What are sexuality and sexual health?

Contrary to what we often hear, sexuality is multidimensional, and involves more than just physical sex. It is a holistic concept made up of several dimensions: biological, cognitive, ethical and legal, psychological and emotional, sociocultural, religious, moral, and spiritual.

Sexual health is defined by the World Health Organization (WHO) as: “A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.”

The WHO also considers that sexual health should be understood from a holistic perspective, encompassing “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.”

With this in mind, full sexual health can only exist if the sexual rights of every person are respected and protected.

As you can see, sexuality and sexual health go beyond the physical; the concept encompasses the persons and her experiences as a whole.

What about desire?

Ideally, sex and pleasure go hand in hand, but as we know this is not always the case. Sometimes, desire is lacking. Just like sexuality, desire is influenced by many factors. There is no “on/off” switch we can flip. Indeed, a person’s age, health, and the state of the relationship with their partner all have an impact on their ability to experience desire, and to seek out or be receptive to their partner’s advances. Fluctuations in desire are normal. If a drop in desire causes friction, learning to communicate openly with your partner is a good way to address the issue, so you can work together to explore ways to make things better.

Where does pleasure fit into all this?

Sex and pleasure are closely related. It is healthy to enjoy sex and derive pleasure from it. Feeling beautiful and desired. The ecstasy of touching and kissing. Experiencing a sexual encounter full of tenderness, or other times, with full consent from both partners, one that is outright rough. The pleasure of initiating sex, masturbation, sex with one partner, or with multiple partners. Whatever you are looking for, what matters is that you are able to live out your desires and find pleasure while respecting yourself and your partners.

Being comfortable in your own skin, taking care of your body, learning to recognize and express your desires and limits…, all of these are ways to enhance moments of pleasure and maintain your sexual health. Knowing how to prevent an unplanned pregnancy is just as important as knowing how to avoid the human immunodeficiency virus (HIV) and other sexually transmitted and blood-borne infections (STBBIs). These strategies will allow you to maintain your sexual health, and above all to continue equating sex with pleasure.

Being a woman

What does “being a woman” mean? Take a few moments to think about what this means for you.

Our gender identities – who we are and who we believe we should be – are constructed by the society we live in and influenced by its values and cultural norms. This is what is referred to as socialization. Our first exposure to socialization is within our families. Society as a whole also contributes to the process of socialization, through institutions like schools and the media. We learn about gender roles by observing our environment.

At school, girls who do not follow traditionally “feminine” fashion norms are often called “tomboys”. But in the end, what is femininity? How should it be expressed? Is there only one, singular way to be feminine? Another example is the woman who has multiple sexual encounters and is affirmative of her sexuality. Oftentimes her behaviour will be judged negatively, despite the fact that society tends to perceive the same behaviour in a man as a testament to his virility.

These stereotypical gender roles can be quite rigid. From one family to another, these roles can be experienced differently. We are all socialized, and have a representation in our minds of what is considered “masculine” or “feminine”.

Sometimes, our feeling of “being a woman” doesn’t necessarily correspond to our biological sex at birth. For example, a child who is biologically male might identify more with the attributes society expects in a person who is biologically female. These questions, often painful, have a significant impact on the overall health and wellbeing of the person experiencing them. If you are in this situation, these specialized resources may be able to help you process your thoughts:

• ASTT(e)Q (Action Santé Travesti(e)s et Transexuel(le)s du Québec)
• Centre for Gender Advocacy
• ATQ (Aide aux trans du Québec) (French)

Body image and self-esteem

A large part of our identity as a woman is rooted in what we learn about sexuality from our parents, at school, and through our experiences, such as our first sexual and emotional encounters and experiences. This is when we begin to build either positive or negative images of our bodies and sexuality. What did your parents teach you about sexuality? What beliefs and values did they pass on through their behaviour, their attitudes, their words, and their non-verbal communication?

The answers to these questions influence our relationship to our femininity, our bodies, our body image, and our self-esteem.

The way that physical beauty is depicted in mass media creates a standard that is not only seen and judged by men, but also by women amongst themselves. Though they are often inaccessible, these beauty standards have become regarded as the norm. It can be very difficult to accept yourself as you are in this context. Whether it happens often or only occasionally, most women can relate to having moments of self-doubt. And when it happens, we do not feel good, we do not accept ourselves, and we do not like ourselves.

In and of itself, there is nothing wrong with wanting to be beautiful, or taking care of your appearance. It is even a sign of good self-esteem – you take care of yourself because you know that you are worth it. The important thing is to find a healthy middle ground.

