How Safe is Your Sexual Health?

- Anju Chhetri

Sadhana was brought up in an urban environment; however, she had to marry in just 16 years of age due to some household problems. In a short span of time, she became mother of two children who are now 15-16 years old. Sadhana has been mentally and physically suffering from a sexual health problem for many years. Her problem is - a pain in the abdomen. A senior gynecologist of Kathmandu has diagnosed that the pain in her abdomen is caused by the swelling in her uterus, and given her a medicine which shrinks the uterus swelling. She has been taking the medicine prescribed by the doctor for a long time. The doctor has also counseled her to keep control in sexual relations with her husband. But the control in her sexual life has not occurred as expected.

In fact, it's Sadhana's husband who is not being able to control his sexual desire. Moreover, understanding Sadhana's problem, he is not cooperating with her. Sadhana explains her problem, "When I abstain from sex for some time, the pain disappears, but it starts right after having sex. Consequently, whenever my husband wants to have physical relation, I immediately get mental tension, and that tension remains in me quite a long time. I anticipate that my pain will start again. These days, a lot of blood clots overflow during my periods. And I'm scared that there might be a great injury inside my body. The doctor has said to examine me through video x-ray. But because of my family problems, I'm not being able to go to Kathmandu to visit the doctor right now."

The problem of Sadhana is one of the many problems regarding sexual health. The problems like that of Sadhana and many other kinds of sexual health problems have been seen among many married women of Nepal in increasing proportion. If a middle-class, educated and urban woman like Sadhana is not being able to solve her problem as she wishes, then imagine about the millions of Sadhanas who live in rural areas, start to bear tough household burdens of marital life in just 14-15 years of age, and become mother very early. They also feel the lack of a confidante who could listen and understand the problems of their mind and body. Very few of them are resourceful to go to visit a doctor for consulting their problems.

This article discusses on what type of sexual health problems many more Sadhanas of Nepal are suffering from; what causes are responsible for such problems; how a woman's sexuality is linked to her sexual health; what type of relation exists between a woman's general health and her sexual health, and what sexual health is meant by itself; what problems are included in the realm of sexual health; what things are to be considered to keep sexual health fit and normal. As it is still very difficult to make general people understand, in a few lines, what human sexuality is, in the same manner, it is very hard to make them understand what sexual health is, defining it in a few sentences. Therefore, it is appropriate to start by how the three doctors having interest in studying women's sexuality view or define sexual health.

Explaining sexual health, expert in child psychology Dr. Karuna Onta says, "Sexual health does not include the things related to sexual intercourse only. The word health denotes both physical and mental fitness. Therefore, for a healthy sexual relation, there must be mental fitness together with physical fitness. We can say a woman is in a good and healthy condition regarding her sexuality only in that condition when she is gratified from sex, or when she does not feel physical and mental pain from sexual relations, and feels the satisfaction and pleasure herself and of her partner. In this situation, I consider the woman's sexual health is in a good condition."

Woman activist Dr. Aruna Upreti says, "When we speak about sexual health, we should not confine it to the situation formed after a man and a woman get married and involve in sex, because sexual health problems begin in men and women when they are adolescents. If we don't have proper knowledge about the sexual symptoms appearing from adolescent age, such ignorance might become sexual health problems in later life. Adolescents considering common and natural sexual processes taking place during adolescent ages as great problems might suffer mentally. In the same manner, talking about sexual health during marital life, if a woman gets pleasure form sex with her husband, we should consider that she is mentally and physically in a good condition. But if she feels physical and mental pain from sexual relations with her husband, we should consider her sexual health is in a bad condition."

Similarly, Dr. Sharad Onta, who is interested in studying women's sexual health, says, "We call a person healthy, when she lives an active life without having any kind of inferiority complex in family and society, being free socially and economically. By the same token, if a woman is spending her sexual life in her family and society without taking any kind of physical and mental pain, regret and inferiority feeling, we should consider that her sexual health is in a good condition."

Sexual health in research papers is defined in brief as "the indication of such a condition in which we are physically and emotionally healthy and fit, and feeling pleasure and happiness from our sexual feelings and act."

