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In our society we tend to equate sex with health and youth and assume that the ill and the handicapped are sexless. This simply is not true. Only during the most acute of illnesses do people go off sex, and increasingly doctors are realising that couples continue their sex lives wherever possible if they have chronic illnesses.

Heart disease and high blood pressure-During intercourse the heart rate may double, as may the breathing rate, and the blood pressure rises too. There is considerable public concern that sexual activity with heart disease or high blood pressure is dangerous or even possibly fatal. Such deaths are in fact very rare and when they do occur they do so more commonly during extramarital intercourse.

Advice about sex after a heart attack varies enormously but it is probably safe to resume sexual activities five to ten weeks after the heart attack unless the attack was exceptionally severe. One way to tell if you are ready is to see how you feel after a quick walk or after going up a couple of flights of stairs.

People with angina should take a tablet before intercourse and should ideally avoid sex immediately after a meal.

Even if one of these conditions makes one wary of returning to or carrying on with intercourse there are several half-way houses that can be tried which stop short of actual intercourse and its exertions.

Mutual masturbation relieves sexual tensions but is less strenuous. The next stage can include woman-on-top positions – when it is the man who is recovering – in which the woman makes most of the physical effort. Slowly a couple affected by heart disease can wean themselves back to normal sex life.

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Many women when they masturbate, or couples when making love, put objects other than their fingers into the vagina, and many wonder if this is safe.

The vagina is fairly tough but anything which might break whilst inside, scratch or be difficult to retrieve afterwards should be avoided. Penis-shaped objects such as brush handles, suitable bottles, fruits, candles and much else, as well as vibrators, are all used. Persistent use in self-masturbation sometimes suggests a higher-than-average degree of guilt about the sex act. Some women even destroy the object after use.

None of this can be regarded as perverse unless masturbation itself is so regarded. More questionable are insertions designed to inflict pain (and orgasm).

Anal sex-Technically, anal sex is illegal between a man and a woman but not between two men of the required age and by mutual consent in private. Until 1861 anal sex was punishable by death in England and it is still illegal in some states of the US.

About two in five married couples admit to having tried anal sex (although the actual figure is undoubtedly higher than this) and historically it has been widely used as a form of contraception and at times when the woman was menstruating or had a vaginal infection.

Anal intercourse is perfectly acceptable medically with a few provisos. First, the man will have to take things gently if he is not to hurt the woman. A couple who want to have anal sex should spend some days preparing for it. Start by gently inserting a well-lubricated finger tip into the woman’s anus while she masturbates or while you are having intercourse. Over the next few days insert another finger or two, never causing pain, and then eventually – with plenty of lubrication – try to use the penis.

The only real problem with anal sex is that it is easy to transfer bowel germs from the anus to the vagina and this can cause troublesome infections. If a penis has been in the anus it should be thoroughly washed before being put into the vagina, or indeed anywhere else. Of course a condom can be used.

Due to AIDS, anal intercourse is best avoided with partners who might have been exposed to HIV injection (whether in a homo- or heterosexual context). It is twice as risky in this context compared with vaginal intercourse.

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Let us now look at the sexually transmitted diseases in turn. But before doing so let us consider vaginal discharges because they can cause such confusion and worry.

This is a viral disease which, it is strongly suggested, can be transmitted via saliva, semen, menstrual flow and other body fluids. To this extent it can probably be transmitted sexually. Homosexuals are more likely to be affected than heterosexuals and the disease is important because it can cause chronic damage to the liver. Having said this, the majority of infections are symptomless and self-limiting. Unlike with other types of venereal disease there is no way of detecting carriers of the disease nor is there any way one could suspect a potential partner of having it. A vaccine is now available against the disease.

Scabies (the itch)-This is an infestation with tiny mites which usually cause itching, often in the webs of the fingers, around the waist, on the wrists and under the armpits. Tell your doctor or special clinic – treatment is simple and effective.

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Unusual practices, although less bizarre, are more widespread amongst girls and women, as we pointed out earlier. The most basic pattern though is to lie in the normal female intercourse position and stimulate the vulva directly with the hand. The variations thereafter are immense. For example, the whole vulva may be massaged or one specific area of the side of the shaft of the clitoris lightly stroked. The edges of the inner lips may be specifically rubbed or they may be trapped between the fingers. A vertical or circular motion may be used. Some women press so hard that their knuckles turn white. This may be because their clitoris has fewer nerves than average. On reaching the plateau stage of sexual response many women change their type of stimulation. As orgasm approaches the area stimulated may be well away from the clitoris. Intermittent stopping is characteristic, although guilty women may race to have an orgasm as quickly as possible to get it out of the way.

Intermittently, one, but more commonly two, fingers may be inserted into the vagina and rotated rather than moved in and out. Since only the entrance of the vagina is very sensitive the purpose’s are to delay progress to orgasm, simply for the pleasure of it and, frequently, to act out a fantasy of penetration. Objects may be used to stimulate the vulva and are sometimes inserted into the vagina. The commonest object used like this today is probably the battery-driven vibrator, but in the past a huge variety of objects has been used if articles which have had to be medically removed from women’s vaginas are anything to go by.

