|Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)|
|Chapter 12: Sexual Health|
We have been ignorant for so long, and full of fear about our bodies.
- Oaxaca, Mexico
Sex is a natural part of life. For many women, it is a way to feel pleasure, express love or sexual desire for their partners, or to become pregnant with the children they hope for.
But sex can also lead to serious problems, such as pregnancies that are unwanted or that threaten a womans health, sexually transmitted diseases (STDs), or physical and emotional harm from forced sex.
To be free from these problems, a woman must have control over her sexual life. This control should include:
· choosing her sexual partner.
· negotiating when and how to have sex.
· choosing if and when she becomes pregnant.
· preventing STDs, including HIV/AIDS.
· being free from sexual violence, including forced sex.
When a woman has this control, we say she has good sexual heath. But in many communities, harmful beliefs about what it means to be a woman make it hard for women to have good sexual health. This chapter gives information and suggestions about how women can overcome these beliefs and gain control over their sexual lives.
Each person is born with either a girls body or a boys body. These physical differences determine a persons sex, which does not change overtime.
A persons gender role refers to the way a community defines what it is to be a woman or a man. Each community expects women and men to think, feel, and act in certain ways, simply because they are women or men. In most communities, for example, women are expected to prepare food, gather water and fuel, and care for their children and partner. Men, however, are often expected to work outside the home to provide for their families and parents in old age, and to defend their families from harm.
Unlike the physical differences between men and women, gender roles and the activities associated with them are created by the community. Some activities, like preparing food and caring for children, are considered womens activities in many communities. But others vary from place to place - depending on a communitys traditions, laws, and religions. Gender roles can even vary within communities, based on how much education a person has, her race, or her age. For example, in some communities women of a certain race are expected to do domestic work, while other women have more choice about the jobs they hold.
Gender roles are passed down from parents to children. From the time children are very young, parents treat girls and boys differently - sometimes without realizing they do so. Children watch their parents closely, noticing how they behave, how they treat each other, and what their roles are in the community.
As children grow up, they accept these roles because they want to please their parents and. because parents have more authority. These roles also help children know who they are and what is expected of them. So in the same way that children learn their own names, they also learn about their gender - that is, what it means to be a woman or a man.
As the world changes, gender roles also change. Many young people want to live differently from their parents. But they sometimes find it difficult to change, because the family and community expect them to continue following old rules. As women struggle to gain the freedom to redefine their gender roles, they can also gain more control over the things that determine sexual health.
Fulfilling the roles expected by the community can be satisfying and can give a woman a sense of belonging. But these roles can also limit a womans activities and choices, and make her feel less valued than a man. When this happens, everyone - the woman herself, her family, and her community - suffers.
In most communities, women are expected to be wives and mothers. Many women like this role because it can be very satisfying and it gives them status in the community. Other women would prefer to follow their own interests - , or they want to have only a few children - but their families and communities do not give them this choice. If she is expected to have many children, a woman may have less chance to learn new skills or go to school. Most of her time and energy will be spent taking care of others needs. Or, if a woman is unable to have children, her community may value her less than other women.
Most communities value mens work more than womens work. For example, this woman has worked all day - and then cooks, cleans, and cares for her children at night. But because her husbands work is considered more important, _ she is concerned about his rest - not her own. Her children will grow up thinking mens work is more important, and value women less.
Women are often considered more emotional than men, and they are free to express these emotions with others. Men, however, are often taught that showing emotions like sadness or tenderness is unmanly, so they hide their feelings. Or they express their feelings in angry or violent ways that are more acceptable for men. When men are unable to show their feelings, children may feel more distant from their fathers, and men are less able to get support from others for their problems.
Women are often discouraged from speaking - or forbidden to attend or speak - at community meetings. This means the community only hears about what men think - for example, how they view a problem and their solutions for it. Since women have much knowledge and experience, the whole community suffers when they cannot discuss problems and offer suggestions for change.
Women and men who have sexual relations with people of the same sex (homosexuals) are sometimes made to feel like outcasts in their own communities. Even if they are community leaders in other ways, they may be forced to live and love in secrecy and shame. In some communities, fear or lack of understanding of people in same sex relationships may even lead to physical violence against them. Any time a person is made to feel afraid or ashamed about who he or she is, it harms the persons mental and sexual health.