On this note, we would like to share a Dove campaign that perfectly illustrates our point. The intent here is not to promote Dove products, but simply to illustrate the impact that society has on our self-esteem and body image.

Real Beauty Sketches, Dove, 2013                                                                                              Dove choose beautiful, 2015

Self-esteem is an inner attitude that allows us to recognise our value, our qualities, our strengths, and our limits. In short, knowing that we are unique! A woman with good self-esteem is able to list her successes and qualities, and is able to learn from her failures and mistakes without tearing herself down. A woman with low self-esteem would tend to dwell on her failures, her faults, and her weaknesses, and ignore all the beauty and positivity within her. She would compare herself to others, and define herself in relation to them.

Good self-esteem is known to go hand in hand with good health, and by extension, good sexual health. If this is something you feel you need to work on, you may wish to consult a psychologist or psychotherapist.

Being in a relationship

Some women choose to be in a stable, monogamous relationship, whereas others choose to see multiple people. Some are attracted to other women, whether it is for a long- or short-term relationship, or simply for a single sexual experience. There are as many different combinations as there are people.

Being attracted to women is completely healthy. It is part of the wide spectrum of love. If you are questioning your sexual orientation, these resources may be able to help you process your thoughts:

• ALGI (Association des lesbiennes et des gais sur Internet) (French)
• Centre de solidarité lesbienne (French)
• Réseau des lesbiennes du Québec (French)
• Community directory of Fugues magazine (French)
• Ordre des psychologues du Québec

Whether you are in a stable relationship or not, opening the door to frank, honest, and non-judgmental communication is an excellent strategy for allowing yourself to open up and learn to communicate your limits. Talking about previous partners (long or short term relation, experimentation with same sex partner) and about your health (methods of contraception, results of previous STBBI tests) can be a good way to keep the lines of communication open, and make informed decisions.

Communicating openly and frequently

It is often said that communication is key in interpersonal relationships, and that is very true! Whether it is to address important questions with your partners, to assert yourself, or simply to fully express your sexuality, a genuine conversation is always a winning strategy!

Communicating openly and frequently with your partner

It is not always easy to express your needs, desires, emotions, and expectations, or listen to your partner express theirs, is it?

There is nothing wrong with taking the lead, speaking up, and letting your partner know what you need. On the contrary! Sharing your desires, taking the initiative, and instigating sex are all healthy expressions of sexuality.

Communication is essential in everyday life, but even more so when it comes to sexuality and relationships. It allows you to know where you stand with each other, to inform, to seduce, to prepare for sex and get excited. If offers an opportunity to get to know more about the other person and about yourself, and allows you to develop real intimacy. Communication also involves coming to an understanding about what practices you would like to explore, and what your limits are.

It can be scary to talk about yourself, to open up to another person, to communicate. Negative emotions, embarrassment about discussing certain desires, and fear of how the other person will react are all examples of obstacles that can hinder communication.

A few tricks to facilitate communication:

1. Choose the right time and place:
   Ideally the conversation would take place in a suitable location, when you both have enough time to devote to it. This helps create a climate of trust.
2. Outline the topic, and express yourself clearly:
   By expressing yourself clearly you avoid ambiguity and leave less room for misinterpretation. It is also important to check that you have been well understood, and that you have correctly understood your partner. Good communication goes two ways. If there is any misunderstanding, clarify.
3. Express your feelings using “I” statements:
   Using “I” can help you express yourself in a non-accusatory way. Saying “I feel bad when…” instead of “You make me feel bad when…” allows you to express your feelings without blaming the other person.
4. Formulate your needs in a constructive manner:
   Expressing yourself in a way that promotes dialogue and mutual satisfaction is a winning formula. “I would like us to take more time for foreplay. It gives me more pleasure, which in turn makes me want to give you more…”
5. Try to understand the other person, not to convince them:
   It is normal to have different perspectives and opinions. The goal of communication is not necessarily to think alike, but to get to know the other person’s ideas, opinions, and positions… and respect them. Sometimes you have to agree to disagree.
6. Allow the other person to react:
   Just as you may react to what your partner tells you, you have to accept that your partner may have a reaction to what you have to say. The ability to respect and welcome each other’s perspectives is the measure of a conversation where both people can express themselves honestly.
7. Be a good listener:
   Don’t forget the flipside of communication… Being able to listen! When you express yourself and share things with your partner, you want to be heard and understood. You want your thoughts to be welcomed, respected, and considered. You have to be willing to extend the same courtesy to your partner when they speak, by listening to them openly. When you listen, be completely attentive and present… mind, body, and heart.

