Don’t Shush on Sexual Health!

In conversation with Dr. Sayalee

Dr. Sayalee Pathak Sankalecha is currently practising as a gynaecologist in Nashik. She completed her graduation from GMC Nagpur and post-graduation in obstetrics and gynaecology from IGGMC Nagpur. “Interested in issues related to reproductive and sexual health and happy to contribute my bit towards toppling the taboo circling sex education in India.”

​ Editorial Board: At what age should kids be introduced to sex education? Dr. Sayalee: I feel puberty is the best time when a person should be introduced to sex education. Basically, the sexual drive starts at the age of puberty around 11 years in girls and 12 years in boys. So, on average, at around 12-13 years, we should introduce them to sex education. This way they can understand that what they are going through, the emotional changes and the physical changes, are normal. The sexual orientation which is concealed for such a long time in some people could be identified at an earlier age. They become more aware and cautious as they are explained about safety. Especially in India, where this is such a taboo, at least a step can be taken towards starting sex education at an earlier age. Editorial Board: How are we supposed to insert a tampon/menstrual cup if your hymen isn't stretched? Dr. Sayalee: Your hymen need not be torn or stretched to insert a tampon or a menstrual cup. Both of them are flexible structures. A menstrual cup, even though it looks like a cup, is foldable. So there are a variety of techniques by which you can insert it through your hymen. One of them is by pinching it. Another is by pinching it in S shape or a T shape pinch technique. Like that, you just have to insert the tip inside your hymen and gently try to push it and release it. You do not have to insert the whole cup or tampon directly through your hymen, you have to pinch it and insert it. Editorial Board: For how long at a stretch should one wear a pad? Dr. Sayalee: It depends on a person’s menstrual flow. In general, if a person has a higher menstrual flow, they should be changing 2-3 pads on an average in a day. The main purpose of changing pads is to keep the area hygienic. The same pad being there for a long time also causes itching and irritation. So, to avoid that, a minimum of twice a day and upto 4-5 times a day is also considered normal. Editorial Board: Is it hygienic to wear a panty liner daily due to discharge? Dr. Sayalee: It cannot be called unhygienic to wear a panty liner but it is not advisable to wear it on a daily basis. Panty liners are basically an external environment to say for that matter and anything besides cloth that comes in contact with the genitals can cause irritation which is called a chemical stimulation and this can again lead to an aggravation of complaints like sticky discharge. So, it is not advisable to wear it on a daily basis unless extremely required in emergency situations like when you have to go somewhere, when you cannot access washrooms, in such cases only you should prefer to use them. Editorial Board: Why is it advised to avoid painkillers during menstruation? Dr. Sayalee: We don’t advise against taking painkillers. In general, the painkillers we advise are usually muscle relaxers. The pain is actually not a physical pain, it is due to uterine contractions. Basically, it is a cramping kind of pain and a painkiller would not relieve this kind of pain. You need a muscle relaxer to relieve this kind of pain. So we recommend muscle relaxants like Meftal-Spas (upon medical consultation or advice) that people consume rather than paracetamol and Diclofenac tablets. Those are more effective and long-lasting rather than painkillers. They are not contraindicated to be used in menstruation and do not have side effects as such. Editorial Board: If at all a woman gets pregnant, how safe is abortion and what are the things we should keep in mind? Dr. Sayalee: The first thing we should keep in mind is that medical termination of pregnancy is legal in India.Until now it was till 20 weeks of gestation, however, recently the government has extended it upto 24 weeks of gestation. It is very safe and legal to medically terminate pregnancy up till 6 months of gestation. So even if you come to know about your pregnancy at a delayed stage, you can terminate it. Regarding safety, you should always consult a doctor/gynaecologist before consuming any pills or before taking any kind of treatment as such. A lot of people consume different kinds of pills which are given by quacks or over-the-counter pills which then lead to excessive bleeding or other complications in patients which they blame on the pregnancy or the relatives and the partner may blame them on the patient. So, we should keep in mind that abortion is safe, it is legal and a lot of options are available for termination of pregnancy medically. We should not go for any illegal means, not consume over-the-counter pills and what we should advocate is that it is solely the patient’s will to terminate the pregnancy. It cannot be forced upon the patient to terminate the pregnancy. Also, one thing to know about abortion is that it is safest when it is less than 12 weeks. So if you come to know that you are pregnant, you can always consult your doctor, get a sonography done and if you make the decision to terminate, it is best to do it before 12 weeks. Editorial Board: Is it possible to get pregnant after having unprotected sex while the female is menstruating? Dr. Sayalee: It is less likely that when a female is menstruating she will get pregnant. The reason is that we need to know