What it means to be a woman or a man in a particular community includes beliefs about mens and womens sexuality - that is, about sexual behavior and how people feel about their own bodies.
A few harmful beliefs about womens sexuality that are common in many communities are described below. These beliefs and other harmful effects of gender roles - the lack of opportunity and choice for women, and the lack of value they feel - prevent women from having control over their sexual lives. This puts them at great risk for sexual health problems.
Harmful belief: Womens bodies are shameful
Mothers and fathers begin to teach their children about their bodies as soon as they are born. Parents do not do this directly. But a baby learns it by the way the parents hold her, and the tone of their voices.
As a little girl grows, she becomes curious about her body. She wants to know what the different parts are called and why her genitals are different from a boys. But unlike little boys, she is often scolded for being curious, and is told that nice girls do not ask such things. If she touches her genitals, she is taught that it is dirty or shameful - and that she should keep her sexual parts hidden.
Parents act differently when little boys and little girls touch their bodies.
Her parents reactions teach a little girl that her body is shameful. As a result, she will find it difficult to ask questions about changes in her body as she enters puberty, and about her monthly bleeding, or about sex. She may be too embarrassed to talk to a health worker, because she does not know what parts of her body are called or what questions to ask. When she starts having sex, she is less likely to understand how her body feels sexual pleasure, or to know how to protect herself from unwanted pregnancy or sexually transmitted diseases (STDs).
¨ A womans body is NOT shameful. Her body is something to discover, love, and value.
Our bodies are not causes for shame. Our bodies allow us to touch and care for others, and to feel sexual pleasure. Our bodies are something to discover, love, and value.
Harmful belief: Womens bodies belong to men
In many communities, a woman is treated like the property of her father or husband. As a child, she belongs to her father, and he can arrange to have her marry whomever he chooses. Sometimes she will be sold - like property - to her husband or to an employer. Her future husband wants his property to be pure and unspoiled by other men, so he expects her to be a virgin. After marriage, he feels he has the right to use her body for his pleasure whenever he wants. He may have sex with other women, but she is to be his alone.
These beliefs can cause great harm. A girl learns that other people make the important decisions about her life - it does not matter what she wants or what skills she could contribute to the community. Because virginity is valued so highly, she may be forced to marry at a young age. Or she may try to remain virgin by using unsafe sexual practices. For example, she may have sex in the anus (so that her hymen will not be torn), which puts her at great risk for STDs, including HIV/AIDS. When she starts having sex, she may have little power to discuss family planning methods with her partner or to protect herself from STDs.
Some girls ore married as children to moke sure they will be virgins. This can cause serious health problems for a girl and her babies.
But men do not own womens bodies! A womans body is hers alone, and she should be able to decide how, when, and with whom to share it.
Harmful belief: Women have less sexual desire
A woman is often taught that it is part of her duty as a wife to meet her husbands sexual demands. But if she is a good woman, she will endure sex, not want it.
Again, these beliefs harm a womans sexual health. First, a woman who believes she should not think about sex will be unprepared to have sex safely. She is less likely to learn about family planning or about how to get and use condoms. Even if she has the information, it will be hard for her to discuss these things with her partner beforehand. If she can discuss sex, her partner may think she is sexually experienced, and therefore bad.
Once she is in a sexual relationship, she is likely to let her partner control the kind of relationship they have. This includes when and how they have sex, whether they try to prevent pregnancy or STDs, and whether he has sex with other women. This puts her at great risk for getting STDs.
But sexual desire is a natural part of life, and a woman can feel as much sexual desire and pleasure as a man.
Improving sexual health means:
· reducing the risk of unwanted pregnancy and STDs. This means women must have access to information about family planning methods and ways to prevent STDs, including HIV/AIDS (safer sex methods and practices). Women also need control over when to use these methods. For information about family planning and choosing a method that works best for you, see the chapter on Family Planning. For information about safer sex, see the next section below.
· feeling more pleasure from sex. What brings pleasure to one person should not be harmful to another.
