Sexual Health

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Sex and sexuality are part of the human experience, but are often considered inappropriate or taboo subjects for discussion. When individuals are uncomfortable talking about these topics because of their cultural beliefs or because they fear judgment from their provider, it may pose challenges for providing sexual health services. Additionally, the sexual double standard in contemporary Western society tends to stigmatize women, but not men, who engage in multiple and/or premarital sexual relationships, which may cause female patients to have an increased fear of judgment (Milhausen and Herold 1999). This fear might be even more significant for those engaging in same-sex sexual relationships, due to the relative lack of understanding and acceptance of this type of sexual activity.

In addition, based on their cultural and individual values, people may have different beliefs about and interpretations of abstinence, virginity, sexual activity, birth control, and health. This may cause miscommunication between patient and provider (Hans & Kimberly 2011). For this reason, healthcare providers should first be aware of their own judgments and perceptions of sexual behaviors. Secondly, they should be prepared to inquire about the judgments and perceptions held by their patients. The information contained in this page is intended to guide the process of asking appropriate, open-minded questions.

Sexual Activity

For some, sexual activity is exclusively intended for reproductive purposes, while for others it may be motivated by their own pleasure or emotional or spiritual connection with their partner.

  • For example, in Judaism, a primary purpose of sexual intercourse is to reinforce the marital bond between husband and wife. Sexual activity is often encouraged even during times when conception is impossible (Rich 2011).
  • In many cultures and religions, sexual activity should only occur within the confines of marriage between a man and a woman.
  • As a result of past experience or the anticipation of judgment, LGBTQ2 individuals may approach a healthcare setting with greater anxiety and fear than heterosexual patients. This may lead to greater degrees of guardedness when discussing sexual health and activity (Association of Gay and Lesbian Psychiatrists 2012).
    • The American Psychological Association recommends the term ‘sexual orientation’ be used to describe a person’s enduring pattern of emotional, romantic, and/or sexual attractions to men, women, or both sexes. This terminology indicates that an individual’s sexual orientation is not a conscious, voluntary choice (APA 2008).
    • It is best not to assume a patient is heterosexual, especially while taking a sexual history. Incorrect assumptions may make trust-building more difficult (Sexual Medicine Society of North America, Inc. 2012).
    • While in the United States, distinct labels such as LGBTQ2 are commonly used to describe non-heterosexual individuals, research demonstrates that sexual orientation actually occurs along a continuum, from exclusively opposite-sex attraction to exclusively same-sex attraction (APA 2008). Be aware that even patients who identify as heterosexual may still engage in same-sex sexual activity.
  • To communicate respectfully about sexual issues with patients from different cultures, healthcare providers may find it useful to learn the culturally acceptable language to discuss them.
    • For instance, in Central American cultures, the term “tener relaciones” (having relations) is appropriate to refer to sexual activity, rather than the word “sexo”.
    • LGBTQ2 patients may prefer neutral sexual terminology, which can apply to lesbians and gay men, as well as heterosexual and bisexual women and men. For example, “When did you first engage in sexual activity?” is more inclusive than “When did you first have sexual intercourse?” (APA 1991).

Virginity

Virginity, especially female virginity, can have special significance in some cultures.

  • For instance, some societies not only prohibit premarital sex, but equate girls’ virginity with the honor and pride of the whole family and/or clan.
    • An intact hymen is often considered proof of virginity. A woman may be expected to bleed—caused by the tearing of the hymen—after having sexual intercourse for the first time.
      • However, the hymen can be damaged or torn without prior sexual intercourse. Potential causes may include physical activities including bicycle riding or gymnastics, tampon use, or pelvic examinations. In addition, not all women are born with hymens. This makes confirming virginity with a hymen “test” unreliable (Perlman et al. 2003).
    • In cultures where virginity until marriage is highly valued, premarital sexually active individuals may be hesitant to admit or discuss their sexual behavior and health.
      • Healthcare providers may be respectful of this by reiterating a commitment to confidentiality to their patients, and by being aware of family members present during an examination or consultation.
  • In some religions, including Catholicism and Buddhism, religious leaders are encouraged or expected to abstain from sexual intercourse in order to demonstrate commitment to their spiritual duties (Skudlarek 2008).

Female Genital Cutting/Circumcision

FGC is the common term for different types of surgical procedures which include partial or entire removal of the external female genital organs, for cultural or non-medical purposes. Previously, FGC was known as Female Genital Mutilation, though the naming convention has been widely changed to appear less judgmental and better correspond to the terminology used in many local languages. Female genital cutting is performed on girls and women of all ages, though the majority of procedures are performed before a girl reaches puberty (DHHS: Womens Health 2010).

