On the basics of sex.

By Shaan Bajaj

A/N: In our original article, we had said that we were using women for simplicity even when including people of other genders with a uterus, which we realise was offensive, and we sincerely apologise to the trans community. We want this guide to be as inclusive as possible and to reiterate our support for people of all genders and orientations. What we meant was that the information here could be applicable for cis-gendered women, transwomen, transmen, and people of other genders with a uterus.

Despite the impact sexual and reproductive health has on our quality of life as uterus-bearers and/or people who identify as women, at some point we all have questions that we may feel too ashamed to ask, like, “Which side is the pad meant to stick to?” or, “Is it normal to experience pain during sex?” As we develop, many of us will experience menstruation, fertility, pregnancy, ageing and menopause. These stages are interconnected with our sexual and reproductive well-being, and thus affect our overall mental and physical health.

Understanding and navigating all the different aspects is overwhelming, and this is only amplified when you may live in a household where sex is still a taboo or not as discussed as it should be, even after marriage. Masala has put together a simple guide to the basics of sex and reproductive health so that we can answer the (sometimes literal) burning questions without you having to ask.

What is consent?
In a world where the definition of rape in India was only extended to marital rape in September of this year, defining consent is paramount.

Consent is about communicating what you are comfortable with, clearly and freely, before engaging in any type of sexual activity. Consent is also an ongoing conversation on physical boundaries and your comfort level during sexual activity, even after you’re already in a relationship, or married to someone. Consent should be verbally or enthusiastically given – the latter of which can be given through body language, smiling, eye contact, or nodding. If you are unsure, stop and communicate to check if your partner is still on the same page as you.

What does consent look like?
If someone asks whether they can kiss you and you say yes, you consent to being kissed. However, consenting to being kissed does not give the individual permission to remove your clothes. Each act requires further consent. Consent can also be revoked if you feel uncomfortable.

So, when can you not give consent?

• Children aged 14 and under cannot give consent according to Thailand’s age of consent, although ethically, most people consider any minor unable to give consent, especially to an adult
• When you are highly intoxicated or incapacitated by drugs or alcohol
• When you are asleep or unconscious
• When agreement is given under pressure, intimidation or threat
• If there is an unequal power dynamic

You can also say no or set boundaries by saying the following phrases:

• I really like you but I am not ready to have sex
• I need to stop, something does not feel right
• I have changed my mind and I would like to stop
• I would like to take things slower
• I like [activity], let’s stick to that

Understanding Your Sex Drive
Your sex drive/libido is your desire to have sex. Your sex drive can change according to where you are in life, mentally and physically – and can even increase as you approach middle age. Many different circumstances and factors impact your sex drive, including hormones, stress, and physical and mental health.

Your relationship with sex can even be shaped by your mentality, and experiences with your romantic partners, family, community and religion. If you are on any medication, these too can affect your libido. If you’re experiencing an abnormal change with your sex drive, speak to a healthcare professional. You do NOT have to have a sex drive at all, and this is also normal – you can be asexual or sex-averse, or may not have a high libido but not be averse to sex. There is a whole spectrum of human sexuality, and you should never feel pressure to fall on one end or another.

Safe Sex
Safe sexual practices can protect you from unwanted pregnancies or sexually transmissible infections (STIs). Condoms are a form of protection and barrier contraception, and are 98 percent effective in preventing pregnancy. Note that they do not protect against all STIs, and it is a myth that couples in long-term or exclusive relationships don’t use them, as many still do. There are male condoms and female condoms. To be cautious:

• Always use a new condom every time you have sex, even before switching between oral, vaginal or anal sex
• Check the expiry date
• Use water-based lubricants as other lubricants can damage the condom
• Get tested frequently

What Are STIs
STIs or sexually transmitted diseases (STDs) are usually caught during sexual contact, and are more common in sexually-active adults than you think, so it’s nothing to be ashamed of. Bacteria, parasites, or viruses may pass from person to person through blood, semen, or vaginal and other bodily fluids. The symptoms of STIs may not be obvious so you may not know you have one.

Some common symptoms include:

• Sores, bumps, or rashes on the genital and or oral area
• painful/burning sensation when peeing
• unusual or odorous vaginal discharge
• unusual vaginal bleeding
• experiencing pain during sex
• lower abdominal pain

See a doctor immediately if you are sexually active and may have been exposed to an STI or if you or a partner experience any of these symptoms. Alternatively, you can also visit a doctor if you plan to become sexually active.

Common STIs and how to prevent them
Although there are several different types of STIs, HPV, gonorrhea, chlamydia, and genital herpes are some of the most common (with chlamydia, gonorrhea, and hepatitis A, B, and C being the most common in Thailand). Lack of proper treatment can lead to cancer or fertility issues, but treatment of most common STIs is straightforward and often just involves a round of antibiotics, so don’t hesitate to talk to a professional if you have any symptoms.

Let’s talk about HPV
Although most people are not aware of it, the Human papillomavirus (HPV) is the most common STI in cisgender women. If you’re sexually active, regardless of whether you’re married or have only had one partner, there is a high chance you have been exposed to it – in fact, around 70 percent of sexually-active people will have been exposed in their lifetime. It can be transmitted through vaginal, anal, or oral sex, or by skin-to-skin contact, and some high-risk strains cause cervical cancer – in fact, in India, cervical cancer is the second most frequent cancer among cisgender women between 15-44 years of age. These risky strains can also cause mouth and throat cancer, and other, less risky strains of HPV can cause genital warts.

