The Diverse Aspects of Sexual Health

Sometimes, depending on age and maybe mood, it does seem like sex is an overrated subject. However, according to the experts, sex is the driving factor of human lives. Great sexual health is a positive force that enhances other dimensions of one’s life, it being fundamental to the overall health and well-being of individuals, couples, and families.

Anyway, having great sexual health will always take you far, while loss of libido and other sexual health problems is sure to keep you awake at nights. There are many aspects of sexual health; aside from issues like sexual expression, sexual pleasure, relationships, and sexual orientation and gender identity, there can also be negative conditions like sexual dysfunction, sexual violence, unplanned pregnancy and abortion, reproductive tract infections (RTIs), sexually transmitted infections (STIs), infections with human immunodeficiency virus (HIV), and female genital mutilation.

Female genital mutilation (FGM)
Female genital mutilation (FGM) involves medically uncalled for removal of external female genitalia or other injury to the female genital organs, with mostly traditional practitioners doing the procedure. Usually, it involves young girls between infancy and age 15, and evidence shows that there is now greater involvement of healthcare providers in the practice (known as medicalization). No health benefits are known with the practice, and it can cause severe bleeding and urination problems, and later cysts, infections, and complications in childbirth. According to WHO data, FGM is practiced in about 30 African, Middle Eastern, and Asian countries, where it is considered a cultural tradition.

The four types of female genital mutilation are: 1. Partial or total removal of the clitoral glans (the most sensitive area of the clitoris), and/or partial or total removal of the prepuce/ clitoral hood; 2. Partial/total removal of the clitoral glans and the labia minora; 3. narrowing the vaginal opening by creating a covering seal (infibulation), formed by cutting and repositioning the labia minora or labia majora; and 4. other medically unnecessary procedures to the female genitalia like pricking, piercing, incising, scraping, and cauterizing the genital area. While there are no health benefits of FGM, there are many short-term and long-term complications, such as hemorrhage, inflammation, fever, severe pain, etc., and urinary problems, vaginal problems, menstrual problems, scar tissue, sexual problems, and increased risk of childbirth complications, etc., besides psychological problems.
Renewed efforts are ongoing to abolish this practice, which is considered to be a violation of the human rights of girls and women. UNFPA and UNICEF launched the Joint Programme on Female Genital Mutilation/Cutting in 2007 to speed up its abandonment, and the following year, WHO and other UN partners released a statement called: “Eliminating female genital mutilation: an interagency statement”. In 2010, WHO published the “Global strategy to stop health care providers from performing female genital mutilation”, and in 2012, a resolution on the elimination of female genital mutilation was adopted by the UN General Assembly.

Sexual dysfunction
Sexual dysfunction is a problem that prevents an individual from gaining satisfaction from sex, and it can occur during any phase of the sexual response cycle, which generally includes excitement, plateau, and orgasm. Sexual dysfunction can be of four types:
1. Lack of interest in sex (desire disorder)
2. Unable to become aroused during sex (arousal disorder)
3. Delay or absence of orgasm (orgasm disorder)
4. Pain during intercourse (pain disorder).
While erectile dysfunction, absent or delayed ejaculation, and premature ejaculation are the symptoms seen in men, in women, they are inability to achieve orgasm, inadequate vaginal lubrication, and inability to relax the vaginal muscles. Common to both men and women are symptoms like lack of sexual interest or desire, inability to become aroused, and pain during intercourse.
The physical causes of sexual dysfunction could be cardio-vascular disease, diabetes, hormonal imbalances, neurological disorders, and chronic diseases like renal or hepatic failure, along with alcoholism and drug abuse. Some antidepressants and the side effects of some medications like antihistamines, anti-hypertensives, and hormones may also cause sexual dysfunction. The psychological causes could include stress and anxiety, depression, relationship problems, low self esteem, etc.

Erectile Dysfunction (Impotence)
Erectile dysfunction is the inability to get and keep an erection firm enough for sex, and its symptoms may be reduced sexual desire, persistent trouble getting an erection, and trouble keeping an erection. Sexual arousal in men is a complex process involving blood vessels, the brain, nerves, hormones, muscles, and emotions. Erectile dysfunction can also be caused or worsened by stress and mental health problems. A combination of physical and psychological issues could be the cause in some instances.

In many cases, erectile dysfunction is caused by something physical, such as obesity, diabetes, CVD, atherosclerosis, elevated cholesterol levels, hypertension, metabolic syndrome (comprising of hypertension, high cholesterol and insulin levels, and excess fat around the waist), multiple sclerosis, Parkinson’s disease, etc. Sleep disorders, enlarged prostate, low testosterone levels, as well as sleep disorders may also cause erectile dysfunction. In some cases, it could be the side effect of some medications. Stress, depression or other mental health conditions, relationship issues could also be causative factors.