Domestic violence

Sometimes the loving relationship that made your heart soar can turn into a relationship marred by violence. Whether it is psychological, financial, physical, or sexual, the warning signs of domestic violence are not always easy to spot or understand in the beginning. They can take the form of: control (controlling your friends, who you see, how you dress), belittling comments and verbal threats, demanding sex, shoving, or hitting. Violent behaviour can occur one time, or repeatedly. Regardless of the form it takes or the frequency with which it happens, violence is never acceptable.

If you have concerns on this subject, these resources may be able to help:

• SOS violence conjugale (French)
• CALACS (Centre for relief of sexual assaults)
• TEL JEUNES

For more information, you can also refer to the following resource:

• Domestic violence section of the Santé et Services sociaux website

Essential exams

The basis of good physical sexual health is the absence of infections, abnormalities, cancer, or pre-cancerous cells on the sexual organs.

A gynecological exam, including a Pap test, is recommended every two to three years for all sexually active women, and is the best way to determine the health of your sexual organs. This exam does not necessarily include STBBI testing, or testing for the human immunodeficiency virus (HIV).

It is normal to be shy, ill at ease, or worried about what might be found during a gynecological exam. The exam itself might be uncomfortable, but overall it is not be painful.

External exam

Many physicians begin the gynecological exam with a breast exam. This involves gently palpating the breast to feel for masses (cysts, bumps, benign or malignant tumours) or abnormalities. Rest assured, most masses that are found are not dangerous, but it is important to identify them, particularly if you have a family history of breast cancer. Heredity is a risk factor for breast cancer.

For the pelvic exam, you will be asked to assume the standard position: on your back, buttocks at the edge of the exam table, feet in the stirrups, legs spread. The vulva will then be examined to verify that there are no lesions, irritations, or signs of infection.

Internal exam

The first step is the insertion of the speculum. The speculum is the small, beak-shaped object that, once inserted into the vagina, is opened and locked in order to open the vaginal walls. This creates a clear path for swabs to be taken, once the cervix is in view. At a glance, the physician can see if there are lesions or inflammation.

The Pap test, also called a Pap smear, is generally the first sample taken. With a long cotton swab, the physician will take a sample of cells from inside the cervix. These cells will be analyzed in order to detect the presence of cancer or the development of pre-cancerous cells.

Then, in some cases, at the patient’s request, or if the woman has had high risk sexual encounters, or has symptoms of gonorrhoea or chlamydia, the physician will suggest taking additional samples. Again using a long cotton swab, the physician will take samples of secretions for analysis. It is recommended that you ask to be tested as a matter of course, just to be certain that you are not carrying an STBBI, even if you are in a stable relationship. The physician will ask you certain questions that will allow him to determine whether further tests are needed.

Samples may also be taken to test for other types of infection, like vaginitis or Gardnerella. These infections, generally caused by an imbalance in the pH of the vagina, manifest through increased vaginal secretions resulting in itching (candida) or a fishy odour (Gardnerella).

It is also recommended to stay up to date with your vaccination. Your doctor or nurse can offer advice on this.

Communicate openly with your doctor – without taboos

We know how hard it can be to talk openly with your doctor, out of fear of judgement, or simply out of modesty. Some details can be embarrassing to share, but keep in mind that the more your healthcare professional knows about your sexual practices, the better equipped she will be to give you the information you need, and take samples from the right areas (the anus, for example).

However, it may happen that you feel uncomfortable with a particular professional. In this case, consider looking for a second opinion by making an appointment with another health professional. If that is not possible, you can also go back to the original physician, but bring along a person you trust, or a community support worker. If you encounter discrimination (because of your sex, sexual orientation, etc.) do not hesitate to report it. It is against the law.

Access to health services

If you have questions about your sexual health, are looking for resources, or simply want to talk about it with your peers, here are a few suggestions that might be useful:

For more information on the services offered in your area, or for general questions, you can:

• contact your local sexual health organization
• contact Info-Santé at 8-1-1
• visit the Resources section of this site.

If you do not have a Health Insurance Card, go to your nearest CLSC. Many CLSCs will see you even if you don’t have a card. They will also let you know what you need to do to apply for a card.

In Montreal, Médecins du Monde Canada provides medical services to people who are waiting to receive official immigration status and to homeless. 514 281 8998 extension 246.

To find an HIV organization in your area, visit the Resources website. Various organizations offer specialized services to women who are drug users, to sex workers, to immigrant women and to trans people.