The above mentioned doctors think that everyone should care for women's sexual health, and appropriate information about it should be disseminated adequately. Keeping in mind the perspective of these doctors, in order to analyze women's sexual health, it should be viewed splitting it into two stages: sexual health before marriage and sexual health during marriage. Pre-marital sexual health indicates the mental and physical sex-related problems appearing among adolescents or youths when they are unable to understand the sexual processes and physical changes taking place with their growing age, and when they consider such processes and changes as problems. Likewise, marital sexual health problems indicate the physical and mental problems that arise after women get involved in sexual relations with their husbands.

Sexual Health in Marital Life

To find out what types of sexual health problems exist among the married women, we just have gynecologists, dermatologists, and psychiatrists as resource persons. Because authentic statistics are not available on this matter in Nepal till date. Senior gynecologist Dr. Bhola Rijal says on this matter, "I see extreme urgency of studying women's sexual health problems in Nepal. I have made a draft for the study. Fifty per cent of the women who come to my clinic says, 'Doctor sahib, I don't have any interest in sex. What should I do?' And most of them already have one child. I take every kind of examination of the women who come here with such problems. For example, I examine that whether they are suffering from some kind of infections, whether they are scared that they might conceive again, whether they feel pain in sexual act, and whether it is all due to the insensitive behavior of their partners. One of these reasons exists in most of the cases. In some cases, however, none of these reasons exists. In such cases, I refer them to a related specialist."

Women's sexual health bears a great importance for a successful marital and family life. Women need responsible sexual behavior from their husbands to keep their sexual health in a good condition. The allegation made by informal studies and women activists focuses on one point. The point asserts that one of the main causes of the bad condition of women's sexual health is the irresponsible sexual behavior of their husbands. Therefore, nowadays, any program intended to improve women's reproductive health also includes men along with women. In such programs, men's sexual behavior is discussed, though in suppressed voice.

There is no doubt that our society is male-dominated. As men are socially and legally endowed with more rights and mobility, women are not. Due to this reason, men have full control over women's sexuality. Though women's sexuality is calm and sensitive, it is in danger because they have to bear the burden of sexual relations, even though their body and mind are not in the condition to bear the burden. Sadhana is a vital example in this regard. Therefore, women's sexual problems occurring with physical pain create such a condition in which women have to go through mental sufferings also.

Sexual Health Measures

The experts in medical sector and women activists view women's sexual health problems dividing them into physical and mental categories. They have also set some criteria to measure these problems. Confined to those criteria, women's sexual health is observed here in brief.

Unwanted Pregnancy

Obstetrician and gynecologist Dr. Kanti Giri, when she was working in the sector of women's reproductive health, obviously saw that the trend of unwanted pregnancy is very high. How does unwanted pregnancy occur? How is women's sexual health related to unwanted pregnancy? Such questions arise here. It is seen from case studies that most of the rural women of Nepal are not being able to use contraceptive methods. Similarly, they are also not being able make their sexual life safe and well managed. Therefore, whenever they have to involve in sex with their husbands, they suffer from a single fear that what to do if they become pregnant.

In this way, instead of realizing pleasure during sexual intercourse a woman has to remain in disturbing state mentally, and if she conceives, the mental disturbance worsens more. Because, on the one hand, she becomes worried by the problems that arise after giving birth to a baby and nurturing of the baby; on the other hand, she becomes worried anticipating the physical pains she has to bear if she goes for abortion. Remarkably, since abortion is illegal, rural women are compelled to carry out unsafe abortion secretly. Thus, there is a risk of loosing life, and also a risk of infections in reproductive organs, by which every sexual act might become painful for her in later years.

An important thing is linked here. If sexual behavior of husbands is responsible and cooperative, women do not have to face the problem of unwanted pregnancy or abortion. Therefore, every married couple, when gets a chance to involve in sex, must create the environment which fully assures them that the problem of pregnancy won't occur. If such things are managed, women can experience sexual pleasure from sex, their sexual health becomes healthy, and seeing the respect shown to their sexuality gives them self-satisfaction.

Women activists opine that the haphazard use of contraceptives has also been a main factor in degrading women's sexual health. But Dr. Kanti Giri does not readily accept this notion. According to her, contraceptives were invented none for other purposes than to obstruct unwanted pregnancy. Likewise, Dr. Karuna Onta also says, "The contraceptives have been invented for the purpose of preventing unwanted pregnancy resulting from the sexual activity between a man and a woman so that they could enjoy sexual pleasure."