when a person can get pregnant. So there is a specific time period when the ovulation occurs and in that period only you can get pregnant if a sperm enters your uterus. That period basically starts from the 11th day to the 18th day. On an average, we tell people, who want to conceive, to have coitus between the 10th to the 18th day of their menses. So while having menses, it is very unlikely that the person will conceive because a sperm can stay in a female’s body for 72 hours and a female egg can stay in her own body for 48 hours. For instance, if a female ovulates on day 14th, her menses is considered to be starting from day 1. So neither the egg will be released during her menses nor the sperm which has entered her body will stay for that long till the time of ovulation. So, practically it is not possible. Editorial Board: What is the appropriate age to engage in sexual activity? Dr. Sayalee: Practically speaking, above 18 years of age is a safer age to engage in sexual activity. There are two criteria for this thought process, from the females' point of view and from the males' point of view. For males, though they attain physical maturity at an earlier age, their emotional and mental maturity comes at a later age. So to say they can engage in sexual activity at 15 years of age but the emotional baggage that comes along with it, they are better equipped to handle it after the age of 18 safely, i.e., when they have entered adulthood. Their mental state gets stabilised over a period of time. Considering it from a female point of view, we know that they are more sensitive and thoughtful about these kinds of things. So again for them, to handle this huge emotional baggage and for her own mental peace and mental stability, it is best to engage in sexual activity after 18 years of age. Also, teenage pregnancies are a huge risk factor for a female. To avoid this, being above 18 years of age is the safest and also legal in India. Editorial Board: How and why does pain vary from woman to woman during their first time? Dr. Sayalee: There are two factors to consider here. One, that the female's anxiety quotient, comfort with her own self, her body image that she perceives, how confident she is about herself. If she is relaxed and excited enough, if she has a good relationship with her partner or they have been intimate but never had an actual physical relationship and have good communication, in all these cases, the patient is highly relaxed and their anxiety is also very low. In these cases, the vagina is very well lubricated and she will have less sensation of pain, comparatively. When exactly the opposite thing happens, she will experience pain because she will have that anxiety, she will have a natural spasm of muscles which is not helping her relax. In majority of the cases, the pain depends on trying to relax oneself. The sex therapy concept has recently taken a lot of news, a lot of people refer to them for the same reason that they are unable to enjoy their sexual experience or have a painless sexual experience. In majority of these cases, they ask you to relieve your stress, to relax, to increase communication and intimacy with the partner and to get self-confident and confident about the relationship they are in. It is actually not a physical concept that causes pain, it is the body’s response that actually causes the pain. This is why the pain differs from woman to woman during their first time. ​ Editorial Board: Should one's first time be only till the third base? Dr. Sayalee: That is a person’s own choice upto what level they want to take their relationship. It actually does not matter if it is till third base or they are actually having sexual contact. The reason is that once you decide to indulge in a relationship of that physical nature, it really doesn't matter upto which level you go. However, in cases such as the marriage is decided, but they want to get intimate before the marriage, they prefer not to go to the fourth base and do that after marriage. In pre-marital sex or one-night stands or for people who prefer to indulge in casual sex, for them, it is not necessary to get to the third base initially to reach the actual stage of sexual contact. It is a personal preference and again depends upon your comfort level with your partner. Editorial Board: A lot of people still struggle to understand what sex is or what pleasure is. If they are not accustomed to porn or erotica, how can they still gain knowledge about it? Dr. Sayalee: Sex and pleasure are two different things in the sense that sex is an objective concept whereas pleasure is a very subjective concept. A person can get or derive pleasure from a lot of things. If they are not exposed to porn or erotica available online, the other sources can be books regarding this. A lot of knowledge is available through books about this. The person can explore their own body and nature to understand what they like and what they don’t like. They can talk to people or doctors who are available for this cause. What is most important is that they should be open-minded in this concept. They should have a non-biased opinion about this. The taboo should be lifted and you can always consult a doctor or gynaecologist if you have any queries. Editorial Board: Is sex about intimacy or human pleasure? Dr. Sayalee: In India, after marriage, in some families, the pressure of childbearing makes people indulge in sexual activities. In some cases like young married couples or today’s generation, it is all about intimacy. It is about having a good communication and comfort level with each other and their own