However, if you’re diagnosed with HPV, don’t worry – in 9 out of 10 cases, your body will resolve the infection by itself in 1-2 years. It’s advised that you get the HPV vaccine before you turn 25 (although you can still get the vaccine until the age of 45), in order to prevent yourself from getting the most high-risk strains of HPV. This is also the reason why Pap smears (a regular check-up by your OB-GYN) every three years are recommended for cisgender women over the age of 21, and every year if you’re over 30.

There is no completely accurate way to test for HPV in men, so even if their STI results have come out clean, they may still unknowingly transmit it – being diagnosed with HPV does not mean that you or your partner have been unfaithful, symptoms may simply have been dormant for years.

Other things you may not have been told as someone with female reproductive organs:

• Yeast infections and UTIs may have similar symptoms to an STI, but are very common and are easily treated. Make sure you know which one you have, as misdiagnosing and treating a UTI can cause or worsen a yeast infection.
• Yeast infections affect 3 out of 4 cisgender women, and are not an STI (although you can pass it on to your partner and vice versa). They can be caused by oral antibiotics, pregnancy, oral contraceptives, diabetes, changes in diet, or staying in your exercise clothes or wet bathing suits for too long, and can usually be treated by OTC anti-fungal medication
• Always pee after sex
• Cigarettes and a diet high in fat content and sugar can cause hormonal imbalances and affect vaginal flora
• Although the combined pill is the most effective form of contraception, it can also cause changes in your body, appetite, libido, and your long-term mood and outlook
• Genitalia will all look different, and this is very normal! Do not subscribe to sanitised versions of what we ‘should’ look like, from porn, art, partners, or elsewhere
• There is the equivalent of Viagra for cisgender women, but ones approved by the US’ FDA can only be used in premenopausal women
• Vaginismus, which is pain associated with having penetrative sex, affects up to 17 percent of cisgender women worldwide, 53 percent of whom are married (according to a study). This can be treated through pelvic floor exercises and by seeking the help of a sex therapist

Sexual dysfunction
If you are experiencing persistent problems with sex, such as difficulty reaching an orgasm, pain during intercourse, or even a sex drive that is unusual for you, you may be suffering from sexual dysfunction. Each case is different from another and it can be temporary or permanent.

These can occur when your hormones change drastically, for example, during or after pregnancy, or menopause. There can also be medical, psychological, or situational reasons behind experiencing sexual dysfunction, such as past trauma.

If you’re experiencing sexual dysfunction, there are many ways to treat your issues including medication, mechanical aids, sex therapy, behavioural treatments, or psychotherapy. There is nothing shameful about this, and you should contact your doctor or consider going to a sex therapist.

Where to go for women’s sexual and reproductive health check-ups:

• Pulse clinic
• The Women’s Health Center at Samitivej Hospital
• MedConsult
• Bumrungrad International Hospital (they’ve also unveiled their Pride Clinic to cater specifically for the LGBTQIA+ community).
• The Thai Red Cross anonymous clinic

What is menopause?
The stage when uterus-bearers stop receiving their menstruation refers to menopause, usually after a year of not receiving your period. As our ovaries age, they slowly stop producing reproductive hormones like oestrogen, testosterone, progesterone and folliclestimulating hormones. The average cis-woman in Thailand experiences menopause at the age of 48-50. Physical symptoms of menopause include hot flashes, night sweats, reduced libido, headaches and joint pain. They are also more prone to forgetfulness, moodiness and depression during menopause.

Here is how to reduce or prevent the symptoms of menopause:

• Exercise 20 to 30 minutes every day; this can help improve your mood and promote a better night’s sleep.
• Add calcium, vitamin D, and magnesium to your diet
• Use moisturising lotions to hydrate your skin
• To avoid hot flashes, dress in comfortable and airy clothing, and stay in cool surroundings or carry a portable fan with you
• Practice mindfulness by adding yoga or meditation to your daily routine
• Talk to your doctor about natural sleeping aids if you are experiencing trouble sleeping
• Seek professional help if you are experiencing depression, anxiety, sadness, isolation, or any other psychological struggles
• If you are experiencing severe symptoms that affect your quality of life, hormonal replacement therapy (HRT) might be a treatment route to consider with your doctor

DR. TANAYA NARENDRA (Instagram: @dr_cuterus), MBBS from Subharti Medical College and MSc in clinical embryology at University of Oxford, shares her five tips for everyone with a vagina:

1. If you wipe after peeing, always remember to wipe front to back (go from the direction of your vagina toward your butt, not the other way around). This way, you avoid bringing bacteria to the front near your urethra, preventing UTIs
2. Examine your breasts every month to know what feels normal, so if there is a change, you can find it
3. Get vaccinated against HPV and protect yourself from cervical cancer
4. Always use condoms, during oral, anal, or vaginal sex; this prevents STIs
5. It is normal for your inner thighs and vulva to be pigmented, it does not need to be treated

Educational information available online:
@dr_cuterus on Instagram & Youtube
@indiansextherapist on Instagram
@stella.menopause on Instagram
r/healthyhooha on Reddit