With divorce rates approaching 50% of marriages within the first 15 years, couples preparing for marriage are keenly interested in how to best prepare for marriage (Williams, 2007). This blog will discuss the core content areas to cover in premarital counseling and the interventions therapists use. Additionally, we must pay attention to how to implement these interventions in an ethical and culturally-sensitive manner.
Core Content Areas in Premarital Counseling
Casquarelli, E. J., & Fallon, K. M. (2011). Nurturing the relationships of all couples: Integrating lesbian, gay, and bisexual concerns into premarital education and counseling programs. Journal of Humanistic Counseling, 50, 149-160.
Gottman, J., & Silver, N. (2013). What Makes Love Last? New York, NY: Simon & Schuster.
Murray, C. E., & Murray, T. L. (2004). Solution-focused premarital counseling: Helping couples build a vision for their marriage. Journal of Marital & Family Therapy, 30(3), 349-358.
Tambling, R. B., & Glebova, T. (2013). Preferences of individuals in committed relationships about premarital counseling. The American Journal of Family Therapy, 41, 330-340.
Williams, L. (2007). Premarital counseling. Journal of Couple & Relationship Therapy, 6(1-2), 207-217.
You’ve spent nine months waiting for your little miracle, getting ready to have another being in your home, and planning how best to adapt to all the changes a baby brings. Pregnancy isn’t usually easy and often connecting sexually with your partner is one of the last things on your mind. By the third trimester, about 75% of people report a loss of sexual desire, while between 83 and 100% report less frequent sexual activity (De Judicibus & McCabe, 2002). So you’ve probably already had less sex with your partner by the time baby arrives. Now what? Should you just get right back to how sex was before pregnancy? What’s normal? What makes sex so challenging after childbirth? How about the role of post-partum depression? And what can you do to get back to your normal? This blog post will answer these questions to help you understand sexuality after childbirth and how to meet those challenges.
When can we have Sex Again?
There’s lots to worry about when you bring baby home – feedings, changing diapers, sleeping, playing, and keeping baby safe. It’s easy to lose sight of the union that created the baby – you and your partner. Should you have sex right away? Is it normal to not want it? First of all, it’s recommended that you wait about two weeks after delivery before having intercourse because there is some risk of infection or hemorrhage (Hyde & Delamater, 2011). That doesn’t mean you can’t do other sexual activities, but you may not want to.
In the month after birth, only about 17% of couples have intercourse, while by the fourth month, 90% of couples have resumed intercourse (Hyde & Delamater, 2011). Couples start enjoying intercourse gradually after birth, with a small amount enjoying it after two weeks, while 67-80% enjoy it at around twelve weeks after birth (De Judicibus & McCabe, 2002). So, if you’re not having intercourse right away, you’re in the majority, and you may not start wanting it or enjoying it until 3-4 months after delivery. That’s totally normal. It might actually be a time that you can try other sexual activities that don’t involve intercourse. More on that later. But what factors cause some couples to re-engage quicker than others?
What Makes Sex Challenging?
There are at least six factors studied by researchers that are related to less sexual desire after childbirth (De Judicibus & McCabe, 2002). It can be difficult to adjust to the role of being a mother, marital satisfaction can change, while fatigue, physical changes, breast-feeding, and mood are also issues. If you are having issues adjusting to parenthood, you’re not alone. It limits your social life and sleep, while also making it difficult to take care of yourself. There’s also a lot of research that shows how difficult a baby can be on a relationship (De Judicibus & McCabe, 2002). Add those stresses to overall fatigue, soreness due to limited lubrication, and evidence that breastfeeding reduces sexual desire, and you have a recipe for limited sexual desire and frequency. So, it’s pretty normal to not want much sex after birth, and there are lots of good reasons for that. There’s one last big factor that deserves special attention – mood.
Post-Partum Depression – Is it Affecting you?