Reproductive tract infections (RTIs)
RTIs are caused by bacterial, parasitic, and viral pathogens that primarily enter the body through the mucous membranes during unprotected vaginal, anal, or oral intercourse with an infected person. RTIs can also be transmitted from the mother to the fetus or to the newborn at delivery.
RTIs may be of the following types:
1. Sexually transmitted diseases (STDs).
2. Endogenous infections caused by overgrowth of organisms that are normally present in healthy women’s genital tract, such as bacterial vaginosis and vulvovaginal candidiasis.
3. Iatrogenic infections due to improperly executed medical procedures like unsafe abortion or poor delivery procedure.

RTIs can lead to complications like pelvic inflammatory disease (PID), due to complications of N. gonorrhoea and C. trachomatis infections. Tubal infertility, ectopic pregnancy, and chronic abdominal pain may be the result of PID. In tubal infertility, there is inflammation and scarring of the fallopian tubes due to entry of gonorrhea and chlamydia into the upper reproductive tract. In the second, a fertilized egg implants outside the uterus, mainly in the fallopian tubes. Genital cancers have also been associated with RTIs, with some types of human papillomavirus (HPV) associated with the development of cervical neoplasia.

Sexually transmitted infections (STIs)
Out of the more than 30 different bacteria, viruses, and parasites that can be transmitted through sexual contact, eight are the cause of most of the sexually transmitted diseases, and among these, four (syphilis, gonorrhoea, chlamydia, and trichomoniasis) are currently curable, while the other four (all viral infections)—hepatitis B, herpes simplex virus (HSV), HIV, and human papillomavirus (HPV)—are not curable; however, HPV and hepatitis B are preventable with vaccination. Common STI symptoms include vaginal discharge, urethral discharge or burning (in men), genital ulcers, and abdominal pain.STIs impact sexual and reproductive health through stigmatization, infertility, cancers and complications of pregnancy, besides also increasing the risk of HIV. The WHO estimates that about 374 million people were infected with one of four STIs around the globe in 2020—trichomoniasis (156 million), chlamydia (129 million), gonorrhea (82 million), and syphilis (7.1 million). In 2016, syphilis infected almost one million pregnant women, leading to over 350 000 adverse birth outcomes, including 200 000 stillbirths and newborn deaths. Gonorrhea and chlamydia are major causes of pelvic inflammatory disease and infertility in women.

More than 490 million people between 15 and 49 years were estimated to have been infected with herpes simplex virus (HSV) as per WHO data, and in 2018, about 570 000 cases of cervical cancer were associated with human papillomavirus (HPV), which is also associated with over 311 000 cervical cancer deaths each year. The WHO estimates that about 296 million people, worldwide, are living with chronic hepatitis B, which resulted in an estimated 820 000 deaths in 2019, mostly from cirrhosis and hepatocellular carcinoma.

Besides preventing unintended pregnancy, condoms are one of the most effective methods of protection against STIs, but condoms are not effective against STIs that cause extra-genital ulcers, such as syphilis and genital herpes. However, bacterial STIs like chlamydia, gonorrhea, and syphilis, and one parasitic STI (trichomoniasis) can be cured with single-dose antibiotic regimens. While drug resistance is a threat in STI treatment, especially in the case of gonorrhea, evidence shows that vaccine against meningitis (MemB) has cross-protection against gonorrhea. As for hepatitis B and HPV, there are safe and effective vaccines available, and some vaccine candidates against herpes and HIV are also in clinical development.

HIV attacks the immune system. It is transmitted through infected blood, semen, or vaginal fluids. Its early symptoms include fever, sore throat, headache, muscle aches and joint pain, swollen glands, and skin rash, while later symptoms include swollen lymph nodes, extreme fatigue, weight loss, fever, and night sweats. The last stage of HIV infection is AIDS (acquired immunodeficiency syndrome).

Regarding herpes, infection can be due to either herpes simplex virus type 1 (HSV-1) or herpes simplex virus type 2 (HSV-2). HSV-1 is generally transmitted through oral-to-oral contact, causing oral herpes (infection in or around the mouth), but it can also be transmitted through oral-genital contact, causing genital herpes (infection in or around the genital area). While oral herpes infection is mostly asymptomatic, sometimes it may show as painful blisters or ulcers in or around the mouth.

HSV-2 is mainly transmitted through genital-to-genital contact during intercourse, causing genital herpes (infection in the genital or anal area). ). While mostly asymptomatic, when symptoms do occur, it is characterized by one or more genital or anal blisters or open sores (ulcers), as well as fever, body aches, and swollen lymph nodes. More women are infected with HSV-2 than men; and infection is lifelong and incurable.

