23 cases, and vaginismus treatment in six cases.
e74 The 18 failed cases were related to a predominant vaginismus noted in four cases, major erectile dysfunction in six cases and mixed etiologies of the couple in eight cases. The outcome was either divorce in eight cases or a stable relationship in 10 cases.
Discussion UCM is a common medical and social problem facing medical practitioners in conservative communities. It accounts for up to 17% of visits to sexual health clinics (El-Meliegy, 2004). Furthermore, social and cultural constraints exert extrapressure on the couple to consummate their marriage soon after the ceremony, on the wedding night. This is particularly evident in conservative societies where there is lack of sex education, sexual prohibition and misconception about genitalia along with unrealistic expectations (Kaplan and Sadock, 1995) In societies in which there is ample opportunity for premarital coitus, UCM is extremely rare (Zargooshi, 2000). Causes of UCM vary widely in the literature. Classically, performance anxiety is considered to be the major etiological factor (Reckless and Geiger, 1978; Ghanem et al., 1998). Source of performance anxiety were represented by lack of sex education, sexual prohibition, overly stressed by parents or society, psychological problems, penis envy, phobia of penetration, passive aggressive personality of the bride, immaturity in both partners, distorted concepts about genitalia, over-dependence on primary families, and problems in sexual identification and/or orientation (Kaplan and Sadock, 1995; Duddle, 1997), fear of sexual failure, request for sexual performance, fear of being rejected by the partner, the couple’s urge to consummate marriage on the wedding night, living in the same house with the family and a lengthy, noisy wedding ceremony. Unreasonable expectations, traumatic early sexual experiences, restricted foreplay, impaired self-image and poor communication, all contributed to performance anxiety (Zargooshi, 2000; Badran et al., 2006; Duddle, 1977). In patients with a history of successful intercourse during a previous relationship (e.g., previous marriage), the novelty of the sexual partner, in addition to other factors, may precipitate the failure (Badran et al., 2006). In the series of Zargooshi (Zargooshi, 2000), the lack of knowledge about sexual functioning in rural regions of Iran results in many misconceptions. In fact, 44% of the rural patients believed that they were ‘locked’ and to be ‘opened’, they had visited traditional healers before seeking medical help. Variations in the incidence of different etiological factors in the reported studies may reflect variations in patient selection or study methodology. Moreover, it may provide evidence for the influence of cultural and social elements on human sexuality (Badran et al., 2006; Duddle, 1977). There are many forms of couple therapy available for the management of relationship problems in those with sexual disorders (Crowe, 2004). For erectile problems, these include ‘teasing’ the erection, by letting it abate and re-establish itself, followed by non-demanding containment in the vagina. Sexual
M. Nabil Mhiri et al. intercourse may follow later in therapy but it is always sensible to start any interaction with sensate focus and to go ahead with intercourse only if both partners feel confident. This approach may be combined with medication (Crowe, 2004). Indeed, facilitator treatment of erection was prescribed per os at the first consultation. ICIs were prescribed at the first or second line depending on the social emergency of UCM and where the couple lived in the family circle (Zargooshi, 2000; Delavierre, 2004; Staerman and Malgrange, 2004). The response rate to ICIs was high (range 80 to 100%) for patients with causes other than vascular (Zargooshi, 2000). Regarding premature ejaculation, its incidence varies from one series to another: 3.1% (Badran, 2006), 8.3% (Addar, 2004) and 23% (Zargooshi, 2000). In our study, its incidence was 20%. Therapeutic approaches for premature ejaculation were based on cognitive and behavioral pacing strategies, and the involvement of the partner in the therapy as the ‘stop—start’ or ‘squeeze’ technique. This involves first attempting to control the ejaculation in self-stimulation, and later in mutual masturbation and intercourse. Other pharmacological treatments may be used such as antidepressants, PDEV inhibitor, and ICIs. (Crowe, 2004; Metz and Pryor, 2000). Regarding the problem of vaginismus, this is one of the most common psychosomatic disorders amongst the female partners precluding the