· changing harmful gender roles, including harmful beliefs about womens sexuality. This kind of change takes time, because it means women and men must develop different ways of relating to each other See suggestions about how you and your community can work to change these roles.
¨ It is best for family planning and STD services to be included in the other health services women already use.
In the past, the main danger from sex was unwanted pregnancy. Now STDs, including HIV/AIDS, have become a serious sexual health problem.
STDs are caused by germs that are passed from one person to another during sex. Some STDs, like genital warts and herpes, are spread by germs on the outer genitals of an infected person. Other STDs are passed by contact with germs in a mans semen, the liquid in a womans vagina, or blood. Infection can happen when the germs pass through the cervix into the womb, or through breaks in the skin - especially in the vagina, onus, tip of the penis, or mouth.
¨ Safer sex can save your life.
Because STDs are spread through sexual contact, avoiding direct contact with an infected mans genitals, semen and blood is the best way to avoid getting an STD. This is called safer sex.
When should a woman practice safer sex?
Everyone should always have sex safely. Women have many different kinds of sexual relationships. Some have one faithful sex partner their entire lives. Others have one sex partner at a time but several partners over the course of their lives. And others have multiple partners (or their partners have multiple partners) at one time. This means different women have different risks of getting STDs.
Many women think they are not at risk for an STD if they have just one sex partner. This is true ONLY if you and your partner know for sure that neither of you already has an STD, and that both of you have sex only with each other
Most women cannot be sure of this because:
· it is possible to have an STD and not know it. If a womans past partners - or her partners past partners - had an STD, she or her partner could have one, too.
· they do not know for sure that their partner does not have other sex partners now. If someone your partner has sex with has an STD, you can get it too.
You can be infected by past partners - and your partners past partners.
Fmas story: Every woman should protect herself
Fma lives in a rural town called Belem - and she is dying of AIDS. When she was 17, she married a man named Wilson. He was killed a few years later in an accident at the cooperative where he worked. Fma had to leave her baby with Wilsons parents and go to the city to find work. When she had extra money, she sent it back home. The work was hard, and she was very lonely.
When she learned that the government was building a highway near Belem, Fma got a job cooking for the road construction workers so that she could stay at home. It was there that she met Emanuel. He was handsome, had cash in his pockets, and charmed her little girl when he came around after work. When the work crew had to move on, he promised to return.
Emanuel did come back, but he never stayed long. He got a new job driving trucks that kept him on the road most of the time. Fma thought he probably had other women, but he always told her she was his only one. They had a baby boy, but he was small and sickly and died after a year. Soon Fma began to feel sick, too. The nurse at the health post gave her different medicines, but nothing helped. Finally she went to the hospital in the city. They did some tests, and later told her she had AIDS. When she asked how she could have got AIDS, the doctor replied, You shouldnt have slept with so many men. Fma did not think she was at risk for HIV/AIDS - she had only had sex with 2 men in her life! She thought that only prostitutes and homosexuals in the cities got AIDS.
Practicing safer sex means using barriers that keep germs from being passed between you and your partner during sex (safer sex methods), and having sex in ways that make infection with an STD less likely (safer sex practices).
Safer sex methods condom for women
Using condoms for either men or women can protect you from STDs, including HIV/AIDS. If they are used correctly, they keep a mans genitals and semen from touching your genitals. Condoms can also prevent unwanted pregnancy.
¨ The more often you use a condom, or avoid sex in the vagina or anus without one, the less likely you will be to get AIDS.
Note: Spermicides - chemicals that kill sperm - used alone or with a diaphragm, also provide some protection against the germs that cause gonorrhea and chlamydia.
To encourage your partner to use condoms:
If he says...
It will not feel as good.
It may feel different, but it will still feel good. Here, let me show you.
You can last even longer and then we will both feel good!
I do not have any diseases.
I do not think I have any, either. But one of us could and not know it.
You are already using family planning.
I would like to use it anyway. One of us might have an infection from before that we did not know about.
Just this once without a condom.
It only takes one time without protection to get an STD or HIV/AIDS. And I am also not ready to be pregnant.
Condoms are for prostitutes. Why do you want to use one?
Condoms are for everyone who wants to protect themselves.
