Gursharan Kaur Lotey

The Role of Ethnic Group and Gender on Beliefs About Sexual Problems: An Experimental Study with South Asians in the UK.

Gursharan Kaur Lotey

Submitted for the Degree of

Doctor of Psychology

(Clinical Psychology)

School of Psychology

Faculty of Arts and Human Sciences

University of Surrey

Guildford, Surrey

United Kingdom

September 2015

Abstract

South Asians have been neglected from studies exploring help-seeking related to sexual problems. This experimental case vignette study aimed to explore the role of ethnic group and gender on the beliefs held about the causes, consequences and possible solutions to sexual problems. The study examined the impact of ethnic group (South Asian versus White British), gender of the person in a fictitious case vignette (male versus female), and participant gender (male versus female) on beliefs about sexual problems and coherence between beliefs. 291 participants randomly received a single sentence case vignette depicting either a male or female with a sexual problem and completed measures online concerning their beliefs about causes, consequences and solutions to sexual problems. South Asian and White British participants equally endorsed a psychological causal model, however South Asians showed greater endorsement for biological and social factors for the causes, consequences and solutions to sexual problems. Participants considering the male case vignette perceived greater psychological consequences and biological solutions compared to those who received the female case vignette. Female participants showed greater endorsement for biological, psychological and social causes, and biological and social consequences. Both ethnic groups showed a coherent model between beliefs about the causes and the solutions to sexual problems. The findings provide theoretical support to cognitive models of help-seeking and offer clinical implications to improve help-seeking behaviour and management of sexual problems.

Keywords: South Asian, sexual problem, beliefs, help-seeking, causes, consequences, solutions.

Acknowledgements

I would like to thank my MRP supervisor, Professor Jane Ogden, for getting me through the last three years and the two viva examinations. Dr Laura Simonds has also been a fantastic support to me in this regard and also more generally for the Clinical Psychology course.

I am grateful to all of the people who consented to take part in my research and allowed me to carry out the research. I appreciate your time and help.

My family, partner and friends have been unbelievably patient with me throughout the last three years and they deserve recognition as I wouldnot have been able to achieve what I have if it wasn’t for them.

I have had the pleasure of being supervised by some fantastic and inspiring Clinical Psychologists on my clinical placements. I would like to thank them for allowing me to develop my skills and for making my placements the most enjoyable part of clinical training.

Finally, I would like to thank the clients I was able to work with over all of my placements. Each and every one has allowed me to reflect on the style and type of Clinical Psychologist that I hope to be. They have also reminded me of why I wanted to embark upon this career and journey.

Contents

MRP Abstract

Major Research Project Empirical Paper

List of MRP Appendices

Major Research Project Proposal

Major Research Project Literature Review

Clinical Experience

Assessments

Major Research Project Empirical Paper

The role of ethnic group and gender on beliefs about sexual problems: An experimental study with South Asians in the UK.

Word count of empirical paper = 9, 998

Abstract

Keywords: South Asian, sexual problem, beliefs, help-seeking, causes, consequences, solutions.

Introduction

Overview

The present paper focuses on the area of sexual dysfunction and problems. As the current literature has used these labels interchangeably the paper begins with defining various sexual problems experienced by males and females, and the variation in prevalence rates by gender due to help-seeking patterns. Help-seeking beliefs and behaviours regarding sexual problems also vary by cultural group, with South Asians showing numerous patterns of help-seeking. The present research therefore focuses on studies exploring help-seeking in South Asian individuals with an emphasis on cultural beliefs, beliefs about the causes and solutions to sexual problems. Some studies have also examined the reasons why some people may or may not seek help and this literature is discussed. However there are some problems with this literature which need to be considered for clinical implications to be effective.

Research indicates considerably high rates of sexual dysfunction for both males (between 20-34%) and females (between 40-45%) (Dunn, Croft & Hackett, 1998; Lewis et al., 2010). This commonly includes erectile dysfunction and premature ejaculation for men and vaginismus for women. Dyspareunia (also known as sexual pain) and orgasmic dysfunction can be experienced by both men and women. The rise of sexual dysfunction has been reflected in increasing demands on health services for assessment and treatment (British Psychological Society; BPS, 2006). It is difficult, still, to gain an accurate picture of the prevalence rates of sexual dysfunction due to problems with service provision, lack of awareness of available services, limitations with existing epidemiological data and problems disclosing sexual issues due to culture and gender norms (BPS, 2006).

