In this thesis I explore the social construction of sexuality and sexual dysfunction. Interviews were undertaken with 20 sex therapists practising in Aotearoa/New Zealand in order to elicit accounts of contemporary sex therapy practice in the local context. Using a feminist poststructuralist lens, I explicate and critically examine the dominant discourses informing the construction of sex therapy, and heterosexual sexual relations, and what these discourses enable and constrain. I draw attention to some of the assumptions embedded in the construction of the sexual dysfunctions in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, APA, 2000), and in accounts of sex therapy practice, examining the ways in which these are based on taken-for-granted norms of (hetero)sexuality and highlighting the differently enabled gendered sexual subjectivities they (re)produce. Although there are nine sexual dysfunctions identified in the DSM-IV-TR, all of which I briefly outline in Chapter Four, I restrict my focus in the analytical chapters to the conceptualisation and treatment of vaginismus, orgasm difficulties in women, discrepancies in desire and, relatedly, the gendering of desire through powerful sociocultural discourses and representations. I pay particular attention to the implications of these for heterosexual women’s sexuality. I also explore some of the generic concepts that dominate the construction of therapy at a broader level than that of sex therapy alone, arguing that while these offer some useful ways of framing therapy they also constrain therapy practice in important ways. Through a critical review of the sex therapy literature and accounts of practice from those interviewed, I contend that contemporary sex therapy tends to reify dominant cultural and sexological norms rather than challenge them. My analyses show that the dominant discourses informing constructions of sex therapy and heterosexual sexual relations produce particular types of sex as normal whilst marginalizing sexual acts or practices that fall outside of such restrictive parameters. In particular, I argue that the genital-coital-orgasm construct that is hegemonic within sex therapy restricts possibilities for alternative erotic pleasures and possibilities amongst heterosexuals whilst contributing to the invisibilization of sexual identities other than heterosexual. Accounts of sex therapy practice that were able to contest such framings are also highlighted. Because these came from sex therapists drawing on radical feminist or feminist poststructuralist discourses, I suggest that these discourses offer important possibilities for a deconstructive (sex) therapy practice that is able to challenge an often inequitable sexual status quo. Attention is also drawn to the significant constraints which act to restrict clients’ choices and possibilities for sex therapists to practise in more critically questioning ways. I conclude this thesis with an ‘invitation to reflection’ where I briefly discuss some deconstructive approaches that I have found useful for developing ongoing reflexive analysis of my own taken-for-granted assumptions in the area of sexuality, and for aiding my thinking about therapeutic practices that support my political and theoretical commitments and that attend to some of the issues outlined in this thesis. / Whole document restricted, but available by request, use the feedback form to request access.

In this thesis I explore the social construction of sexuality and sexual dysfunction. Interviews were undertaken with 20 sex therapists practising in Aotearoa/New Zealand in order to elicit accounts of contemporary sex therapy practice in the local context. Using a feminist poststructuralist lens, I explicate and critically examine the dominant discourses informing the construction of sex therapy, and heterosexual sexual relations, and what these discourses enable and constrain. I draw attention to some of the assumptions embedded in the construction of the sexual dysfunctions in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, APA, 2000), and in accounts of sex therapy practice, examining the ways in which these are based on taken-for-granted norms of (hetero)sexuality and highlighting the differently enabled gendered sexual subjectivities they (re)produce. Although there are nine sexual dysfunctions identified in the DSM-IV-TR, all of which I briefly outline in Chapter Four, I restrict my focus in the analytical chapters to the conceptualisation and treatment of vaginismus, orgasm difficulties in women, discrepancies in desire and, relatedly, the gendering of desire through powerful sociocultural discourses and representations. I pay particular attention to the implications of these for heterosexual women’s sexuality. I also explore some of the generic concepts that dominate the construction of therapy at a broader level than that of sex therapy alone, arguing that while these offer some useful ways of framing therapy they also constrain therapy practice in important ways. Through a critical review of the sex therapy literature and accounts of practice from those interviewed, I contend that contemporary sex therapy tends to reify dominant cultural and sexological norms rather than challenge them. My analyses show that the dominant discourses informing constructions of sex therapy and heterosexual sexual relations produce particular types of sex as normal whilst marginalizing sexual acts or practices that fall outside of such restrictive parameters. In particular, I argue that the genital-coital-orgasm construct that is hegemonic within sex therapy restricts possibilities for alternative erotic pleasures and possibilities amongst heterosexuals whilst contributing to the invisibilization of sexual identities other than heterosexual. Accounts of sex therapy practice that were able to contest such framings are also highlighted. Because these came from sex therapists drawing on radical feminist or feminist poststructuralist discourses, I suggest that these discourses offer important possibilities for a deconstructive (sex) therapy practice that is able to challenge an often inequitable sexual status quo. Attention is also drawn to the significant constraints which act to restrict clients’ choices and possibilities for sex therapists to practise in more critically questioning ways. I conclude this thesis with an ‘invitation to reflection’ where I briefly discuss some deconstructive approaches that I have found useful for developing ongoing reflexive analysis of my own taken-for-granted assumptions in the area of sexuality, and for aiding my thinking about therapeutic practices that support my political and theoretical commitments and that attend to some of the issues outlined in this thesis. / Whole document restricted, but available by request, use the feedback form to request access.