NO CONDOM, NO SEX!
Do what you can to make sure that you both enjoy having sex with a condom. That way, it may be easier to get him to use one the next time.
Safer sex practices
Sexual practices in which there is less contact with a mans semen are also less likely to spread STD germs, including HIV. The box below shows which kinds of practices are safer than others. Sex with the penis in the vagina (vaginal sex) is the most common kind of sexual practice for many men and women. But other couples give and receive sexual pleasure by using many different kinds of talk and touch. If your partner does not want to use condoms, try to get him to have other kinds of sex with you. These other practices may feel just as good to him - and mean less risk for you.
¨ Moke sex safer:
· Use a latex condom every time.
· Replace risky practices with touching and kissing.
· If you cannot use a condom, it is better to use spermicide alone or with a diaphragm.
Some kinds of sex are safer than others
Kissing. Kissing mouth-to-mouth is safe, even if your mouths are open or your tongues touch. But if you or your partner has a sore in the mouth, you should wait until the sore has healed.
Touching. Touching is always safe, as long as neither person has blood, discharge, or sores on the genitals or hands.
Oral sex. Oral sex is much safer than vaginal or anal sex. But the less time you have semen in your mouth, the better. So, if the man ejaculates into your mouth, you should swallow or spit right away, and rinse your mouth afterward. If you get a sore throat a couple of days after having oral sex, be sure to have it checked by a health worker. You can get gonorrhea in your throat and herpes sores in your mouth. The safest way to have oral sex is if the mans penis is covered with a condom before you take it into your mouth.
Vaginal sex. Vaginal sex is less safe than oral sex, but safer than anal sex. Always use a condom to keep the semen from touching your vagina. If you cannot, try to have the man withdraw his penis before he ejaculates. You can still get HIV and you can still get pregnant, but it is safer because less semen gets into your body.
Anal sex. Sex in the anus is very dangerous because the skin there tears even more easily than the skin in the vagina. If you and your partner have anal sex, it is important that you use condoms and make the anus wet first. Never have sex in the vagina after having sex in the anus without the man washing his penis first, or you could get an infection.
Avoid dry sex. In some places people prefer to have sex when the vagina is very dry, so some women put herbs or powders in their vaginas or douche before sex. But if the vagina (or anus) is dry or irritated, it will tear easily during sex and make infection more likely. You can make the vagina less dry by not using powders, herbs, or douches, and by taking more time with sex to allow the body to make more of its own wetness. Or use saliva, spermicide, or lubricant to make the vagina slippery so the skin will not tear Do not use oil or petroleum gel, which can make a condom break.
Everyone needs to think about ways to make sex safer, even if you do not think you are at risk. How you make these changes will depend on whether you expect your partner to support your wish to have safer sex.
If your partner is supportive, it is best to talk together about the health risks of STDs. But this is not always easy! Most women are taught that it is not proper to talk about sex - especially with their partners or other men - so they lack practice. A man may talk with other men about sex, but is often uncomfortable talking with his partner Here are some suggestions:
Practice talking with a friend first. Ask a friend to pretend to be your partner and then practice what you want to say. Try to think of the different things he might say and practice for each possibility. Remember that he will probably feel nervous about talking too, so try to put him at ease.
Talk with your partner. Do not wait until you are about to have sex. Choose a time when you are feeling good about each other and when you are not likely to be interrupted. If you have stopped having sex because you have a new baby, try to talk with him before you have sex again. If you and your partner live far apart or must travel often, talk ahead of time about what having other partners would mean for your sexual health.
¨ Work with your community to educate women and men about condoms and how to use them. This will help make condoms more acceptable.
Learn as much as you can about the risks of unsafe sex, and about safer sex methods and practices. If your partner does not know much about STDs and how they are spread, or about their lasting health effects, he may not understand the real risks involved in unsafe sex. If you give him this information, or encourage him to talk to a health worker about it, you can help convince him of the need to practice safer sex.
If you think your partner will not want to practice safer sex, you will need to be more creative to get what you want:
Bargaining for safer sex
Think about how you bargain for the other things you need. In these situations, you must know what you want and then talk to the other person in such a way that you get it. Start by asking yourself: Exactly what changes do I want my partner to make? Is there something I can offer him that will make him more likely to agree? What am I willing to offer?