There are mixed findings in help-seeking attitudes and behaviours for men and women. Some research exploring help-seeking across both genders has found that help-seeking is similar and has found that 77.8% of men and 78% of women had sought no professional help or advice (Moreira et al., 2005) whilst other research has indicated that there are vast gender differences with women significantly more likely than men to report sexual problems especially when it lasted over one month (Mercer et al., 2005; Shifren et al., 2009). Other global studies have similarly identified gender differences in help-seeking but have also included a role for culture (Laumann et al., 2005; Moreira et al, 2005; Moreira et al., 2008). Research has highlighted that individuals from various ethnic groups generally exhibit different help-seeking attitudes (Gonzalez, Algeria & Prihoda, 2005). Thus the management and treatment of sexual problems is expected to be heavily influenced by cultural norms and practices including a variety of beliefs, expectations and customs (Ahmed & Bhugra, 2007). It has also been noted that terms such as “sexual dysfunction” may not be a valid or appropriate label within certain cultures (Weerakoon, 2001). This highlights the importance of understanding how sexual problems are perceived by individuals from different cultures.

To date, many global studies have neglected the Indian subcontinent, and this makes help-seeking patterns within this ethnic group more difficult to establish (Laumann et al., 2005; Moreira et al., 2005; Moreira et al., 2008; Nicolosi et al., 2006). The region South Asia is defined by the following countries: Afghanistan, Bangladesh, Bhutan, India, Iran, Maldives, Nepal, Pakistan, Sri Lanka (United Nations, 2014). Thus, the broad ethnic category of “South Asian” is used to refer to individuals whose cultural backgrounds originate from the Indian subcontinent (Anand, 2005). Individuals identified under this broad ethnicity are known to have more similarities, such as attitudes, values, social and cultural norms, with each other than other groups (Ahmed & Bhugra, 2007; South Asian Concern, 2015). Across the UK, the major sub-groups which comprise the South Asian ethnic group are defined as Indian, Pakistani, and Bangladeshi (Office of National Statistics, ONS, 2012; Department of Health, DoH, 2005). Other research has also focused on Indian, Pakistani and Bangladeshi sub-groups when undergoing sexual problem research regarding South Asian individuals in the UK (Bhui, 1998).

It is important to include South Asians in research as they are not excluded from experiencing sexual problems (Aggarwal et al., 2012; Gupta, 1994; Steggall, Pryce & Fowler, 2006) but are also stated to have differing perceptions in help-seeking patterns to those in Western countries (Bhui, 1998; Nene, Coyaji & Apte, 2005). In particular, South Asians in the UK have been observed to report physical complaints over psychological issues, due to acceptable gender norms and the pursuit for a more medical explanation (Bhui, 1998). Yet, there are few studies exploring help-seeking patterns in regards to sexual problems for South Asians. One explanation for limited research in this area may be the recognised taboo and shame in discussing sexual issues amongst this ethnic group (Bhugra & Cordle, 1988; Jillani, 2014; Kalra, Tandon & Rao, 2014; Manjula, Prasadarao, Kumaraiah, Mishra & Ragarum, 2003).

Help-seeking beliefs and behaviours for South Asians

Beliefs about sexual dysfunction, specifically about the causes, are known to play a large role in how sexual problems are understood and managed (Mercer et al., 2003; Moreira et al., 2005; Nobre & Pinto-Gouveia, 2006). Culture bound syndromes offer further support to this notion. A culture bound syndrome is how the sufferer makes sense of their symptoms and the causes, and this concept is highly established in South Asian culture and within the area of sexual problems (Ahmed & Bhugra, 2007; Sumathipala, Siribaddanna & Bhugra, 2004; Udina, Foulon, Valdes, Bhattacharyya & Martin-Santos, 2013). For example, ‘Dhat’ (semen related problems) and ‘Kamjori’ (weakness) syndromes are reported as presenting complaints and perceived as the cause of further sexual problems (Ahmed & Bhugra, 2007; Verma, Sharma, Singh, Rangaiyan & Pelto, 2003). One research study also found that 89% of its male Indian sample believed that sexual activity such as excessive intercourse, masturbation and the sexual desire could cause sexual problems (Verma et al., 2003). These findings regarding culture bound syndromes help to explain why South Asian males appear to attribute causality to physical symptoms (Bhui, Herriot, Dein & Watson, 1994; Kalra et al, 2014; Low, Wong, Zulkifli & Tan, 2002; Verma et al, 2003).

Research illustrates ethnic differences in beliefs about sexual problems, however little is investigated regarding gender differences amongst South Asians. The limited research indicates that South Asian women may perceive causes of sexual problems by social and environmental factors. For example, South Asian women have reported to freeze and disengage from further sexual behaviour due to familial pressures, lack of privacy, interference from the wider family context and forced marriages (Agarwal, 1977, cited in Ahmed & Bhugra, 2007). In heterosexual couples where one partner experiences a sexual problem, each partner may have differing perceptions about the cause and this undoubtedly influences treatment options (Bhugra, 2004). This is important to explore as sexual problems are defined as gender specific and consequently may not be perceived in the same way by the opposite gender. Surprisingly, research fails to explore how one gender views sexual problems on a wide scale when it is experienced by the other gender. Studying this would assist in understanding whether there are gender differences in perception when working with couples, especially as the context of a relationship is often where a number of sexual problems are identified (Bhugra, 2004).