Women are more reluctant to admit that they do anything to their vaginas when masturbating than they are to massaging and caressing the vulva. Some women use only the vagina when masturbating. It is in masturbation rather than in intercourse that women demonstrate their greater sexual capacities than men – although of course they may not fully use them. Women have been known to obtain fifty and (many) more orgasms in a single session. Such sessions are sometimes repeated frequently, especially if a vibrator is used. Clinically such women are no more likely to be ‘neurotic’ or ‘obsessional’ than other women (as has been suggested by ‘experts’ over the years), nor are they more likely to show over-growth of the inner lips or clitoris than are other women (as some women fear). Such an over-growth, which many women attribute to masturbation, is probably part of the normal anatomical variation between individuals. During early adolescence the labia may be more vulnerable to such enlargement.

In later life many women who have nothing physically wrong with their uterus or their hormones, but who nevertheless menstruate so heavily and so frequently that they are likely to end up having a hysterectomy, are, on psychosexual investigation, found to be poor and inadequate at having orgasms when masturbating and during intercourse. They often express strong opposition to masturbation. Psychosexual therapy designed to reverse the opposition to indulgence in sexual pleasure can sometimes bring the situation under control without a hysterectomy being needed. The underlying cause of the bleeding is possibly the continuous congestion of blood rarely relieved by orgasm.

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There is now no doubt that breastfeeding is best for a baby, yet few babies are still being totally breastfed at one month. It is true that more than half of mothers breastfeed their babies in hospitals in most of the Western world today, but as soon as they get home ‘problems’ intervene and the babies are soon on the bottle.

Men are well known to influence their partners’ choice of feeding method and successful breastfeeding is much more likely if the man is supportive. Breastfeeding counselling experience indicates that breast feeding is not so much a matter of nutrition as of sex; most women think of their breasts as having a sexual function first and a nutritional one second. Many men and slightly fewer women feel that a woman’s breasts (and therefore her sexual attractiveness) may be permanently affected for the worse if she breastfeeds. Research shows that this is not so. It is pregnancy with its breast enlargement that causes sagging, if it occurs at all, and not breastfeeding.

Letting the breasts become stretched and over-full (engorged) is probably detrimental too. It is sensible to wear a well-fitting bra in the last few months of pregnancy, even at night, so that the breasts’ natural supportive tissues are given some help, and to wear a bra all the time whilst nursing.

Many men are jealous of the baby being at their partner’s breasts so much and some create a real fuss. The woman herself, the man and their baby can all enjoy them. In fact a lot of women feel more sexy and breast-centred when they are breastfeeding than they ever usually would and this can be to the man’s advantage.

Making love while lactating needs a few words. Many women’s breasts become tense and uncomfortable when they are full, especially if squeezed or played with sexually. The answer is to express some milk or feed the baby before making love so as to reduce the tension. This also makes milk leakage less likely if the woman has an orgasm. One answer is to encourage her man to suck her nipples while making love. There will be plenty of milk left for the baby. Intercourse positions have to be chosen so as not to squash full breasts but this is usually no problem for most couples.

One important thing about breastfeeding from a sexual point of view is for the woman to encourage her man to fondle her breasts, even if he is reticent or shy. This helps prevent him from feeling completely left out.

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Health care workers are at risk through contact with potentially infected patients and their body fluids. Other people are sometimes also inadvertently exposed to body fluids or needle-stick injuries. The risk of infection in this way depends on how much virus is present in the fluid or on the object (is the infected person encountered late or early in the infection, or during the middle period?) and how long the object has sat around after being used. It also depends on what type of injury a person sustains (was it a small scratch or a deep wound that went into the muscle?). A person who is stuck with a needle containing blood from an infected person runs about a 0.3 percent risk of becoming infected with HIV

Wearing gloves when coming into contact with potentially infected body fluids decreases the likelihood of becoming infected. Wearing two sets of gloves (a practice referred to as double gloving) decreases the risk from a needle-stick injury by about 50 percent compared to using just one set of gloves. This risk is reduced even further with the use of antiviral drugs immediately after exposure (see the section on treatment).

There is no evidence of transmission from infected health care workers to their patients, except for the widely publicized incident of an infected dentist who was found to have infected five of his patients during the 1980s. Exactly how this transmission occurred is not clear. A study of 15,000 patients of 32 infected physicians found that none of them had been infected by their providers.

Drug users who share injection drug works have a high risk of becoming infected with HIV In “shooting galleries,” where persons often share injection drug equipment and may exchange sex for drugs, one study found that a large percentage of the equipment was contaminated with HIV Using household bleach to sterilize the equipment for at least five minutes (and washing it with water afterwards) may decrease the risk of infection but does not eliminate it. The use of sterile needles, sometimes available through a needle exchange program, decreases the risk of HIV infection through injection drug use.

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Gonorrhea is transmitted through sexual contact with a person who is infected, whether or not the infected person has symptoms. The throat, genital area, and rectal area can become infected. Gonorrhea is very easy to transmit through sexual contact. A man who has unprotected genital sex with an infected woman has a 20-30 percent chance of becoming infected. A woman who has unprotected genital sex with an infected man has a 60-80 percent chance of becoming infected.