Focus on safety. When you talk about safer sex, your partner may say that you do not trust him. Tell him the issue is safety, not trust. Since a person may have an STD without knowing it, or may get HIV/AIDS from something other than sex, it is difficult for a person to be sure he or she is not infected. Safer sex is a good idea for every couple, even if they only have sex with each other.
But if you or your partner has had or now has another sexual partner, it may be hard to talk about. If your partner is having sex with others now, do not use this discussion to punish him. Try to talk honestly about why you are scared and how each of you will behave in the future. If he is not willing to stop having sex with others, ask him to use condoms every time he has sex with you and with anyone else.
Use other people as examples. Sometimes learning that others are practicing safer sex can help influence your partner to do so, too.
Ask for help if you need it. If you are afraid your partner will get angry or violent when you talk, you may need someone to help you discuss safer sex with him. Ask someone you trust for help.
If your partner does not want to change
If your partner does not want to change his sexual habits, you must decide what to do. You may be able to choose not to have sex, to find protection you can control - like the female condom, or the diaphragm with spermicides - or think about ending the relationship.
What you must weigh if your partner is unwilling to stop unsafe sexual practices.
It is natural for women and men to want to share sexual pleasure with their partners. When each partner knows the kind of sexual talk and touch that the other likes, they can both enjoy sex more.
¨ Both men and women are capable of feeling - and controlling - their desires.
If a woman does not feel pleasure with sex, there may be many reasons. Her partner may not realize that her body responds to sexual touch differently from the way a mans body does. Or she may have been taught that women should enjoy sex less than men, or that she should not tell her partner what she likes. Understanding that women are capable of enjoying sex just as much as men, and that it is OK to do so, may help her like sex more. But she should remember that these kinds of changes often take time.
¨ What brings pleasure to one person should not be harmful to another.
How the body responds to sexual pleasure
Both women and men feel sexual desire but their bodies respond differently to sexual thoughts and touch. When men and women have sexual thoughts or are touched in a sexual way, they feel excited. More thought and touch makes the body more excited. It is easy to see sexual excitement in a man, because his penis gets hard. When a man reaches his peak of pleasure, his penis releases fluid with his sperm (ejaculation). This is called orgasm, or climax. After orgasm, the penis becomes soft again.
The womans body also gets excited, but it is harder to see. The clitoris gets hard and may swell, and the labia and walls of the vagina become sensitive to touch. If sexual touch and thought continue, sexual tension builds up until she reaches her peak of pleasure and has an orgasm. Touching the clitoris is the most common way this happens. It often takes longer for a woman to reach orgasm than a man. But when orgasm happens, the energy and tension in her body releases, and she feels relaxed and full of pleasure.
It is possible for almost all women to have orgasms, but many women have them only once in a while, or never. If she wants, a woman may be able to learn how to have an orgasm, either by touching herself, or by letting her partner know what feels good. It may make him feel good too, to know that he pleases her
Touching oneself for pleasure (masturbation)
A woman can touch herself in a way that gives sexual pleasure. This is a good way for her to learn about her body and what kinds of sexual touch feel best. Many communities have beliefs that touching oneself is wrong, so sometimes people feel shame about doing it. But touching oneself does not cause harm or use up sexual desire.
Lack of desire
Many things - including everyday life events - can affect how much sexual desire a woman or man feels. For example, when life seems exciting - such as when starting a new relationship or a new job - a woman or man may feel more sexual desire. But you may feel ess desire when:
· you feel stress from hard work, not enough food, illness, or a new baby.
· you have a partner you do not like.
· you fear that others will see or hear you having sex.
· you are afraid of becoming pregnant or getting an STD.
¨ If a woman has been raped or forced to have sex, she may need time - or to talk with someone she trusts or a trained mental health worker - before she wants to have sex again.
When a woman lacks desire, her body makes less of its natural wetness, and she may need to use lubrication, like saliva, so that sex is not painful. When a man lacks desire, it is more difficult for his penis to get hard (impotence). He may feel ashamed, and this may make it more difficult for him to get hard the next time.