Background: Brazil has high frequency of inappropriate obstetric practices and cesarean sections. This procedure may be associated with increased maternal and perinatal morbidity. Objective: to describe practices and interventions used during labor and childbirth and factors associated with such practices and to evaluate the impact of mode of delivery in breastfeeding incentive practices and in neonatal and maternal complications. Methods: A Cohort study was conducted, between june 2015 and april 2017, at the 11 maternity hospitals in Sergipe with 768 puerperal women, interviewed in the first 24 hours after delivery, 45-60 days and 6-8 months after delivery. The associations between good practices and interventions used during labor and delivery with exposure variables were described by simple frequencies, percentages, crude and adjusted odds ratios (ORA) with the confidence interval and the association between breastfeeding incentive practices, neonatal and maternal, both short term and late complications and the exposure variables were evaluated by the relative risk (95% IC) and the Fisher exact test. Results: were fed 10.6% of women and 27.8% moved during labor; non-pharmacological measures for pain relief were performed in 26.1%; the partograph was filled in 39.4% of the charts and the companion was present in 40.6% of deliveries. Oxytocin, amniotomy and analgesia occurred in 59.1%, 49.3% and 4.2% of women, respectively. The delivery occurred in the lithotomy position in 95.2% of the cases, there was episiotomy in 43.9% and Kristeller's maneuver in 31.7%. The factors most associated with cesarean section were the private health sector (ORA = 4.27,95% CI: 2.44-7.47), had higher education (ORA = 4.54,95%CI 2.56 -8.3) and high obstetric risk (ORA = 1.9,95%CI: 1.31-2.74). Private-sector users had a greater presence of the companion (ORA = 2.12,95% CI:1.18-3.79) and analgesia (ORA = 4.96,95% CI:1.7-14.5). The C-section delivery resulted in less skin-to-skin contact immediately after delivery (intrapartum c-section: RR=0.18;95%CI:0.1-0.31 and elective c-section: RR=0.36;95%CI:0.27-0.47) and less breastfeeding within one hour of birth (intrapartum C-section: RR=0.43;95%CI:0.29-0.63 and elective C-section: RR=0.44;95%CI:0.33-0.59). Newborns from elective c-section were less frequently breastfed in the delivery room (RR=0.42;95%CI:0.2-0.88) and stayed less in rooming- in (RR=0.85;95%CI:0.77-0.95). Women who were submitted to intrapartum c-section had greater risk of early complications (RR=1.3;95%CI:1.04-1.64; p=0.037) and sexual dysfunction (RR=1.68;95%CI:1.14-2.48; p=0.027). There was no difference in the frequency of neonatal complications, urinary incontinence and depression according to the mode of delivery. Conclusions: good obstetric practices are poorly performed and unnecessary interventions are frequent, and the factors most associated with cesarean delivery have been the private health sector, higher schooling and high obstetric risk. C-section was negatively associated to breastfeeding incentive practices. C-section after labor increased the risk of early maternal complications and sexual dysfunction, six to eight months after delivery. / Introdução: No Brasil, verifica-se elevada frequência de práticas obstétricas inadequadas e de cesáreas. Este procedimento pode associar-se a aumento de risco de morbidade materna e neonatal. Objetivo: descrever as práticas utilizadas durante o trabalho de parto e parto e fatores associados e avaliar práticas de incentivo à amamentação, complicações neonatais e maternas precoces e tardias segundo tipo de parto. Pacientes e Métodos: estudo tipo coorte, no período de