For trans people:

In Montreal

• ASTT(e)Q,
• Centre for Gender Advocacy;
• Aide aux trans du Québec (ATQ)

In Regions

• IRIS-Estrie – Projet Caméléon
• MAINS Bas-Saint-Laurent
• Trans Mauricie et Centre-du-Québec

Contraception

No method of contraception is 100% effective, but many come close. To minimize your chances of getting pregnant, you can try a combination of methods; the pill and condoms, for example. Remember that, aside from external condoms (often called male condoms) and internal condoms (often called female condoms), birth control does not protect you from sexually transmitted and blood-borne infections (STBBIs), including the human immunodeficiency virus (HIV).

Contraceptive methods fall into three categories: hormonal, barrier, and spermicide. There is also the rhythm method, which involves monitoring your menstrual cycle, and avoiding vaginal intercourse without a condom during ovulation (your fertile period).

Choosing a method of contraception that works for you

From the extensive range of available methods, it is important to choose a form of birth control that you are comfortable with. Some criteria you may want to consider:

• How many partners you have
• How often you have sex
• How comfortable you are communicating with your partners
• Your age and health
• The advantages and disadvantages of each method
• Accessibility, cost, and availability of your chosen contraceptive method
• Your level of comfort with your body (for example, how comfortable you are with the idea of touching your vagina)

Questions? Talk to a nurse or physician. You can also refer to the following websites:

• Sexualityandu.ca
• Needhelpnow.ca (for youth)
• Fédération du Québec pour le planning des naissances (French)

Emergency contraceptive pill (morning after pill)

In situations where a condom was either not used or broke during sex, emergency contraception (the morning after pill) can prevent unplanned pregnancy if taken right away. Although it is possible to take it up to five days (120 hours) after unprotected sex, it is recommended to take it as soon as possible to maximise effectiveness.

This pill is available without a prescription, and is accessible to women and girls aged 14 and up. It can be obtained through pharmacies, CLSCs, school nurses, hospital ERs, and in most clinics and women’s health centres.

The pill is free for girls under 18 and for full-time students under 25. Emergency contraception has few to no serious side-effects, and will not prevent future pregnancies. However its use is best kept for emergency situations.

Post-exposure prophylaxis (PEP)

You did not use a condom or if a condom broke during sex, and you believe there is a risk of HIV infection, you can take a treatment to prevent infection. See a doctor quickly or visit the ER.

Planning for a pregnancy

You feel ready for a child and are thinking about trying to get pregnant? Before getting rid of the condoms, getting tested for HIV and other STBBIs allows you to find out if you have an infection, and get treated if necessary. Untreated STBBIs can cause problems during pregnancy, and may harm your baby. If testing reveals that you are infected with HIV, you should know that an HIV-positive woman, who receives appropriate medical care and is under treatment, can have a healthy pregnancy and give birth to a healthy, HIV-negative baby.

Voluntary termination of pregnancy

Unplanned pregnancies can sometimes happen. If you decide to terminate your pregnancy, several options are open to you. The following resources are available to provide information and support:

• SOS grossesse.ca (French)
• Grossesse-secours.org (French)
• FQPN (abortion resources directory) (French)
• Quebec repertory of resources offering abortion services
• A nurse at your school/cegep/university/CLSC
• Info-Santé health hotline (call 8-1-1)
• A professional at a sexual health clinic or women’s health centre

A few definitions

Sex: Refers to a person’s physiological and biological characteristics.

Gender: Gender refers to the expectations and norms constructed and propagated by a particular society for each sex. Not only do these norms dictate male/female relationships, but also shape those we have with all other people, male or female. Gender is learned, and transmitted through socialization.

Gender identity: A person’s private, inner sense of being a man or a woman (or a boy or a girl). For trans* people, the gender identity is different from the sex they were assigned at birth.

Gender expression: This is the outward expression of our gender identity, and refers to the manifestation of masculinity, femininity, and other gender variations: clothing, haircut, voice, and other physical characteristics. For trans* people, gender expression is generally a reflection of their gender identity and not their biological sex.

Sexual orientation: Defined in relation to the sex we experience desire and affection for, emotionally as well as physically. It can consist of an attraction to people of the opposite sex, the same sex, or both. Sexual orientation is an important part of our overall identities, that is to say, the way we think of ourselves, and the way others think of us. Note, however, that it is not tied to either sex or gender. It can also change over time, as a function of our experiences and encounters. Romantic orientation is not the same as sexual orientation, but the two can be related: you can love and desire a person, and have feelings for them, without feeling sexual desire, or on the contrary, be sexually attracted to a person without having romantic feelings towards them.

Sex role*: The attributes and behaviours defined by a given culture as belonging to a particular sex.

Sex role stereotypes*: A collection of shared cultural beliefs about the traits or qualities of men and women.

* these definitions were taken and translated from: Lexique sur les différences sexuelles, le féminisme et la sexualité (French)