If you or your partner are having less desire, try to forgive each other and to talk about it. Plan time for sex when you both want it, and try to do things that awaken sexual thoughts and feelings for both of you.
If sex is painful
Sex should not be painful. Pain during sex is usually a sign that something is wrong. A woman may feel pain with sex when:
· her partner enters her too soon, before she is relaxed or wet enough.
Changing harmful gender roles takes time, because ideas about gender are some of the most deeply-held beliefs a community has. But overtime, women and men can learn to take on new roles, especially if they understand how these roles will help girls and women live healthier, more productive lives.
To begin changing these gender roles, you will need to find ways to help your community. Here are some suggestions:
· Develop an awareness of what gender roles are, and how they are passed on by parents, community traditions, and the media (the radio, television and newspapers).
· Examine different gender roles to see which are harmful and need changing.
· Make plans for change.
Here are some suggestions for fun activities that have been used in some communities to help women and men think about gender roles and how they affect sexual health:
Using sexual language
Understanding that men and women see each others sexuality differently can help people think about how gender roles affect their beliefs about sexuality. This activity can help women and men learn how to talk openly about sex without shame, and to begin to think about the different ways that men and women view sexuality.
1. Write down (or draw) several sexual terms, each at the top of a separate piece of paper: for example male genital organ, female genital organ, sex, condoms, etc.
2. Divide into groups of 2 or 3 people. Give each small group one of the pieces of paper. Let each group have a few minutes to think of every polite, rude, medical, and common way to say the words on their paper, and call them out. Then pass the papers to a different group until each group has had a chance to add to each list.
3. Discuss the words with the whole group.
What does each word make people feel? Do they make the women in the group feel differently from the men? What words are used more by men? Which are used more by women? If a woman uses these words, what do people think of her? What do they think of a man who uses the same words? Why? What words are the best to use in different situations? Why?
Gender messages in the media
If people understand how harmful ideas about womens sexuality and gender roles are learned, they can begin to think about how to change those ideas. This activity will help people think about how radio, movies, popular songs, and advertising communicate ideas about gender roles.
1. Listen to some popular songs on the radio (record them ahead of time if you have a tape recorder) or have members of the group sing (or act out) the songs. Listen carefully to what the words of the songs are saying about women and men. How are the women and men being described? Are these songs passing on ideas about womens roles and sexuality? Note each gender message the group identifies in the songs, and decide whether it is harmful or helpful to women.
2. Divide into small groups. Give each group an advertisement cut out of a magazine or newspaper, or copied from a billboard (pick advertisements that have women in them). Ask each group to identify what the advertisements say about womens roles and sexuality. Then, bring everyone together again to say what messages are being passed on in each advertisement. Then decide as a group whether the messages are harmful or helpful to women.
3. Discuss how messages about women are passed on by radio, songs, and advertisements. How do these ideas influence us, our husbands, our children? Do these ideas lead to practices and beliefs which are harmful to women?
4. Identify ideas about womens roles and sexuality that are important and helpful to pass on. How can these ideas be communicated in advertisements, songs, and movies? Ask small groups to draw an advertisement, or prepare a song or a skit that teaches helpful and healthy ideas about women. Have each group present their work to the others.
Gender roles are different in each community, and so are the difficulties women and men face when trying to improve their sexual health. Here is a way to begin a discussion about why it may be hard for women to practice safer sex in your community.
¨ To work for change in your community, it is important to identify the barriers to practicing safer sex.
1. Begin by telling a story, like Fmas story. Talk about Fma and Emanuel as if they lived in your community.
2. After telling the story, start a discussion with questions like, Why didnt Fma protect herself from AIDS? Do you think she realized that she could get AIDS? If no, why not?
3. Once the group has talked about the importance of understanding risk, you can talk about other barriers to safer sex. For example: What are the difficulties that women like Fma face if they try to practice safer sex? Why do women find it hard to talk with their partners about safer sex? What can women do to convince their partners to practice safer sex?
4. Talk about what can be done in your community to help women like Fma. Discuss how you can help to overcome barriers to safer sex in your community. End the discussion by making a plan to improve sexual health in your community.