  • FGC is performed across central Africa, the southern Sahara, and parts of the Middle East, though almost one half of women who have experienced genital cutting live in Egypt or Ethiopia. To a lesser degree, FGC also occurs in Indonesia, Malaysia, Pakistan, and India (DHHS: Womens Health 2010).
  • Sometimes, FGC is incorrectly attributed to Islam. Actually, the practice is not specific to any one religion or culture, and is generally condemned by political and religious authorities (DHHS: Womens Health 2010).
  • Female genital cutting is not common in the United States. However, within immigrant communities from regions where FGC is commonly practiced, it may occasionally occur. Female immigrants may also have undergone a FGC procedure in their home countries.
  • There are four types of FGC, according to the WHO classification (WHO 2008).
    • Type I– Partial or total removal of the clitoris and/or the prepuce. This may be referred to as “clitoridectomy”.
    • Type II– Partial or total removal of the clitoris and the labia minora, and/or excision of the labia majora.
    • Type III– Partial or total excision of the external genitaIia, and sealing of the vaginal orifice (to various degrees).
    • Type IV– Other harmful procedures done without medical purpose to the genital organ, which includes stretching, piercing, pricking, scraping, incising or cauterization.
  • Women who have had the vaginal orifice sealed shut (Type III) may seek medical care for defibulation or opening prior to sexual intercourse or giving birth. In cases where the woman is not defibulated before her first intercourse, there is the potential for added trauma to the genital region (Horowitz and Jackson 1997).
  • Though reasons for FGC vary by community, they are likely to include (DHHS: Womens Health 2010):
    • The continuance of cultural/ethnic tradition
    • Preserving “honor” and “purity” by limiting sexual desire
    • Preparing a girl for entry into womanhood, marriage, and sexual debut
    • Perceived health benefits
  • When treating female patients who have undergone FGC, it is important to be open and sensitive to a variety of opinions, values, and experiences. Despite the widespread condemnation of the practice, especially in the West, this is a procedure encouraged and practiced by many cultures, and patients and providers may have different perspectives on the issue. It is important to ask rather than assume how a patient feels about this practice and their own experience.
    • For some women, undergoing an FGC procedure may have been traumatic. As a result, subsequent gynecological examinations or procedures may be mentally and/or physically challenging and require awareness and care from the provider.
    • On the other hand, some women may consider FGC a completely normal or even favorable practice, for the purposes of marriage, chastity, aesthetics, or maintenance of cultural standards. For them, their own circumcision may be a non-issue or a point of pride (Horowitz and Jackson 1997).
  • For more information on this topic, including recommendations for communicating with and treating circumcised women, visit: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497147/.

Rape

Rape is one of the most complex issues in the medical, social, legal, political, and psychological fields. Rape has been used throughout history as a tool of warfare, oppression and intimidation. It has only recently been discussed as a legal matter in many countries of the world, and some still do not have the proper legal, medical or social systems in place to address criminal rape.

  • Rape and sexual assault is one of the most underreported crimes. In the United States, 54% of sexual assaults are not reported to the authorities. This suggests that only 3% of rapists ever serve a day in jail for their crime (RAINN 2009).
  • Social and historical depictions of rape commonly portray it as an assault by a stranger on a young, chaste girl or woman. However, 60% of rape or sexual assault victims report that they were assaulted by an intimate partner, relative, friend or acquaintance (National Institute of Justice 2010).
    • This inaccurate portrayal of what rape “looks like” has skewed perceptions of rape, and therefore, access to care and support for survivors. For example, in Costa Rica, Ecuador and Guatemala, if a woman who is not “chaste and honest” is raped, the incident is not legally recognized as rape (Heise et al. 1993).
    • This particular illustration of rape assumes a man is always the offender, and a woman is always the victim.
      • In fact, in the United States, about 10% of sexual assault victims are male.
      • Male survivors may be less likely to seek help, for fear of stigma or blame. They may fear being thought of as weak or “less of a man,” or be confused if they became physically aroused during an attack. Not all survivors will react in the same way; a range of reactions is normal (RAINN 2009).
  • There is the same chance of pregnancy as a result of rape as there is from one act of consensual sexual intercourse. Research places this rate of pregnancy somewhere between 3.1% and 5% (Wilcox et al. 2001; Holmes et al. 1996).
  • Sexual assault is detrimental to mental as well as physical health. WHO data indicates that victims of sexual assault are (RAINN 2009):
    • 3 times more likely to suffer from depression.
    • 6 times more likely to suffer from post-traumatic stress disorder.
    • 13 times more likely to abuse alcohol.
    • 26 times more likely to abuse drugs.
    • 4 times more likely to contemplate suicide.
  • Healthcare providers should understand that survivors of sexual assault may experience difficulty with gynecologic examinations or procedures, and may present as hesitant, unwilling, or unusually uncomfortable. It is also possible for patients to have trauma-like responses to gynecologic care. These may include overwhelming emotions, intrusive or unwanted thoughts, memories, body memories, and feelings of detachment from their bodies (Robohm and Buttenheim 1997).

