Pre-Nuptal Consultation
Guide for healthcare professionals

Dr. Afifa Belmejdoub *

Corresponding Author: Dr. Afifa Belmejdoub, DU in clinical sexology, Faculty of Medicine, Hassan II University, Casablanca, Morocco.

Copy Right: © 2022 Dr. Afifa Belmejdoub, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: July 28, 2022

Published Date: August 05, 2022

Without any pretension, I would like to try to present to you a model of prenuptial consultation, adapted to our social context and which could replace the prenuptial certificate currently in force, compulsory before any signing of a marriage contract in Morocco (medical certificate of non-contagious disease).

Definition

The premarital consultation can be defined as an informative and preventive consultation in matters of sexual health.

This would indeed be an opportunity for the couple to have information concerning:

- First sexual intercourse and penetration (very high percentage of young girls and young men who are virgins on the wedding day in our country).

- Prevention of STIs and knowing how to recognize the symptoms for some.

- Contraception: which contraceptive to use for the first few months or the first year if pregnancy is not planned right away.

Start of The Interview: some instructions….

• The health professional must be able to approach the subject of sexuality without hesitation, especially when it concerns a young couple with no experience in this area.

• There should be no hesitation in the voice, saying that we are there to advise and inform: there is no shame in verbalizing inexperience in this area, because this inexperience is legitimate in our country (religious and socio-cultural legitimacy): the patient will better understand the purpose of the consultation, without feeling devalued...

• “If the subjects we are going to discuss make you uncomfortable, know that you are with a professional, that you can trust him, and that no value judgment will be made”.

The main topics covered will be:

the subject of masturbation, not as a reprehensible act but as a physiological initiatory passage in adolescence.

pornography (“is it a tool for you to learn about sexuality?”): Talking about the criteria falsely induced by porn films such as the duration of penetration, the fact of making your partner come during any penetration, suggest that the sexual reactions of women are modeled on those of men, etc.

Try to play down the “first time”, and encourage instead the discovery and learning of the other.

compulsory defloration on the wedding night should no longer be part of our traditions or our culture: This point is very important to raise, because in this way, the "marital rape" authorized on the wedding night would no longer be perpetrated ……

Interrogation

This questioning must be empathetic, without any judgment, and will essentially focus on brief questions, asked without hesitation, without innuendo, simply and with sympathy:

- Notion of previous sexual intercourse, with or without penetration, initiatory masturbation habits, around what age…

- History of sexually transmitted infection, if so, method of diagnosis and what treatment.

- Knowledge of sexual health, STDs, and contraception. This will allow us to better orient the rest of the consultation.

Clinical Examination

It must be explanatory and constructive for both spouses.

Using understandable and explicit anatomy charts (Fig.1), learning of female and male anatomy by both partners.

? Clinical examination of the young man:

- General examination, examination of the external genitalia, reassurance on their "anatomical normality".

- Take advantage of this examination time to learn about overrated ideas and deconstruct received ideas of "functional normality": for example, the average duration of penetration, regardless of the countries studied, is on average 6-7 minutes, far from the criteria induced by friends and porn...

When viewing anatomy charts, keep in mind that while many men have probably had penetrative sex before marriage, few are "expert" in defloration, and most are clumsy first times and this is especially related to the ignorance of the two partners of the female anatomy, and this is why I will insist more on the gynecological examination of the young girl.

? Examination of the girl:

We will systematically propose an examination, giving convincing arguments to be accepted: “As your genitals are between your legs and therefore not visible, we will check together that everything is normal and see what type your hymen is”. These 2 arguments alone are sufficient for the girl to agree to be examined. Awaken his curiosity!

From experience, this examination is very important, and if it is well carried out, should allow the young girl to better understand a sexual relationship:

Procedure of the gynecological examination:

We must keep in mind that for the young girl, it is most often the first time that she will undergo such an examination, which is to say the importance of explaining to her how it went well:

–The positioning of the legs on the stirrups must be done in a very gentle way, explaining that this is the only way to visualize the external genitalia (do not say “spread your legs” but rather “drop your knees on each side ").

