Article contributed by Dr Basab | for AHC FOGSI website
Sexual Health, Normal and Abnormal Sexual Activity
Sexual health is a state of physical, emotional, mental and social wellbeing related to
sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual
health requires a positive and respectful approach to sexuality and sexual
relationships, as well as the possibility of having pleasurable and safe sexual
experiences, free of coercion, discrimination and violence. For sexual health to be
attained and maintained, the sexual rights of all persons must be respected, protected
and fulfilled. (WHO 2002)
The sexual and reproductive health needs of adolescents differ from those of adults.
We should understand what adolescents need and how best we can reach them to
encourage responsible sexual behavior and help them protect their sexual and
reproductive health.
Normal sexual activity means intercourse between two consenting individuals. It
is important to realize that the individuals should be responsible for their action.
Contraception in the form of barriers (condoms) to prevent infections and oral
pills to prevent pregnancy should be used. The activity should not arise out of
compulsion or coercion or forced against the will of either partner.
Though relationship between a man and a woman is most common, sexual
activity may occur between two male or two female partners. This sexual
relationship between members of the same sex is called homosexuality
(colloquially gay or lesbians). Homosexuality is not a disease and has its origins
in the genetic, psychological and environmental make-up of the individuals.
Though often discriminated in society, activists for couples of the same sex are
fast gaining ground.
Another aspect of normal sexual activity revolves around genito-genital contact.
Usually during the act of intercourse the penis of the male partner is inserted
into the vagina of the female partner. Ejaculation (seminal discharge) in the male
and strong pelvic contractions in the female constitute orgasm and denote the
pinnacle of sexual pleasure. Sometimes, couples may experiment with orogenital, ano-oral and genito-oral contacts.
Oral stimulation of the penis by licking or sucking is called fellatio (colloquially –
blowjob). This runs the risk of sexually transmitted diseases being spread as
barrier contraception is mostly not used. Similarly, oral stimulation of the clitoris
or vagina (cunnilingus) could run the similar risks of infections. In anal
penetration besides infections, complications of mucosal tears, sphincter damage
and incontinence may occur.
Masturbation is a process of stimulation of genital organs for self-gratification.
This does not run the risk of infections and can to some extent satisfy sexual
urges. However, one should not get obsessed with masturbation so that it starts
affecting one’s academic performance, expectations of elders and daily activities.
Having intercourse with children (pedophilia) or animals is abnormal and illegal.
Similarly exhibitionism or displaying private parts in public or voyeurism i.e.
secretly watching intimacy of others cannot be constituted as normal sexual
behavior. Though watching pornographic material does not necessarily
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Article contributed by Dr Basab | for AHC FOGSI website
constitute sexual offences however it often gives a distorted perception to sexual
activity per se. Some individuals may get obsessed with pornographic material,
which may affect their mental status and start having a negative impact on their
personality.
Reproductive Anatomy and Physiology
It is important to understand the basic structure and function of the male and
female reproductive systems. This is more important, during the phase of
puberty where transformation of a child to an adult takes place.
The reproductive organs are categorized into (i) external genitalia i.e. what one
can see from outside and (ii) internal genitalia i.e. what is present inside the
body - seen during an operation or imaging tests (USG, CT Scan, MRI etc).
For men, the external genitalia consist of a
penis and a scrotum, which contains the testes. The
penis which is normally flaccid, gets engorged with
blood during times of sexual excitement (erection)
and becomes longer and harder. The pair of testes
in the scrotum produces sperms and the male
hormone – testosterone. The hormones from the
testes enter the bloodstream while the sperms
travel through tubes (vas deferens) to join the
common duct through which both semen and urine
is discharged. The penis has a shaft and sensitive
tip which is called the glans penis, which is covered
by a retractile skin sheath called the prepuce.
During circumcision the foreskin (prepuce) is
stitched to the base of the glans penis. Besides the testes, the other organs
contributing to the quality and quantity of seminal fluid include the seminal
vesicles and the prostate gland.
For women, the external genitalia (vulva) consists of two outer pads of fat
seen called the labia majora. The inner thinner folds of skin are called labia
minora which cover the vaginal and urinary openings. Just above the urinary
opening is the knob-like clitoris, a highly sensitive structure with limited
function other
than
sexual
stimulation. The
urethral orifice
is superior to
the
vaginal
orifice
and
much smaller in
size.
The
vaginal orifice is
usually covered by the hymen which is a thin fold of skin situated in front. The
hymen usually ruptures after the first intercourse but this may also occur
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Article contributed by Dr Basab | for AHC FOGSI website
following masturbation and astride injuries. Below the vaginal orifice lies the
anal opening. The vaginal passage is the route through which menstrual blood
flows out from the uterus. It also acts as the birth passage during a normal
delivery and is the part of the genital tract used during intercourse.