About 35-40% of women experience some depressive symptoms after childbirth, while it is estimated that around 10% of women suffer from more severe symptoms and have post-partum depression (De Judicibus & McCabe, 2002). There can be a loss of identity and personal space, as well as feelings of not fulfilling expectations in addition to the normal challenges of adapting to a baby (Edhborg et. al., 2005). How do you know if you have post-partum depression and not just the fairly typical less severe form of depression? Symptoms of sadness, anxiety, low energy, reduced sexual desire, irritability, crying episodes, and changes in sleeping and eating patterns would need to be present for at least two weeks to meet the criteria. In extreme cases, thoughts of homicide or suicide can also be present. Talk to your doctor if you’re not sure if you need medical attention, but a good rule of thumb is that if you have these symptoms for most days out of two weeks, then you should see your physician or psychologist to talk. Some research has found that maintaining a healthy marital relationship where parenting is shared helps with post-partum depression, while other research says that it’s important to challenge perfectionist expectations of motherhood and talk about feelings (Edhborg et. al., 2005). That’s a couple of specific things related to depression, but what else can you do to manage less sex?
What Can You Do About It?
We’ve talked about the challenges, but what you really want to know is what can you do about it? The first thing is to recognize that you are completely normal if you aren’t having sex right away after childbirth, and it’s also normal if you just don’t want to or don’t enjoy it. It doesn’t mean there’s anything wrong with you. If intercourse isn’t enjoyable, think about using more lube or focusing on all the different things you can do sexually. It doesn’t have to include intercourse or vaginal contact, and it might not include as much nipple play either if you’re breastfeeding. Find other things you enjoy, like massages, hugging, or kissing if you can’t or don’t want to do your normal sexual activities (Hyde & DeLamater, 2011). In most cases, it will take until the fourth month after childbirth to get back to your old activities, and sometimes it takes longer (De Judicibus & McCabe, 2002). You may also have some sadness and relationship changes. Make sure you find time to nurture your marital relationship and talk to your doctor if your sadness makes life difficult for more than two weeks.
Take Home Messages
It’s normal to have less sex and desire for sex after childbirth. Though it can be the most special time in your life, it can also be difficult to adjust to the role of being a mother (or father), marital satisfaction can change, while fatigue, physical changes, breast-feeding, and mood are also issues (De Judicibus & McCabe, 2002). Be especially careful about your mood since post-partum depression may affect around 10% of women while less severe sadness affects almost half of women (Edhborg et. al., 2005). Make sure you talk to your doctor if you think your depression has lasted for more than two weeks. However, difficulties with sexuality are pretty normal, and it doesn’t mean there’s anything wrong with you. Pay attention to your relationships, your self-care, your expectations, your sleep, and take action to prevent less sex from overwhelming you. Do other things with your partner to connect, share your experiences together, and keep an eye on each other. You can get through this – together. And if you're partner isn't around, make sure to get support from family and friends. It's hard to do this on your own.
De Judicibus, M. A. & McCabe, M. P. (2002). Psychological factors and the sexuality of
pregnant and postpartum women. Journal of Sex Research, 39(2), 94-103.
Edhborg, M., Friberg, M., Lunch, W., & Widstrom, A. (2005). “Struggling with life”:
Narratives from women with signs of postpartum depression. Scandinavian
Journal of Public Health, 33, 261-267.
Hyde, J. S. & Delamater, J. D. (2011) Understanding Human Sexuality (11th ed.). New York:
We've seen the fallout of the #metoo campaign which hopefully includes an understanding that sexual assault is much more common than we think and many changes need to occur in our society to manage this reality. One of the issues is how to help these survivors. So, I took a look at some of the research on college students to glean some ideas about what needs to be included in a task force for sexual assault survivors. This is by no means a comprehensive review, but it's important that we are having discussions about how to help these survivors. Appropriate and respectful comments are welcome as it will take all of us to work together to help mitigate the effects of a huge problem.
