Introduction: This multiphase qualitative study explored the understanding of middle-aged women’s sexuality and sexual difficulties and the way they address these difficulties. Nurses’ and midwives’ role in sexuality-related care was also explored. The need to address the subject was triggered by the multidimensional nature of female sexuality that could not be limited to one single definition; the medicalisation of female sexual problems that is based on the standards of sexual function and dysfunction; the scarcity of research that reflects on women’s subjective views on sexuality and sexual difficulties and the way they address these difficulties. This is particularly crucial at the middle-age where women undergo hormonal and psychosocial changes that may affect their sexual life. Methods: Interviews and focus group discussions were used to capture the narratives of 52 middle-aged women of 40-55 years in phases one and two of the study. They were chosen purposively by education and menopausal status from clinical and non-clinical settings regardless of their marital status and sexual orientation. Additionnally, a sample of 11 nurses and midwives working in the hospital and primary healthcare centres participated in two focus group discussions. Results: Women’s narratives led to a comprehensive understanding of sexuality and sexual problems and the implications for help-seeking. Findings showed how women’s interpretation of sexuality resonates within bio-psychosocial and cultural perspectives driven by double standards and inhibiting sexual socialisation. Women’s sexuality is ‘muted’, conflicting between frustrating experiences, personal expectations and the perception of sexual selves as affected by the middle-age and social myths. Yet, sexuality is central to women’s life where they tend to play a sacrificing role and gain agency. Their sexual difficulties are multifaceted mirroring their inhibitions, relational conflicts, husbands’ sexual problems and contextual burdens. Women would firstly rely on their husbands to discuss together their common sexual issues as nobody can understand their needs more than both of them. In parallel, the gynaecologist is reportedly the first one they consult as they are familiar with him/her. Yet, some do not know who else to turn to for help. Women highlighted many personal, relational and contextual barriers to help-seeking focusing on their husbands’ negative attitude. They also criticised the services offered and the lack of resources. Within this context and in focus group discussions, 11 nurses and midwives reflected on their attitude and behaviour towards sexuality-related care. They had opposing views concerning their involvment in the assessment of patients’ sexual health and identified many barriers to having an effective role in the field. Discussion and implications: This study has a unique contribution in voicing women’s views and concerns as sexuality is underreported and poorly researched in Lebanon. Women’s narratives shed light on many aspects of their sexuality, sexual difficulties and the facilitators and barriers to help-seeking focusing on the role of nurses and midwives in this field. This comprehensive perspective that is contextually based has implications on education, clinical practice and research. It is particularly important to provide middle-aged Lebanese women with a culturally sensitive professional assistance to satisfy their sexual life. In addition, the publication of two papers from the study enriches knowledge in the field. It is of note that in this study sexuality and sexual life are interchangeably used. Nevertheless, sexuality has a broader meaning and encompasses all the thoughts, fantasies, desires, beliefs, attitudes, values, behaviour, practices, roles and relationships (WHO, 2006), whereas sexual life is more related to sexual relationships and activities (Segen's Medical Dictionary, 2012).

Sex after breast cancer treatment has hitherto been studied chiefly by quantitative methods, which have found that at least a third of women concerned have sexual difficulties. The reasons for this were not clearly identified, but were usually held to be associated with depressed mood and negative body image. This study gathered information about sex and the couple relationship by means of in-depth interviews with fdteen women, and reports their experiences as they recounted them. All had been treated with breast surgery, four with radiotherapy, nine with chemotherapy and eight with the hormone treatment, tamoxifen. Fourteen had had sex since their treatment, and twelve of these had sexual difficulties they had not been having before the treatment, These difficulties were not connected with either mood changes or body image concerns, but were mainly due to problems with desire and orgasm and to vulva1 and vaginal symptoms. Most women attributed these problems to menopause, whether natural, induced by the chemotherapy or exacerbated by tamoxifen. The couple relationship in this circumstance has not been intensively studied until now. The study found that a positive shift commonly took place in the less stable relationships, so that the couple became closer, and sex, including heterosexual intercourse, became more acceptable to the woman. There was no change in the stable relationships. In both stable and less stable relationships, though intercourse was wished for by the heterosexual women, the sexual difficulties described above inhibited its successful accomplishment. The study also reports the coping methods used by the women and their experience of trying to find information about the subject of sex and sexual difficulties, from health professionals and other sources.

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An adult female sample of childhood sexual abuse survivors (N=467) were surveyed to determine whether internalized shame moderated the effects of sexual inhibited difficulties. Other variables such as severity, duration, and frequency of sexual abuse, as well as whether physical abuse was also part of their experience, were examined to determine their role in later sexual inhibition. It was predicted that there would be a significant positive relationship between 1) Scores on variables of physical abuse, severity of abuse, frequency of abuse, duration of abuse, identity of the perpetrator and scores on the variable of inhibited sexual difficulties; 2) Scores of internalized shame and scores of inhibited sexual difficulties and 3) Scores on variable of physical abuse, severity of abuse, frequency of abuse, duration of abuse, identity of the perpetrator and scores on the variables of internalized shame. Through Structural Equation Modeling using AMOS, the results indicated a statistically significant positive relationship between severity, frequency and inhibited sexual disturbances but found no direct relationship between physical abuse, the identity of the perpetrator, the duration of the abuse and inhibited sexual disturbances. Results also indicated that shame had a direct positive relationship to inhibited sexual disturbances. The third finding was that physical abuse and severity of abuse had a significant positive relationship with shame which implies that shame is a moderating variable for inhibited sexual disturbances in adult women survivors of childhood sexual abuse. Internalized shame may be an important factor for therapists to consider in helping survivors overcome sexual inhibition as a result of childhood sexual abuse. If a woman develops a shame-prone identity she may be at risk for experiencing inhibition in her sexuality.