junho de 2015 a abril e 2016, nas 11 maternidades de Sergipe, com 768 puérperas entrevistadas após 6h do parto, 45 a 60 dias e 6 a 8 meses após o parto e análise de dados do prontuário das puérperas e dos recém-nascidos. As associações entre as boas práticas e intervenções utilizadas durante o trabalho de parto e parto com as variáveis de exposição foram descritas em frequências simples, percentuais, razões de chances brutas (OR) e ajustadas (ORA) com o intervalo de confiança e as associações entre as práticas de incentivo à amamentação, as complicações neonatais e maternas precoces e tardias e as variáveis de exposição foram descrias por risco relativo (IC=95%) e pelo teste exato de Fisher. Resultados: alimentaram-se 10,6% das mulheres e 27,8% movimentaram-se durante o trabalho de parto; medidas não farmacológicas para alívio da dor foram realizadas em 26,1%; o partograma estava preenchido em 39,4% dos prontuários e o acompanhante esteve presente em 40,6% dos partos. Ocitocina, amniotomia e analgesia ocorreram em 59,1%, 49,3% e 4,2% das mulheres, respectivamente. O parto ocorreu na posição de litotomia em 95,2% dos casos, houve episiotomia em 43,9% e manobra de Kristeller em 31,7%. Os fatores mais associados à cesárea foram ser do setor privado de saúde (ORA=4,27;95%CI:2,44-7,47), ter maior escolaridade (ORA=4,54;95%CI:2,56-8,3) e alto risco obstétrico (ORA=1,9;95%CI:1,31-2,74). Usuárias do setor privado tiveram maior presença do acompanhante (ORA=2,12;95%CI:1,18-3,79) e analgesia (ORA=4,96;95%CI: 1,7-14,5). Os recém-nascidos de puérperas que se submeteram a cesárea tiveram menor frequência de contato pele a pele com suas mães imediatamente após o parto (cesárea intraparto: RR=0,18;95%CI:0,1-0,31 e cesárea eletiva: RR=0,36;95%CI:0,27-0,47) e mamaram menos na primeira hora de vida (cesárea intraparto: RR=0,43;95%CI:0,29-0,63 e cesárea eletiva: RR=0,44; 95%CI:0,33-0,59). Recém-nascidos de cesárea eletiva foram menos frequentemente colocados para mamar na sala de parto (RR=0,42;95%CI:0,2-0,88) e ficaram em menor frequência em alojamento conjunto (RR=0,85;95%CI:0,77-0,95). As mulheres submetidas a cesárea intraparto tiveram maior risco de complicações precoces (RR=1,3;95%CI:1,04-1,64; p=0,037) e de disfunção sexual (RR=1,68;95%CI:1,14-2,48; p=0,027). Não houve diferença nas frequências de complicações neonatais, incontinência urinária e de depressão segundo tipo de parto. Conclusões: boas práticas obstétricas são pouco utilizadas e intervenções desnecessárias são frequentes e os fatores mais associados à operação cesariana foram ser do setor privado de saúde, ter maior escolaridade e alto risco obstétrico. A cesárea associou-se negativamente às práticas de incentivo à amamentação. A cesárea após trabalho de parto associou-se a maior risco de complicações maternas precoces e a disfunção sexual seis a oito meses pós-parto. / São Cristóvão, SE

Title: Methods of secondary prevention of the pelvic floor after childbirth Objectives: This is a theoretical work with a descriptive-analytical part. It includes an analysis of the literature from available sources, an analysis of active approaches in the secondary prevention of the pelvic floor and the creation exercise unit for further research. Methods: Literature analysis including processing of information from available sources. Results: Handbook of pelvic floor training with methodical descriptions. Keywords: Pelvic girdle, pregnancy, gynecological weaknesses after childbirth, incontinence, pelvic organ prolapse, sexual dysfunction, pelvic floor examination, Arnold Kegel method, Ludmila Mojžíšová method, Alexander method, Feldenkrais method, Cantienica, exercise unit