Dr. Onta says further, "Sometimes, after the use of a contraceptive, some hormonal irregularities may take place in women's body, and they may face difficulties in sexual intercourse and acquiring sexual gratification. But there is no truth in the notion that contraceptives worsen women's sexual health."

Contraceptives have always been a matter of debate among women activists and medical practitioners of the related field. One of the causes behind this is that except the temporary contraceptive condom used by men, all of the contraceptives have been invented to be used on women's body. We know about many studies which assert that contraceptives have been indiscriminately used on women's body, and women are facing many side effects on their body due to those contraceptives. Similarly, women also raise the issues like men do not want to involve in sex using condom. Sometimes, women's sexual health also becomes a part of such controversial issues.

But, making the final judgment about the use of contraceptives should be given to the women who desperately need a contraceptive, or who are using a contraceptive. Whether they give more importance to the problems caused by the use of a contraceptive or they want to stop unwanted pregnancy? Let's decide them. In governmental statistics, it is shown that whereas 98 per cent of married women of Nepal are informed about at least one contraceptive method, only 29 per cent are using it. The reason behind the less number of women using contraceptive may be that adequate contraceptives are not disseminated among them. Whatsoever, women probably want to use a contraceptive because they still have to struggle more to acquire the capacity to change the sexual behavior of men.

Sexually Transmitted Diseases (STDs) have a direct relationship with sexual health. STDs are very infectious, and they may be infected from men to women and vice versa. STDs in men's physical organs can be detected immediately, but cannot be detected immediately in women's body. Because women's sex organs are naturally made in such a way that STDs cannot be detected in them on the onset, unless the effect of an infection becomes externally visible.

Sexual relation is the main cause for the infection of STDs. According to the effects and categories, there are 30-35 types of STDs. However, there are just 10-15 types of STDs found in general. Some of the major STDs are: gonorrhea, syphilis, sangphoid, granuloma inguinal, lympho granuloma venerium, non-gonococal utheritis, harpies genetalis, venereal or genital wart, clamidia, urea plasma, and urealitic. Besides these diseases, the relatively new fatal disease AIDS is also viewed within the bounds of STDs. Dr. Subodh Pokharel of the Sexologist Doctors Clinic says, "Women do not come to the clinic on their own to consult their problems. In the seventy-five per cent of cases, their husbands come here for counseling on their problems. They bring their wife only after they are told that for their problems we have to examine their wives also." According to the experience of doctors, people suffering form STDs do not go to doctors' clinics unless the problem becomes traumatic and very painful.

If women have STDs, white discharge flows from their sex organs. A kind of bad smell comes from their sex organs. They feel pain during sexual intercourse. If STDs are not treated in time, they may increase the possibility of sterility in the infected women. Naturally, because of the body structure, the germs of diseases get more chance to spread in women than in men. Therefore, women suffer more from STDs than men.

Among the STDs affected men and women of Nepal, there is no statistics available on which group is more infected. But a concept has been raised strongly. And that states, the main carrier of importing STDs among the married women has been their own husband. For that reason, women have felt that there is a need of healthy sexual behavior and cooperation from their men in order to keep their sexual health in a good condition.

Sexual Exploitation

If a woman becomes the victim of sexual exploitation during her childhood or adolescence, she won't ever be mentally capable to involve in sex as normal. Likewise, the women who bear painful sexual intercourse forcefully by their husbands in the initial days of their marriage also cannot involve in sex with their husbands both mentally and physically. Sex always becomes a painful experience for such women.

We are not in the condition to say definitely that because of sexual exploitation how many per cent of women's sexual health has been or is in a bad condition. Because, first of all, any woman cannot easily claim, "I've been sexually exploited". Even when she feels that she has been exploited from her own husband, the situation becomes more complex. Other mental problems also appear in the women who are going through such problems.

Many married women who go to gynecologists' clinics express that they have intense dislike for sex. A question often comes in their mind, they are whether being sexually exploited through the sexual behavior of their husband. It seems that this is affecting their mental health more than their physical health. In such situation, thinking that a doctor is the best person who understands their problem, they go to a doctor and say, "When my husband comes close to me, I think of kicking him out."