Task Force for Sexual Assault
Sexual assault is a global problem, found in every human society, and is defined as a non-consensual sexual encounter involving sexual contact or penetration (Koo et. al., 2014). Globally, studies estimate that a female’s lifetime risk of sexual assault is between 14 and 25 percent, though all studies are confronted with under-reporting of this issue (Hyde & Delamater, 2011). Sexual assault is especially prevalent among college students, with estimates that one-half of college females will experience some form of sexual aggression, while a quarter will experience a completed or attempted rape (Bradley, Yeater, & O’Donaghue, 2009). Sexual assault can lead to devastating effects, including Post Traumatic Stress Disorder (PTSD), self-blame, sexual dysfunctions, fear, anxiety, self-esteem issues, risky sexual behavior, and self-harm (Hyde & Delamater, 2011; Mason & Lodrick, 2013). Following an increase in reports of sexual assault at the local college campus, a task force was created to provide recommendations to decrease the prevalence of sexual assaults at the college campus. This blog post will review two programs aimed at sexual assault prevention that have been used elsewhere, and then develop recommendations of how a program can be applied to the local college campus.
Description of other programs
Rothman and Silverman (2007) evaluated the effectiveness of their sexual assault prevention program aimed at first-year students at a Northeastern University in the United States. Their program consisted of education about the definition of consent, reducing risky behaviors through peer support, and creating a culture supportive of victims. The program included two sessions that were each ninety minutes. One session was a dramatic presentation called “Sex Signals” produced by a drama company performed at many college campuses. It uses audience participation and humor to educate students on issues of gender role stereotypes, communication, and different kinds of rape. The other session was an education workshop developed by the college sexual assault prevention office, which included discussing the definition of rape and sexual assault, the consequences of rape for perpetrators and victims, risk reduction for victims, using peers to limit risky situations, the statistics on sexual assault, and helping students communicate in dating relationships. This program is entirely based on preventing sexual assault through psychoeducation and appears to be based on the assumption that if students understand risky situations and take precautions, then they may be at a decreased risk of sexual assault. In terms of perpetrators, since this programs involves both men and women, another assumption is that if men understand the harm of sexual assault, then they will be motivated to not commit the offense. Indeed, Rothman and Silverman (2007) acknowledge that they did not have a model of behavior change that informed their intervention, and this limitation will be discussed further in the section that evaluates this program. However, they still found that their prevention program was correlated with a reduction in the reports of sexual assault overall. Notably though, they did not find this effect among students with a prior history of sexual assault.
Stewart (2014) presented an evaluation of “The Men’s Project,” a sexual assault prevention program aimed specifically at college males. This program occurs over eleven weeks and each session is two hours. It includes education on social norms, empathy, and bystander interventions. The program attempts to present sexist norms, correct this misinformation, and change the participant’s attitudes towards sexual assault. Additionally, they discuss the impact on victims, encourage empathy, and attempt to inspire activism. Finally, information is provided to help men notice sexist behavior and encourage them to intervene, thus changing the culture of accepting sexist norms. The authors were guided by the theory that this program would be effective because it would reduce sexist behavior among men and improve the culture of feminist activism on college campuses. Indeed, participants reported lower sexism and rape myth acceptance after completing the program. They were also more willing to confront sexism and intervene as bystanders when they witnessed sexist behavior. Additionally, their attitudes were changed, they used less gender-biased language, and they were more willing to be activists in changing the culture of sexist norms and assault acceptance on campus. The authors conclude that the Men’s Project is effective as a prevention program for sexual assault.
Evaluation of programs
Rothman and Silverman’s (2007) program was assessed as reducing the reported prevalence of sexual assault. Among participants who completed the program, 12% reported sexual assault victimization in the following year. Meanwhile, 17% of individuals who were not exposed to the program reported being sexual assaulted in the year. The program appeared successful for women, men, heterosexuals, and those who did not have any prior sexual assault victimization. However, students with a prior history of victimization were not at a reduced risk after completing the program. Gay, lesbian, bisexual, and students who drank alcohol were also measured to be at an increased risk as compared to heterosexuals and students who were alcohol abstinent. Rothman and Silverman (2007) stated that they were the first to find positive program effects for men, and were also the first to evaluate the effects of a prevention program based on consumption of alcohol. Therefore, a major takeaway from this evaluation is that special precautions may need to be taken with certain highly vulnerable populations, such as non-heterosexuals, those who arrive at college with previous victimization, and active alcohol users.