intravaginal deposition of sperm. It was reported to be the reason for UCM in 20% to 67% of cases and leads to dyspareunia, infertility and sexual dysfunction in either partner with secondary erectile dysfunction in the male partner (Jindal Umesh and Jindal, 2010; Ozdemir et al., 2008; Dogan and Dogan, 2008). The incidence rate of vaginismus varies from 2% in the general population to 47% in sex therapy clinics (Jindal Umesh and Jindal, 2010). In our study, we recorded a rate of vaginismus of 40%. Vaginismus was defined as an involuntary spasm of the pelvic floor muscles surrounding the outer third of the vagina, especially the perineal muscles and the levator ani muscles (Cherng-Jye, 2004; Masters and Johnson, 1970; Kaplan, 1974). In severe cases of vaginismus, the adductors of the thighs, the rectus abdominis, and the gluteus muscles may also contract involuntarily as opposed to the rhythmic contraction during orgasm. Increased muscle tension that precludes vaginal entry may cause sexual pain (Eserda˘ g et al., 2011). This reflex and spastic contraction is triggered by imagined or anticipated attempts at vaginal penetration or during the act of intromission or coitus (Cherng-Jye, 2004). Vaginismus can be global, in which case the woman is unable to place anything inside her vagina, or situational, in which case she can use a tampon and tolerate a pelvic examination but cannot have intercourse (Ghazizadeh and Nikzad, 2004). The severest form of classical vaginismus makes penetration virtually impossible, causes a severe burning pain, and leads to UCM (Graziottin et al., 2009). The condition may be primary (present from the first attempt at penetration) or secondary (following physical or psychological trauma, infection, menopausal change, or pelvic pathology) (Caplan, 1988).
Unconsummated marriage in the Arab Islamic world: Tunisian experience Various etiologic factors have been postulated as an important causes of vaginismus: misinformation, ignorance and guilt about sexuality (Ellison, 1968), fear of pain, experiencing or witnessing sexual trauma or sexual violation, background of religious orthodoxy and cultural taboos, organic pathology, personality, parents’ relationship and the father—daughter relationship, male partner’s personality, male partner’s sexual dysfunction and the couple’s relationship (Reissing et al., 1999). Ideally, a multidisciplinary approach for sexual pain is recommended. Psychological issues as well as interpersonal issues should be first addressed early on with psychotherapy. Involvement of the partner in the treatment should be encouraged but remains the decision of the woman (Crowley et al., 2006). The first step of treatment was based on education to correct any misinformation about sexual functioning and the genitals, perception of the vagina, and relaxation training to reduce anxiety for slacking the vaginal muscles (Pourhosein and Bahrami Ehsan, 2011). Different techniques can be used: cognitive behavioral therapy, vulvar and vaginal desensitization, building of a positive attitude toward sex and stepwise tolerance of intravaginal insertion of fingers and objects like a transvaginal ultrasound probe or a speculum (Jindal Umesh and Jindal, 2010) or by hypnotherapy (Pourhosein and Bahrami Ehsan, 2011) which was quite effective to diminish anxiety and phobia, resolve fear and facilitate relaxation and loosening of the muscles (Eserda˘ g et al., 2011). In refractory cases of vaginismus when conventional therapies have failed, local injection of botulinum toxin can be considered (Ghazizadeh and Nikzad, 2004). This technique has been receiving increasing attention since it was first described in a 1997 case report by Brin and Vapnek (1997). In a controlled study by Shafik and ElSibai (2000), all the women given Botox were able to have intercourse, none required reinjection, and there was no recurrence or complication during the follow-up period. However, therapy with botulinum toxin should be considered experimental and ideally administered as part of clinical trials.
Conclusion UCM is quite frequent in the Arab Islamic world. The identification of its etiological factors may be essential for the proper management to achieve a successful outcome. There are many forms of couple therapy available for the management of relationship problems including those with sexual disorders. The best treatment is prevention based on sexual education of youngsters and treatment of sexual dysfunctions for people who consult before marriage.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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