Gonorrhea is also easily transmitted through anal intercourse, and the rates of transmission for oral sex are similarly high, especially for a man or woman performing oral sex on a man who has gonorrhea. Similarly, if a man or woman has gonorrhea in the throat and performs oral sex on a man, the man receiving oral sex has a high risk of becoming infected in the urethra. However, a man or woman with gonorrhea in the throat performing oral sex on a woman has a lower risk of transmitting gonorrhea to the woman, because the area of the gonorrheal infection (the throat) is not contacted during oral sex with a woman. If the woman who was receiving oral sex from the man or woman had gonorrhea in the genital area, there would be a low risk of transmission as well, because the throat would not come into contact with the genitals or cervix.

Transmission does not occur through inanimate objects, such as towels or toilet seats. Condoms, if they are used consistently and correctly and do not break or leak, will prevent transmission of gonorrhea. Other barrier methods, such as diaphragms and cervical caps, may help prevent transmission to women, but they are not as effective as condoms in preventing infection. Nonoxynol-9 has antibacterial and antiviral properties in addition to being a spermicide, and therefore it may help prevent transmission of gonorrhea, especially if used with a condom.

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Depending on the study consulted, between 2 and 10 percent of the general population of men in the United States have sex with other men. They may be homosexual (have sex only with other men) or bisexual (have sex with both men and women). Some men may see themselves as heterosexual (have sex only with women) but occasionally have sex with male partners as well. As have lesbian women, men who have sex with other men have often had to evolve as sexual beings in an environment that has told them that what they are doing is wrong or immoral. That social pressure—along with the HIV epidemic, which in the United States and Europe initially hit the homosexual population the hardest—has made life difficult for many gay men in the last two decades.

Many men who have sex with other men have felt marginalized because of prejudice and excluded from traditional health care settings because of homophobia or the unvoiced assumption on the part of their health care providers that they are heterosexual. Health care providers do, unfortunately, sometimes bring their own prejudices into the work setting. Many health care providers do not receive education about STDs, let alone sensitivity training in dealing with sexual minority groups. This is not an excuse, but rather an unfortunate reality— one that is changing slowly.

For issues of sexual health, men who have sex with other men may choose to seek health care providers other than their regular providers, with whom they may feel uncomfortable being open about their sexuality. Clinics that provide health care primarily to men in same-sex relationships have come into existence since the 1980s for just this reason. Some men may feel more comfortable seeking sexual health care in county or city STD clinics, or in other settings where anonymity can be guaranteed. It is important for any person, irrespective of sexual orientation, to have a relationship with a nonjudgmental health care provider with whom he or she feels comfortable discussing these issues.

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However, in every state in the United States, when a person is diagnosed with gonorrhea, syphilis, acquired immunodeficiency syndrome (AIDS), or chlamydia, this fact must be reported to the state or local health department. This information is important in helping to develop programs in that area to help stop the spread of these infections. The health department will also assist those who have been diagnosed with these infections in contacting partners to be treated. This partner notification is done anonymously: The health department contacts partners and tells them “Someone you have been intimate with has been diagnosed with an STD, and you should be tested and treated, too.” The name of the person diagnosed with the infection is not revealed, and this information is not released to any other individuals or organizations, such as insurance companies. This is a very important way to help make sure that people get treated. The laws governing the reporting of STDs, including HIV, vary from state to state. Talk with your health care provider about the requirements for your state.

A final thought: Health care providers should not try to impose their own beliefs about sexuality Usually the first thing that happens when you visit a health care provider is that he or she takes a medical history by asking a lot of questions about your health, your behavior (for instance, “Do you smoke?“), and your family’s health. When you are seeking advice about sexual health, some of the questions you will be asked may seem embarrassing. It may seem that a health care provider is prying, but that is usually not the case. These questions help the health care provider assess or religion on patients. To be effective, the health care environment must be supportive and nonjudgmental. If it is not, you would be well advised to find another health care provider.

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The vagina is a muscular canal that is visible when the labia minora are spread open. From the time of birth, a membrane of tissue called the hymen covers the opening of the vagina; this membrane is usually torn with first sexual intercourse, though it can be torn before. The vagina is usually only 3-4 in. in length, but it can expand during childbirth and slightly during sexual intercourse in women who are past the age of puberty. There are normally bacteria in the vagina, the most common type being Lactobacillus. Some common infections of the vagina (which will be discussed in detail later in the book) are fungal (yeast) infections, bacterial vaginosis, and trichomonas infections. The vagina should not hurt or itch normally. A clear, odorless discharge from the vagina is normal for some women, especially during ovulation (the production of an egg from the ovaries), which occurs in the middle of the menstrual cycle. The cells of the vagina are shed constantly. This process, and the vaginal secretions that are normally produced, keep the vagina clean. Douching is not necessary.

Women whose mothers took the medication diethylstilbestrol (DES) during pregnancy in the 1960s have a higher risk for an unusual cancer of the vagina called vaginal adenocarcinoma. It is important to tell your health care provider if you fall into this category, since special tests must be done during your yearly Pap smear to screen for this type of cancer.

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