Dr. Karuna Onta says on this regard, "Though a husband and a wife engage in sex, but in our society, it seems that they don't talk and discuss on this matter. I think, husbands surely want their wives to acquire pleasure and happiness from sex. But they may not know what and how to do it. The society cannot digest the talk on this matter. So how to seek the solution to the problem? I'm not being able find out the answer."

It has been considered that there is more sexual exploitation within marital life. Sexual exploitation within marital life has been pointed out as one of the main components in the violence against women. It has been a crucial issue in the discussions among women activists. Though this issue directly related to women's mental sexual health has been much publicized, finding a solution to it still seems far away.

Dr. Bhola Rijal says, "The sexual health of Nepali women can be improved to some degree, if they pay attention in the cleanliness of their sex organs." Infections occur in women mostly due to the lack of cleanliness. This problem is equally seen in both married and unmarried women groups. This problem is not found more among the educated urban women. Because in this group, the trend of using sanitary towel is increasing, and even while using a piece of cloth, they have become very aware about cleanliness.

However, there is a great lack of cleanliness among simply literate and lower middle-class women. Due to that reason infection is very much prevalent among this group. The behavior of not washing the cloth used during menstruation properly and not drying them in the sun has created the problem of cleanliness. Similarly, the behavior of using underwear but not paying attention for its cleanliness has also created problem. Because of the infection also, married women suffer from the problems like severe pain and bleeding during sexual intercourse with their husbands.

Very different from the above factors, another factor is - our family environment. The burden of household chores is extremely heavy on the general women of Nepal. Because of physical exhaustion and responsibilities, the women have very little time to think about themselves. Besides, they do not pay much attention to their diet. In such situation also, when they have to be active in sex, probably they won't feel sexual pleasure. Therefore, Dr. Bhola Rijal says, "In our society, in the life of many married women, sex is a mechanical act occurring between a husband and a wife during bedtime just like someone taking regular meal day and night. Thus, I see that sex has become a hazard for women."

The problem of uterus prolapse, which has direct relationship with women's maternal health, has also been a major sexual health problem that is molesting a large group of Nepali women. Due to this problem, found particularly among the illiterate women of rural areas, the women have to bear sexual life painfully. Because of the lack of right information about this problem, the rural women think this as a natural problem which every married woman must bear. But this problem does not occur naturally; it appears due to social reasons. Getting married in younger ages, picking up heavy load during pregnancy, giving birth to a baby each year, not getting health facility in the right time are the causes behind this problem. And more distressing truth is that husbands force their wives to involve in sex, even though they see the uterus popping out. The women of illiterate and economically weaker family are facing this problem much more.

It has become very imperative that the young women, who are entering adolescent stage from childhood, get knowledge about sexual health. Especially in urban areas, the media presents sex in such a glamorous way that it creates so much curiosity towards sex among the younger women from the very low age. Healthy informative materials that resolve their curiosity are not available anywhere. Therefore, due to the ignorance about their physical changes and sexual feelings, which come according to age-growth during adolescence, the cases of being victim of mental tension reach doctors' clinics.

It is important for women to understand and make others to understand about the development of external physical organs and internal sexual feelings during adolescent and youth stages. Dr. Karuna Onta says, "The media has opened many things about sex in front of the youths. But the family and society are not trying to understand their feelings and problems." Though the voice has been raised among the large section of intellectual group to start sex education, yet there is a lot of debates on what kind of sex education and how to give it.

The international concept about adolescent and youth stages represents a very little group of people in case of Nepal. Because majority of the population of Nepal lives in villages. The number of girls going to school is also less. Even today, adolescent Nepali girls have to bound in marital ties before they reach the age of puberty. Their sexual life already starts. Even many of them become mother. Their sexual health problems already take new turn.

Showing this picture, the sexual health problems of adolescents and youths of urban areas should not be minimized. Education and awareness have made them conscious about the healthy sexual contact, the right age and ethical limits for sexual contact, but because of the lack of materials, which resolve their sexual problems and inform them, they often fall prey to the materials that give them unscientific and unhealthy information. Therefore, there is much confusion on how to fight the sexual health problems resulted form misunderstanding sexual feelings and the lack of cleanliness. This has also created many sexual health problems among them.