Another learning from this study regards how the researchers collected and evaluated their data. Yeater and O’Donague (1999) reported that while sexual assault prevention programs are widespread among college campuses, few have any empirical evidence of their effectiveness. One of the problems from Rothman and Silverman’s (2007) study was the lack of responses received for the control group who did not receive the intervention. They suggest giving students an incentive in order to participate in future studies, as it is important that every sexual assault prevention program be evaluated. Another issue with data collection is the consistent under-reporting of sexual assault on campuses (Yeater & O’Donaghue, 1999). While this issue does not have a defined solution, it is still an important consideration in the development of any future programs. Potentially related is that this study did not design their program based on a grounded theoretical model of behavior change. The authors noted that future studies should start with a theoretical basis in order to elucidate the specific mechanisms of reducing sexual assault. The study suggests that changing attitudes about sexual assault may reduce the likelihood of victimization. However, it is unclear exactly which aspects of the program are behind the change and therefore how future programs should be developed. Nevertheless, this study will help the development of the task force’s program as it illustrates potential areas of importance and groups of students that are missed.
Stewart’s (2014) evaluation of the Men’s Project provides helpful information for this task force. Specifically, Stewart (2014) found utility in engaging men in sexual assault prevention, which may be helpful since men are typically the perpetrators of sexual assault (Yeater & O’Donaghue, 1999). Since most programs do not arise from a theoretical framework first, it is unclear what population should be the focus of sexual assault prevention programs. Some studies suggest that targeting potential perpetrators is important, while other studies emphasize targeting potential victims (Yeater & O’Donaghue, 1999). However, the measures that Stewart (2014) used to assess positive change, such as less sexist beliefs, less acceptance of rape myths, and willingness to challenge sexual violence, may or may not translate to actual behavior change. Attitude change does not necessarily dictate behavior change, so it is unclear if this program will actually change the rate of sexual assaults on college campuses. Yeater and O’Donaghue (1999) also argue that changes in attitude do not typically make for long-standing change, and that most programs that change attitudes only do so for a short period of time. Furthermore, it is unclear what parts of the program (social norms, empathy, and bystander interventions) are responsible for the change in attitudes. Another limitation of Stewart’s (2014) program is that it is time-intensive and not feasible for most busy students as they adjust to the demands of student life. Eleven weeks of attendance, at two hours per week, may be impossible for most students, so this task force needs to balance practicality with program effectiveness.
Recommended new program
Based on the two programs reviewed, this task force is recommending a program for both males and females that includes elements of psychoeducation, as well as specific targeted programs for vulnerable populations. Specifically, the educational program offered by Rothman and Silverman (2007) has a demonstrated effect on helping to reduce sexual assault, so most students should be part of a program that reviews the definition of consent, reduces risky behaviors through peer support, and creates a culture supportive of victims. Heterosexual students who drink infrequently and in limited amounts who have no history of sexual assault victimization will complete this program. However, students who consume more alcohol, have a history of victimization, and who have non-heterosexual orientations will require a more comprehensive program.
To further solidify the program for heterosexual non-drinkers without victimization history, the task force recommends using the theoretical models presented by Finkelhor and Hotaling’s (1984, as cited in Bradley, Yeater, & O’Donoghue, 2009) and McFall (1982, as cited in Bradley, Yeater, & O’Donaghue, 2009). The first model suggests that sexual offending is a product of four factors: factors that increase motivation to assault (deviant arousal patterns), factors that decrease inhibitions to assault (sexist attitudes), factors that make assault more likely (alcohol), and factors that decrease a victim’s ability to detect and resist assault (limited ability to detect danger cues). The second model emphasizes how females process information, which includes decoding skills (perceiving stimuli in the environment), decision skills (generating solutions), and enactments (responding appropriately). Slight modifications from Rothman and Silverman’s (2007) program would be to include reference to each of these aspects of the models during the educational component.