– Propose to the young woman to visualize her intimacy herself, by giving her a mirror: it is only in this way that we will allow her to appropriate this part of her body by restoring the erroneous imaginary visions. Fig.3

The examination will be done using sterile compresses, and we will begin the explanations by naming each part of its anatomy, from the outside to the inside, then from top to bottom: labia majora, labia minora, clitoris= organ of pleasure, urinary meatus, hymen: there, give her time to visualize, explain to her that this is the entrance to her vagina, explain its elasticity, explain the action of breathing and the perineum on this part (abdominal expiration, contraction-relaxation of the perineum).

Then, we will insist particularly on the vestibule, by naming it and explaining that the traumatisms of this zone are responsible for hemorrhages of the wedding night, chronic vestibulitis and vestibulodynies, primary-secondary vaginismus. Fig.2

Putting a name on each well-visualized part will allow the patient to better integrate her anatomy, to learn its particularities, to mentalize the entrance to her vagina, to feel it through appropriate exercises, and we will suggest to her to practice recognizing them by touch...

Finally, he will be explained how to guide penetration when the couple feels ready.

End of the Interview: a few more instructions

? Talk Contraception:

The different methods of contraception: oral, mechanical, natural…

Generally, the prenuptial consultation takes place in the month preceding the wedding, and it is therefore necessary to talk about contraception by favoring oral contraception and/or condoms, for the first 3 months at least, without forgetting of course the morning after pill.

? Speak IST:

Teach the couple to know how to recognize the main visible clinical signs of STDs:

Burns, itching, warts, ulcers, vesicles, leucorrhoea (to be differentiated from physiological secretions), urethral discharge...

Do not hesitate to suggest that the couple donate blood, with a free STD check-up in return!

Free STDs! HPV vaccination is finally covered in the free national vaccination program since 2022 for teenagers.

HPV vaccination?

Talk about sexual health:

Discuss some notions of sexuality education:

• Desire: We should no longer speak of conjugal duty, nor of sexual needs!

? Excitement in men is manifested by an erection, and in women by lubrication: this physiological lubrication is important to know, because it is necessary for a pleasant sexual relationship, without pain, avoids irritation by friction, while as a good erection is necessary for penetration.

? Know that male sexual pleasure is obtained by rubbing the penis and that of women by rubbing the clitoris (although in reality it is not so simple...).

Insist on the notion of learning to have good sexuality by the couple themselves, discover together what pleases or does not please one or the other: there is no manual for a fulfilling sexuality , nor any standard and we can allow ourselves everything in a couple, in the respect of the other.

A sexual relationship should be considered a "game", a moment of relaxation, a moment of pleasure, with the only rule not to be broken: mutual consent.

Do not be in performance but in well-being Learn to know yourself: there is no point in simulating. Learn to feel, listen and communicate.

Finally, in our society in particular, insist on a few points:

Teach the couple that sexual intercourse is not just about penetration, but more like a moment of letting go.

Unfortunately, in our culture and traditions, defloration must take place at the during the wedding night and the presence of blood allows the man to "prove" his virility and the young girl to give "proof" of her virginity. But only 60% of women bleed during a well-conducted first penetration: would that be to affirm that 40% of men are not manly and 40% of women are not virgins when their "first time"?

If this ancestral tradition begins to be neglected by a minority of families and young couples, the fact remains that it continues in the majority of cases, with the consequences of physical trauma (Fig.4) and psychological repercussions both in men and women…. Hence the interest of the prenuptial consultation.

Our society should no longer tolerate authorized rapes and the long-term repercussions of the "wedding night" (primo-secondary vaginismus, vestibulodynia, dyspareunia... and sexual disorders in men...).

Our society, with its entrenched traditions, should no longer tolerate permitted wedding night rape.

Discussion

If I chose to rely on 3 axes for the development of this project, it is because despite all the efforts made by our leaders, by health professionals, the various very active associations of our country, the The situation in terms of sexual health remains very bleak.