Contraception

Contraception is a controversial topic, here in the United States as well as in many other societies. Reasons for this include the fact that birth control interferes with natural reproduction and might imply sexual activity outside of marriage and/or with multiple partners. Despite this, roughly 99% of women ages 15-44 in the United States have used a contraceptive method other than natural family planning at some point, in order to prevent and/or plan the timing of pregnancy (Guttmacher Institute 2012).

  • In the United States, commonly used contraceptive measures include (Planned Parenthood 2012):
    • Male and female condoms
    • Oral contraceptives (“the pill”)
    • Hormonal patch, injection, implant, or vaginal ring
    • Intrauterine devices (IUDs)
    • Sterilization
  • Among American women who use birth control, the majority use the pill (28%), followed by tubal sterilization (27%) and the condom (16%). However, these numbers vary by social and ethnic group (Mosher and Jones 2010).
  • Some women may take hormonal birth control for non-contraceptive reasons, including treatment of excessive menstrual bleeding, menstrual pain and acne. This is especially common among adolescent women, who may or may not be sexually active(Jones 2011).
  • Certain religions do not condone the use of contraceptives.
    • However, many women and families make a personal decision to use contraception despite belonging to religions that officially prohibit it. This highlights the importance of respecting patients’ individual preference as well as religious denomination (Jones and Dreweke 2011).
  • In communities where contraceptive use is unacceptable, stigmatized, or unavailable, individuals may not be able to choose or negotiate contraceptive use.
  • In some cultures, women may use traditional herbal contraceptives that may or may not be effective and/or may have potent health effects.
  • Women who historically have been unable to have full control over their fertility because of anti-natalist or pro-natalist policies/practices/pressures may be suspicious of contraceptives.

Glossary:

Anti-natalism: Anti-natalism is a form of population control that includes policies, practices, and other pressures to discourage childbirth to reduce the fertility and thus the population size of a community. Historically in the U.S., antinatalism was an expression of racism and xenophobia, and has disproportionately affected specific communities, including Native Americans and Puerto Ricans. The “one-child policy” in China is also a form of anti-natalism. Anti-natalism can include forced contraceptive use, sterilization, or abortions, denying women (and men) the control over the conditions in which they reproduce and the size of their families.

Pro-natalism: Pro-natalism is a form of population control that includes policies, practices, and other pressures to encourage childbirth to increase the fertility and thus the population size of a community. Pro-natalism may include denial of contraceptives and access to abortion, forcing women to give birth and denying them (and men) to control the conditions in which they reproduce and the size of their families.

Sexually Transmitted Infections

Sexually transmitted infections or diseases (STIs or STDs) are often considered a taboo topic. The secrecy and embarrassment surrounding STIs has created a disinclination for many patients to seek regular testing and treatment when necessary. It has also contributed to a lack of widely available, correct, and comprehensive information and resources. Additionally, because STIs often do not display symptoms, many individuals remain undiagnosed and untreated. As a result, infections are inevitably spread. Culturally sensitive communication around these infections as well as proper education about their etiology and transmission should therefore be a part of all preventative, primary, and secondary health promotion programs/plans.