As previously highlighted, the perceived cause of sexual problems is very likely to influence which solutions are sought (Mercer et al., 2003). This is supported by the self-regulatory model whereby symptom perception of a problem/illness influences behaviour and problem management (Leventhal, Meyer & Nerenz, 1980 cited in Ogden, 2012). Research indicates variability in how South Asians seek out solutions for sexual problems, which include not seeking help, seeking professional help and using traditional methods. In line with global research (Mercer et al. 2005), it appears that many South Asians do not seek help, and men in particular do not believe there are any solutions to their sexual problem (Verma et al., 2003). This suggests that despite identifying a sexual problem, the potential causes, and suffering significant distress, many believed to be helpless in their efforts to solve the problem. This finding is also apparent for females, where a third of women did not seek any type of help due to ‘time constraints’ and ‘not occurring to them to do something’ (Vahdaninia, Montazeri & Goshtasebi, 2009). One explanation offered is the lack of education and knowledge of sexual problems. However, as sexual knowledge may be culturally informed (Manjula et al., 2003), differences between ethnic groups in beliefs about potential solutions are likely to continue to exist.

South Asians tend to prefer to use ‘traditional’ methods as a way of alleviating their sexual problems, particularly before seeking professional help. These include self-medication and strengthening foods such as meat and chillies to boost sexual performance and libido (Low et al., 2002; Nene et al., 2005). The delay in professional help-seeking may be due to beliefs regarding what is culturally acceptable (Bhugra, 2004; Bhui, 1998; Nene et al., 2005). It is important to understand beliefs’ regarding possible solutions to sexual problems as this is likely to affect help-seeking behaviours and what treatments are offered and attempted.

Studies demonstrate that those who do eventually seek professional help tend to prefer medical solutions. It appears that although South Asian females attend sexual health clinics less than South Asian males (Bhui et al., 1994; Kalra et al., 2014; Kendukar, Kaur, Agarwal, Singh & Agarwal, 2008) there is a general preference to visit gynaecology and urology departments as the first line of help (Steggall et al., 2006; Vahdaninia et al., 2009). From couples and individuals who seek professional help, South Asian males preferred to see medical doctors, use medication as a rapid first solution, or to consider surgical options (Bhugra & Cordle, 1986; Bhugra, 2004; Manjula et al., 2003; Steggall et al., 2006), notably over psychological interventions (Steggall et al., 2006; Verma et al., 2003). Interestingly, when South Asian men perceived sexual problems through culture bound syndromes, they were more likely to seek help (De Silva & Rodrigo, 1995; Manjula et al., 2003; Verma et al., 2003). This finding suggests that individuals were more likely to seek help to aid physical symptoms when they believed that their problems had a physical cause. This is not a conclusive finding in the literature, especially when considering South Asian females. Exploring whether there is a coherent relationship between beliefs about the causes and solutions of sexual problems will provide an enhanced understanding of help-seeking.

Factors influencing help-seeking

Aside from identifying beliefs about the causes and solutions to sexual problems, there are other reasons that someone may or may not seek help. Infertility, marital stress, fear, embarrassment and beliefs about social stigma and discrimination from society, were reported to be negative consequences of sexual problems, and in some cases, stated as presenting complaints (Nene et al., 2005). Additionally, South Asian females have described marital conflict and social taboos to negatively impact upon sexual problems (Aggarwal et al., 2012), whilst South Asian males have reported that shame and embarrassment prevented help-seeking (Edwards, 2007; Griffiths, Prost & Hart, 2008). For single South Asian men seeking psychological treatment, their motivations related to marriage pressure, (Manjula et al., 2003), sexual relations outside of marriage (Beck, Majumdar, Estcourt & Petrak, 2005) and general family happiness (Low et al., 2002). These findings indicate that biological, psychological and social consequences are key factors in driving or reducing treatment seeking behaviour. As studies have failed to include a mixed gender sample it remains unclear whether these consequential factors vary by gender amongst South Asians.

Clinical importance

The need to develop and refine services is essential given the inconsistency of help-seeking amongst South Asians and the high drop-out rates (between 43% to 83%) compared to non-South Asian attenders (29%) (Ahmed & Bhugra, 2007; Bhugra & Cordle, 1986; Bhugra & Cordle, 1988; Kalra et al., 2014; Manjula et al., 2003). Drop out from therapy may be due to conflicting beliefs between couples and/or the client and professional regarding the causes and solutions for sexual problems, with attenders becoming preoccupied with the medical model (Manjula et al., 2003). Understanding what beliefs may be exhibited by this ethnic group is warranted. Given the increase of sexual problems in the UK, services need to be equipped to manage differences and diversity, and develop pathways to best meet the needs of this ethnic group so they are not excluded. This is especially pertinent in the UK as sexual health services are reportedly perceived as being culturally inappropriate and inaccessible for South Asian people (Beck et al., 2005).