- The Moroccan Association for the Fight against Clandestine Abortion (AMLAC) estimates, in 2019, "that between 600 and 800 abortions are performed every day in Morocco, in a clandestine manner and in sometimes disastrous sanitary conditions" .

- According to the Moroccan Ministry of Health, cervical cancer due to HPV is the 2nd cancer in women after breast cancer and the estimated number of people living with HIV is 22,000 (data collected in 2020 ).

Sex outside marriage being prohibited by the Muslim religion and penalized in Morocco, the vast majority of couples have never had penetrative sex before marriage. sexuality education is non-existent in schools and universities and the number of sexologists listed in the medical directory does not exceed the derisory figure of 20 for all of Morocco…

According to figures issued by the High Commission for Planning (HCP), the average age at first marriage is 25.5 years for women compared to 31.9 years for men (figures published in 2021) and divorce certificates before consummation of marriage represent 8% of divorces in 2020.

The percentage of unconsummated marriages varies from one study to another (5 to 17%) but this figure is underestimated due to very scattered recruitment (general practitioners, sexologists, psychologists, gynecologists, alternative medicine, etc.).

- There are few studies on the management of female sexual disorders, unlike male sexual disorders (1). In the letter from the gynecologist of January February 2012, Philippe Descamps writes: "no one can deny that the intimate is at the heart of the gynecological consultation”. “For women, the gynecologist is the specialist in the genital apparatus, therefore of the sexual apparatus they think most often. Yet of many gynecologists are reluctant to take on this position,” continues Sylvain Mimoun in the same magazine

The main female sexual disorders leading women to consult a gynecologist in Morocco are:

• primary or primary vaginismus secondary to a first traumatic penetrating sexual intercourse.

• Dyspareunia of intromission due to vestibulopathies by repeated traumatic penetrations.

• Loss of libido.

The main male sexual disorders encountered by urologists are erectile dysfunction, loss of libido.

 
Conclusion

Although the awareness of young people is beginning to manifest itself in our country, many points still remain obscure, taboo, forbidden….

In our culture there is an overvaluation of virginity, so much so that young girls do not dare to touch themselves, let alone masturbate, for fear of damaging this precious membrane.

There is also an overvaluation of male sexual performance and their experience of sexuality.

The development of the project to set up a supervised prenuptial consultation for health professionals stems from my experience and my practice as a gynecologist for more than thirty years in the liberal sector and I adapted my training as a clinical sexologist to the context. Moroccan socio-cultural situation due to the following observations:

- If the Moroccan man requires that his wife be a virgin before marriage, he requires bleeding as proof, and this does not mean that he seeks information on how to proceed the first time, he knows just that he must "push to force the passage".

- Within my modest practice as a gynecologist-sexologist in a liberal environment, I estimate the number of unconsummated marriages at 20%, this figure having been doubled over the past 5 years, and a prospective study on this subject on this topic is in progress.

- Conjugal sexual violence is not penalized in Morocco, and the first sexual violence that many Moroccan women still suffer is that of the wedding night:

This is a real public health problem, and I allow myself to sound the alarm!

The premarital consultation must allow the health professional:

• to approach patients without rushing them, without being intrusive, to provide them with clarifications and explanations on their genital anatomo-functional “little difference”.

• It must also, and above all, make it possible to establish a dialogue to talk about sexuality in a framed way and to restore a coherent body image.

• It must make it possible to detect and detect vaginismus due to phobia (reassure about pain, bleeding, disgust, taboos, hchouma) and demystify all the false beliefs which are transmitted from generation to generation.

Offering a prenuptial consultation as a lesson to health professionals would allow them to enlighten our young people on the fundamentals of a well-structured sex education.

Sexual health must be taken into account by all, as defined by the WHO (2002):

“Sexual health is a state of physical, emotional, mental and societal well-being. related to sexuality. It cannot be reduced to the absence of disease, dysfunctions or infirmities. Sexual health requires a positive and respectful approach to sexuality and sexual relations, as well as the possibility of having pleasurable and safe, free from coercion, discrimination and violence. To achieve health and maintain it, everyone's sexual rights must be protected.