  • Common STIs include (Reproductive Health Technologies Project 2012):
    • Human Papilloma Virus (HPV)
      • More than half of sexually active men and women will acquire HPV at some point in their lives.
      • 6.2 million cases are diagnosed in the United States each year.
      • Some strains of the virus are linked to cervical cancer.
    • Chlamydia
      • There are 2.8 million new cases diagnosed each year, making chlamydia the most common bacterial STI.
      • During 2006-2010, chlamydia rates increased by 26.9% among blacks, 4.9% among American Indians/Alaska Natives, 11.0% among Hispanics, 23.7% among Asians/Pacific Islanders, and 25.3% among whites (CDC STD Surveillance 2010).
      • The chlamydia rate among black men was almost 11 times the rate among white men (761.8 and 69.9 cases per 100,000, respectively) (CDC STD Surveillance 2010).
      • As many as 75% chlamydia infections in women are asymptomatic. When left untreated, it can develop into Pelvic Inflammatory Disease (PID), which may cause long term damage such as infertility.
    • Genital Herpes
      • An estimated 45 million people in the United States are infected with genital herpes.
      • Women are more susceptible to the herpes virus than men; one out of every four women over the age of 12 in the United States is infected.
      • Herpes increases a person’s susceptibility to HIV.
    • Gonorrhea
      • There are approximately 718,000 new cases of gonorrhea reported each year.
      • In 2010, 69% of all reported cases of gonorrhea occurred among blacks (CDC STD Surveillance 2010).
      • Gonorrhea rates among racial/ethnic minority groups are considerably higher than the rate for whites.
    • Syphilis
      • Syphilis is a bacterial STI that affects approximately 32,000 people each year in the United States.
      • This STI has experienced ups and downs in prevalence in the last few decades. A 1980s epidemic occurred predominantly among heterosexual men. In the 1990s, incidence rates decreased among all racial and ethnic groups. During 2006-2010, syphilis rates rose again, among all groups except American Indians/Alaska Natives (CDC STD Surveillance 2010).
      • In 2006, 64% of the reported cases of Syphilis cases were among men who have sex with men (MSM) (CDC Syphilis MSM 2008).
    • Trichomoniasis
      • Trichomoniasis is a parasite that affects approximately 7.4 million new people each year.
      • It is often asymptomatic, especially among men.
  • For further information regarding STIs and their symptoms, please visit the Center for Disease Control’s online Fact Sheets at http://www.cdc.gov/STD/.
  • Around 19 million new STI cases are reported in the United States each year. Young people, women, and racial and ethnic minorities are disproportionately affected.
    • While men and women aged 15-24 are 25% of the sexually experienced population, they account for nearly half of new STI cases (Guttmacher Institute 2008).
    • Anatomical differences put women at a greater risk for infection than men. The surface area of the vagina and cervix is considerably larger compared to the area of the penis where transmission can occur. Because the vagina is warm and moist, it is also an ideal location for bacteria to grow (Sheth and Thorndycraft 2009).
    • Adolescent women are particularly susceptible due to the prevalence of cervical ectopy, where the vulnerable cells that line the inside of the cervix extend to the outer surface. (FHI 360 2012).
  • Sexual health is important across the life span: adolescence, adulthood, and older age. STIs can be transmitted between same and different sex partners of all ages. Because elders and same-sex partners have diminished or no reproductive capabilities, there may be a misconception among them and providers that they cannot transmit and contract STIs, and as such do not need to use barrier contraceptive methods or STI testing.
    • Condom non-use among sexually active men who are neither married nor cohabiting substantially increases with age:

HIV/AIDS

HIV/AIDS is the most serious and fatal type of STI, and is often stigmatized or considered shameful. Secrecy about infection status and misconceptions complicate transmission prevention and adequate treatment of those who are HIV positive and/or have AIDS.

  • Approximately 50,000 individuals are newly infected with HIV in the United States each year. (CDC 2012). Worldwide, there were about 2.7 million new cases in 2010 (UNAIDS 2011).
    • Globally, sub-Saharan Africa is the region most affected by HIV/AIDS (UNAIDS 2011).
    • In the United States, there has been a recent and significant increase in new infections among young, African American men who have sex with men (CDC 2012).
  • Stigma occurs when others “devalue a person or a group of people because they are associated with a certain disease, behavior or practice.” Individuals who are stigmatized, including for HIV/AIDS, are likely to also experience discrimination within their communities (International Center for Research on Women 2012).
    • Some of the stigma of HIV/AIDS derives from the assumption of immorality on the part of the infected individual, and the belief that a person became infected because they chose to engage in risky (particularly sexual) behaviors (International Center for Research on Women 2012).
    • Misconceptions about how HIV is transmitted also contribute to the stigma surrounding the disease. Though transmission only occurs through the exchange of certain bodily fluids, including blood, semen, vaginal secretions, and breast milk, a lack of information may lead some individuals to fear day-to-day contact with those who are HIV positive (WHO 2012). This may cause a feeling of isolation for HIV-positive individuals.
  • Historically, this disease has been associated with homosexual activity and gay men. While men who have sex with men are at an increased risk for infection, women and heterosexual individuals also make up a large proportion of cases.
    • More than half of all people living with HIV/AIDS in the world are female.
      • Women are biologically more vulnerable to sexually transmitted infections, including HIV.
      • Social expectations, especially regarding relationships, may limit women’s ability to control their sexual lives and protect themselves from transmission (International Center for Research on Women 2012).
  • HIV-positive parents may face additional emotional and psychological challenges.
    • Mother-to-child transmission (also known as ‘vertical transmission’) can occur during pregnancy, labor, delivery, or breastfeeding. In the absence of any interventions, the likelihood of an HIV-positive mother transmitting the virus to her child ranges from 15-45%. However, with effective interventions, the risk can decrease to less than 5% (WHO 2012).
    • Concerns about disclosure, testing of children, and adherence to rigid treatment regimens may add to the usual stresses and demands of motherhood.
    • However, parenting may also provide an HIV-positive individual with a sense of purpose, social support, and a reason to live and fight their infection (Pereira et al. 2011).
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