The internal genitalia in women consist of a uterus (womb), which is the cavity
in which the baby develops. The inner lining of the
uterus (endometrium) is shed every month and is
seen and interpreted externally as a menstrual
period. The neck of the uterus is called the cervix,
which plays a significant role in labour. Besides the
uterus, there are the fallopian tubes and ovaries. The
ovaries
produce
the
hormones
estrogen,
progesterone and androgen, which help to keep
women healthy and have regular menstrual
periods. Ovaries also produce eggs (ova),
which have the potential to become a tiny
baby cell (zygote) if fertilized by a sperm.
When fertilization i.e. union of an egg with a
sperm does not occur, the inner uterine
lining is shed every month (menstrual
period). The fallopian tube is the conduit
and site of union of the egg with the sperm.
While the egg traverses a short distance in
the tube, the sperms traverse a long
distance – swimming up the vagina, passing through the cervix and gliding along
the uterus to finally reach the tubes. Diseases or obstructions of the tube
especially related to infections can interfere with fertility hindering fertilization.
Gynecological Problems
PCOS
Polycystic Ovarian Syndrome is a condition associated with hormonal imbalance
commonly seen in the 15 – 30 year age group. Though the exact cause of the
disease is unknown and still under research, genetic and environmental factors
are suspected to have an important role. Nearly half of women with PCOS are
overweight. Some have irregular periods and problems in conceiving. Cosmetic
issues in the form of acne and excess hair growth may trouble some women.
Unchecked and uncontrolled, the disease in the long run may be the forerunner
of chronic ailments as serious as diabetes, heart disease and uterine cancer. The
diagnosis is suspected clinically and clinched with a battery of tests including
hormonal assays and an ultrasonography. For women whose bodyweight crosses
that expected for height, weight reduction is the cornerstone of therapy. Longterm cyclical hormone therapy (often combined oral contraceptives) may be
offered for regularizing the cycle and restoring hormonal balance. The same
treatment would often correct excess hair growth and acne. Spontaneous
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conception may be delayed and couples may need to resort to assisted
reproduction techniques.
Endometriosis
This is a disease essentially comprising of proliferating endometrium (inner
lining of the uterus) outside the uterus. It may affect any woman in the
reproductive age group in the 20 – 40 year age group. However recently, there is
an increase in the incidence of adolescent endometriosis. The disease presents
classically with distressing lower abdomen and pelvic pain worsening around
the time of periods and during intercourse. In severe disease, the pain may
persist throughout the month. Besides
pain, the disease is often associated
with sub fertility and artificial methods
for reproduction may be required. In
some cases, a sonography reveals
ovarian cysts (chocolate cysts) in
which tarred blood collects. Though
endometriosis is diagnosed clinically,
the absolute confirmation is made after
seeing the disease by a laparoscopy
operation. During the course of a
laparoscopy, besides the chocolate
cysts, inside the abdomen, the pelvic
organs may be seen stuck to each other, the surrounding gut and the abdominal
walls. Often treatment may be combined with the diagnostic laparoscopy. The
treatment of endometriosis is usually a combination of medicines and surgery
depending on the presenting complaints and the extent of the disease. During
medical treatment often menstruation is purposely arrested, albeit temporarily,
to attempt a cure. However, endometriosis is notorious for recurrence and a 50 60% chance of relapse could be expected even a few years after completion of
treatment.
Fibroids
These are tumors arising from the uterus and could be detected at different
reproductive age groups in women. In more
than 99% of cases these do not transform to
cancer. Depending on their size and location,
fibroids can cause disruptions in menstrual
patterns, pain during periods, heaviness in the
lower abdomen, sub fertility and pressure
effects on surrounding organs (e.g. bladder).
Fibroids are suspected by clinical examination
but confirmed by an ultrasound. There are no
medicines to ‘cure’ the tumors but treatment,
for the problems they cause, may be offered.
Most commonly, they do not cause any problems and are found incidentally
during a sonography done for another reason. Often if small, the fibroids can be
ignored with reassurance. Treatment options for large fibroids or those causing
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Article contributed by Dr Basab | for AHC FOGSI website
persistent problems include removal of the tumor alone or the entire uterus
along with it. This may be done by the laparoscopy (microsurgery) route besides
the conventional route of a cut on the tummy. If just the tumor is removed, it may
recur at a future date but may not necessarily need surgery again. A more recent
treatment strategy by blocking the blood supply to the tumor may be considered
in selected cases.
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