Sexual Health and Sexuality

Sexual health also has direct link with the general health of men and women. If a person's general health is not in a good condition, her sexual health also cannot be in a good condition. Therefore, sexual health should also be included as a component in general health. If there are deficiencies in men's general health, they become unable to involve in sex. But, since this article focuses on women's sexual health only, it does not discuss about men and the relation between their general health and sexual health. Sexual health also belongs to a component of women's reproductive health. To improve women's reproductive health, both governmental and non-governmental sectors are very active, but very little signs of improvement in the situation are seen.

Though sexual health problems appear right from the beginning of adolescence, it is particularly seen just relating it to sexual intercourse. The reason of viewing sexual health linking it merely to sexual intercourse is probably because it is considered that most of the people are sexually active. Likewise, the other reason is that mostly married women visit doctors' clinics taking their sexual health problems. Though the married women go to doctors' clinics to seek the solution to their reproductive health problems and their unwillingness in sexual relations; during investigation, their problems are found to have link with their sexual health.

In Nepal, the sexuality of the people in their adolescent and youth stages was not discussed until a few years back. Because there was such a notion that first a girl then an adult woman. Only after the Cairo Convention of 1994, the concept of adolescent and youth stages has come forth. Additionally, in urban areas due to education, the marriageable age has been increasing. On the other hand, because of the spread of media the issue of sex has come into open from closed rooms, and become a subject of intellectual discussions as well as a thing of entertainment. This has created curiosity about sex among adolescents.

In case of Nepal, viewing sexual health of adolescents or youths and women's sexual health separately, what should be considered is that sometimes both groups fall in the same category. On the basis of international measures, the ages from 15 to 19 years are considered adolescent ages. The process of physical development in adolescent women is attached to this age group. But in case of Nepal, in the population of this age group 4.7 per cent get married, in which 19 per cent become mother of one child.

Therefore, only men cannot be blamed for the worsening condition of women's sexual health. Family and society are also equally responsible. Family and society marry daughters before they reach marriageable age. They become mothers before they reach proper age. Since contraceptives have not adequately reached rural areas, the process of bearing children shortly is still the same. Accordingly, bearing many children, having unwanted pregnancy, executing unsafe abortion, suffering by the problem of uterus prolapse, getting infections from uncleanness due to the lack of awareness, being infected by the STDs carried from husbands, and bearing irresponsible behavior of husbands, women's sexual health is in degrading condition.

It has been imperative to discuss on these aspects of women's sexual health. The experts and medical practitioners of the related field accept the fact that this problem has unknowingly taken a serious form. Dr. Bhola Rijal says on this regard, "If a qualitative study is done on this matter, the programs to fight these problems can be designed. We don't even have necessary bases and statistics to evaluate the exact nature of the problem now. We are talking merely according to the cases coming to our clinics."

Women's sexual health should be included as a critical issue in their sexuality. As women's sexuality has become abstract, so are the factors of their sexual health. The general women have problems, but they feel difficulty to express them. Intellectual group is informed about the depth of the problem, but they have reluctance, shyness, fear and hesitation to address it. Hari Khanal of the Family Plan Organization says, "We are trying to raise the crucial issues of women's sexuality in the areas where we are launching our programs. But it has been very difficult to make women speak out on this matter. Because of our social taboos, we are not being able to conduct our programs directly addressing women's sexuality."

Why this problem occurs is because to execute the program addressing women's sexual health directly related to women's sexuality, we have to talk against the strong pillars and values of the society. Women have to be asked what happens inside their bedroom. Men have to be persuaded what they should think about while having sexual contact with their wife. Likewise, complicated ideas like the power relation between men and women, gender discrimination, women's empowerment, the need of women's decisive role in sexual activity have to be discussed. Of course, all these are not easy tasks. Besides, other things that make women's sexual health fit, uncomplicated, humane, and natural have to be find out. For this, aware women have to conduct a widespread campaign. And, if men, family and society help the campaign taking it positively, the sexual relation between men and women will take a new turn.

Asmita, Vol. 13, No. 56, Pp. 32-39

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