bodies. The generation is gradually changing and is now shifting from pleasure to intimacy. Intimacy is now being valued more than just mere pleasure. A lot of people are now comfortable with not having sex immediately after marriage or they want to give their partners adequate time to get to know each other. It is a changing trend and hopefully, it will change more from pleasure to intimacy and there is nothing bad in deriving pleasure from it. It is always an added advantage. Editorial Board: How to masturbate is a big concern amongst young teenagers, any advice you would like to give? Dr. Sayalee: First of all, it should be very clear in mind that masturbation is a very natural process and there is nothing to be ashamed of. Recently, more and more news surveys are suggestive of the fact that a lot of people are now accepting it more openly. Women are becoming more aware of masturbation as compared to men. So to satisfy oneself, there are a lot of options available. Clitoral stimulation is very common in women and they stimulate by rubbing and stroking with hand/ vibrators/ dildos / Ben Wa ball. For men, the most common method for masturbation is rubbing or stroking the penis with the hand. Other methods for men can be the use of artificial vaginas or the use of a sex mannequin. Editorial Board: How can disabled people seek pleasure? Dr. Sayalee: It is a very untouched topic and very few studies have been conducted regarding the sexual desire for disabled people. A lot of articles are there online that say that disabled people should have the right to own their sexuality and their desire to have sex. However, there are very few options available for them. It also depends upon their degree and type of disability. There are hands-free stimulator devices available for both men and women. They are basically machine-controlled or automated. They can also go to their doctor and can stimulate their clitoris or penis which is controlled by the doctor or the operator. However, this is not available in India. If the person is physically disabled, it is still possible to provide them with options. However, if there is a physiological disability like erectile dysfunction, then it is not practically possible to provide the person with a solution. Editorial Board: How to identify if you have an STI? Dr. Sayalee: There are a lot of different STIs basically, one of the most common being Gonorrhea. Then there are Genital herpes, Syphilis, the most dreaded one AIDS and a lot of minor infections. The common symptoms include vaginal discharge, itching over the area, inflammation over the genital area, the appearance of papules or warts over the area and burning sensation during menstruation. Now, what to do if you have an STI? You need to consult a doctor because there is a treatment for every STI except AIDS. If you recognize it at an earlier stage, you need to get yourself treated. The most important part is that you need to get your partner also treated so that they do not get infected and would not re-infect you in the future. You should also understand the importance of prevention of STIs and devices like a vaginal diaphragm and cervical cap are very effective tools for the prevention of STIs and should be definitely used and promoted. Editorial Board: What causes PCOS and who can get it? Dr. Sayalee: Anyone can get PCOS. We can only come to know once you get PCOS. It is a retrospective diagnosis and not a prospective diagnosis. So, because of PCOS, you develop a body type and a hormonal imbalance and because of that body type and hormonal imbalance, you show symptoms of PCOS. So it is a vicious cycle and you cannot term what is causing what. A person with PCOS can have excessive hair growth, excessive weight gain, irregular periods and difficulty in conception. So when these symptoms occur, we retrospectively think to do an ultrasound to see if they have PCOS or check for hormone levels if they have a hormonal imbalance. PCOS also gets unidentified a lot of time. A lot of people live under the impression that they have PCOS when actually that is not true. It might happen that due to your weight gain, you develop PCOS. Editorial Board: What methods or lifestyles should we incorporate to help reduce the effects of PCOS? Dr. Sayalee: Pcos is retrospective, i.e., it has already occurred. There is no particular cure for it. General lifestyle modification, weight loss, dietary changes and all such things help to reduce this vicious cycle. If you see any symptoms, you should consult your doctor. There are also medications that help control hormonal levels. Editorial Board: Is it common in India to be sexually active at this age? Dr. Sayalee: Unfortunately, even if it is common, it is not known to everyone. It is possible especially in rural areas where people of this age,i.e.,18+ or even teenagers might be sexually active but no one knows. However, as far as the data is available, the current statistics do not suggest a lot of sexual activity in this age group as compared to the western population. Since there is a lot of taboo about this topic in India, one cannot be sure of this data. But again, in India, the age of marriage for girls is above 18, so there is a possibility that a lot of girls are sexually active at this age especially in the rural areas which form a major chunk of our country. Compared to the western population, we are definitely at a lower rate but compared to the Indian population itself, the trend is definitely shifting towards a younger age of the society.

Clockwise names: Rishika Chawla, Maryam Mozayan, Shraddha Menon and Dr Sayalee Pathak Sankalecha