(introduction...)

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 women’s 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.

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Safer sex for sexual health

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 man’s semen, the liquid in a woman’s 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 man’s 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 woman’s past partners - or her partner’s 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 partner’s past partners.

Fma’s 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 Wilson’s 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 shouldn’t 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 man’s 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.

Figure

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...	Figure	try saying...
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 man’s 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. Figure Touching. Touching is always safe, as long as neither person has blood, discharge, or sores on the genitals or hands. Figure 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 man’s penis is covered with a condom before you take it into your mouth. Figure 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. Figure 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. Figure 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.

Making changes for safer sex

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:

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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.

Figure

¨ 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? Figure 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. Figure 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. Figure 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.

Feeling more pleasure from sex

Figure

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 man’s 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 woman’s 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 Figure

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.

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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. · she feels guilt or shame, or does not want to have sex. · she has an infection or growth in her vagina or lower belly. · she has been circumcised. Figure IMPORTANT Pain with sex after recent childbirth, miscarriage, or abortion can be a sign of serious infection. See a health worker right away.