Endometriosis is characterized by the presence of tissue resembling the lining of the uterus (endometrium) outside the uterus, causing a chronic inflammatory reaction that leads to scar tissue formation in the pelvis and other parts of the body. The lesions may be superficial endometriosis (found mainly on the pelvic peritoneum), cystic ovarian endometriosis (found in the ovaries), and deep endometriosis (found in the recto-vaginal septum, bladder, and bowel). Symptoms include painful periods, painful bowel movements, abdominal bloating and nausea, painful urination, chronic pelvic pain, pain during and/or after sex, fatigue, and depression or anxiety. Endometriosis can also cause infertility. Commonly used therapies include contraceptive steroids, NSAIDS, and analgesics. Treatments focus on either lowering estrogen or increasing progesterone to change hormone environments that promote endometriosis, and may include the combined oral contraceptive pill, progestins, and GnRH-analogues. Surgery can remove endometriosis lesions and scar tissue.

Family Planning
Family planning is an integral part of modern life that has great impact on both the mother and child’s health and well-being, and greater numbers of women are using it than ever before. Contraception use prevents pregnancy-related health risks, especially that of adolescent girls. Additionally, infant mortality rate is 45% higher when births are separated by less than two years than it is when births are two-three years apart, and 60% higher than it is when births are four or more years apart. Family planning also offers a range of non-health benefits, such as more education opportunities and better career development.

Many methods of contraception are available now, these include:
1. Male condoms: Forms a barrier to prevent sperm from meeting egg.
2. Female condoms: Forms a barrier to prevent sperm from meeting egg.
3. Male sterilization (vasectomy): Keeps sperm out of ejaculated sperm.
4. Female sterilization (tubal ligation): Eggs blocked from meeting sperm.
5. Combined oral contraceptives (the ‘pill’): Prevents release of eggs from ovaries (ovulation).
6. Progestogen-only pills (the ‘minipill’): Thickens cervical mucus to block sperm and egg from meeting and prevents ovulation.
7. Progestone-only injectables: Thickens cervical mucus to block sperm and egg from meeting and prevents ovulation.
8. Monthly injectables or combined injectable contraceptives: Prevents release of eggs from ovaries.
9. Combined contraceptive patch and combined contraceptive vaginal ring (CVR): Prevents release of eggs from ovaries.
10. Intrauterine device (IUD) copper: Copper component damages sperm and prevents it from meeting egg.
11. Intrauterine device (IUD) levonorgestrel: Thickens cervical mucus to block sperm and egg from meeting.
12. Implants: Thickens cervical mucus to block sperm and egg from meeting and prevents ovulation.
13. Lactational amenorrhea method (LAM): Prevents release of eggs from ovaries.
14. Standard days method: Avoiding unprotected vaginal sex during most fertile days.
15. Basal body temperature method: Avoiding unprotected vaginal sex during fertile days.
16. Two-day method: Avoiding unprotected vaginal sex during most fertile days.
17. Sympto-thermal method: Avoiding unprotected vaginal sex during most fertile days.
18. Emergency contraception pills (ulipristal acetate 30 mg or levonorgestrel 1.5 mg): Pills taken to prevent pregnancy up to 5 days after unprotected sex; prevents or delays the release of eggs from the ovaries.
19. Calendar method or rhythm method: Avoiding unprotected vaginal sex during the 1st and last estimated fertile days.
20. Withdrawal (coitus interruptus): Tries to keep sperm out of the woman’s body.
Note: Only one contraceptive method, condoms, can prevent both a pregnancy and the transmission of STIs, including HIV.

Menopause and Andropause
There is a decline in hormone production in women in their mid-30s that is further accelerated in the late 40s, which results in irregular menstrual cycles and random periods of heavy bleeding. By the early to mid-50s, there is no menstruation, and this is called menopause. Perimenopause is the period of 10 to 15 years before menopause, with symptoms like hot flushes, night sweats, irregular periods, diminished sexual desire, vaginal dryness, difficulty in sleeping, mood changes, anxiety, etc.

Male menopause (andropause) could be the result of declining testosterone levels, which is significant by the time a man is 50 years, with obesity, illness, depression, dementia, etc. being the triggering factors. Diminished sex drive, mood swings, listlessness, irritability, and depression are common symptoms, but unlike in women, where menopause leads to complete loss of fertility, men are able to have continued production of testosterone and sperm even in their 80s. Testosterone replacement therapy is the main treatment for andropause; however, sadly, it may not correct erectile dysfunction:

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