It is clear from the research on sexual assault prevention programs that specific and more extensive interventions are needed for college students who were previously victimized, those who are non-heterosexual, and those who consume more alcohol (Yeater & O’Donoghue, 1999; Rothman & Silverman, 2007; Bradley, Yeater, & O’Donoghue, 2009). This task force recommends a more comprehensive review of the literature on interventions with these groups, as interventions may need to be tailored for each. Outreach to the campus LGBT community and connections with the other community sexual assault centers would be advised in order to provide comprehensive care for these groups. More investigation is necessary to determine how best to help the higher alcohol use group. In order to distinguish these groups, the task force recommends an informalized screening process as part of orientation to college. It is unethical to ask students about their previous victimization and sexual orientation, so enlisting the other community groups (LGBT and sexual assault centers) would be necessary. The college can develop a program with both of these groups and offer them through these community groups. For example, the campus LGBT community can advertise to their members about a collaborative program that will help this vulnerable population deal with their increased risk of sexual assault. Also, the local sexual assault center can advertise to their population about their collaborative program that would help students preparing for college study. It is acknowledged that a limitation of this approach is that it would only access those students who are a part of these groups, and would not access those students who are in these vulnerable groups but who have not sought treatment from the sexual assault center or become involved in the campus LGBT community. It may be more simple to ask students during orientation about their alcohol consumption, and those who are more prone to binge drinking can be asked, or even incentivized, to participate in additional programming. It may also be helpful to offer these programs not only at the beginning of the college year, but midway through the year, since alcohol use may change during the semesters.
Another important element of the task force’s recommended program is that it must be evaluated. Students should be asked to complete measures of attitudes, like those included in the Men’s Project (Ambivalent Sexism Inventory, Illinois Rape Myth Acceptance Scale, and informal questions regarding bystander efficacy and feminist activism) pre and post intervention. Additionally, these measures should also be administered to the same students at the end of the semester to verify if any changes hold. However, like Rothman and Silverman (2007) did, incidences of sexual assault should also be collected to examine potential behavior change that may be due to the programs.
Sexual assault is present in all societies in the world, but especially prevalent in the college student population. This task force was formed to address the increase in reports of sexual assault at the local college campus. Upon reviewing the sexual assault prevention programs developed and evaluated by Rothman and Silverman (2007) and Stewart (2014), it became clear that a “one size fits all” approach will not address the issue adequately. While there appears to be a demonstrated efficacy with psychoeducational sexual assault prevention programming, this efficacy does not translate with non-heterosexual students, students who have previous victimization, and students who drink alcohol more regularly. The other area of concern was the lack of a theoretical framework underpinning these programs, so models found in Yeater and O’Donoghue (1999) were suggested to integrate into Rothman and Silverman’s (2007) program. The Men’s Project was deemed to be too taxing on student and campus resources based on its model of an eleven-week program, while Rothman and Silverman’s (2007) model consisted of two 90 minute sessions (much more feasible). The task force recommends contacting and collaborating with the campus LGBT community and the local sexual assault centers in order to provide more comprehensive programming for these two vulnerable populations. More study is needed to develop and refine these programs for these groups, as well as the higher alcohol consuming group. Overall, there may need to be four separate programs that run simultaneously for four different populations of students. Each program must be monitored and evaluated to determine its effectiveness using both attitude and behavior change measures.
Bradley, A. R., Yeater, E. A., & O’Donoghue, W. (2009). An evaluation of a mixed-gender
sexual assault prevention program. Journal of Primary Prevention, 30, 697-715.
Hyde, J. S. & Delamater, J. D. (2011) Understanding Human Sexuality (11th ed.). New York:
Koo, K. H., Nguyen, H. V., Gilmore, A. K., Blayney, J. A., & Kaysen, D. L. (2014).
Posttraumatic cognitions, somatization, and PTSD severity among Asian Americans
and white college women with sexual trauma histories. Psychological Trauma:
Theory, Research, Practice, and Policy, 6(4), 337-344.
Mason, F. & Lodrick, Z. (2013). Psychological consequences of sexual assault. Best Practice
& Research Clinical Obstetrics and Gynaecology, 27, 27-37.
Rothman, E. & Silverman, J. (2007). The effect of a college sexual assault prevention
program on first year students’ victimization rates. Journal of American College
Health, 55(5), 283-290.
Stewart, A. L. (2014). The men’s project: A sexual assault prevention program targeting
college men. Psychology of Men & Masculinity, 15(4), 481-485.
Yeater, E. A. & O’Donoghue, W. (1999). Sexual assault prevention programs: Current
issues, future directions, and the potential efficacy of interventions with women.
Clinical Psychology Review, 19(7), 739-771.