3. SEXUAL HEALTH

3.1. INTRODUCTION

Our sexuality, well‐being, and physical health are closely intertwined. Most of us do not even give it a second thought, especially if we’re in good health. On the other side, we may experience difficulties and issues related to our physical and mental health, many of which may have a significant impact on our sexual life.

To properly prevent or address these issues, we first need to educate ourselves about them. Here are some questions that can be a good start:

• What are our attitudes and feelings about our bodies, how are these influenced by culture and media and how does this influence our sexual lives? 
• How does body image impact our sexual lives?
• How and why are alcohol and drugs involved in human sexual lives? 
• How can specific diseases influence our sexual lives physically and emotionally?
• Do LGBTQ+ people face specific challenges in terms of their sexual health?

Sexual health is rather a complex state of well-being and encompasses more than just the absence of STIs or diseases STDs. According to WHO (n.d.), talking about sexual health requires a positive and respectful approach, in which it is possible to have sexual interactions and pleasurable experiences which are safe and free of coercion, discrimination and violence. To achieve sexual health, fulfilment of certain human rights is also needed (health and reproductive rights). Sexual health can be also influenced by mental health and communication, for example in stating one’s boundaries, capability of asking and giving informed consent or agreeing on contraception methods. The physical aspects of sexual health are connected to states such as STIs, RTIs (reproductive tract infections) health status.

Other definitions of sexual health can include considerations of (1) the role of sexuality and relationships (either romantic and/or sexual) in our healthy lives; and (2) the role of positive experiences of individuals and their partners. 

Knowing and understanding our bodies and being at ease with them is necessary for good health. Knowing how different human bodies work is also essential to sexual health. It is recommended to teach children and youth about reproduction, hygiene, diseases, and prevention/protection options. But it is equally important: to know your own body and boundaries and to be able to understand what bodies of other people can experience and discuss and respect their boundaries. 

Some challenges to sexual health may also interfere with various cultural norms including the masculinity and femininity representation. For example, masculinity norms may motivate men to disregard their pain and suffer in silence, whereas sexual health of people of all genders requires them to be honest, knowledgeable, and responsible about their bodies and be mindful about its relationship with their sexuality.

3.2. DEVELOPMENT OF THE TOPIC

3.2.1. Sexual health and desire

Differential desire, how much desire is “normal”?

Sexual desire can be affected by many factors, and it is absolutely normal that it changes over time. Here are a few factors that can influence our sexual desire:

• Physical and psychological causes in people of all genders, role of stress and relationships.
• Health problems such as diabetes and alcohol misuse can cause erectile problems. 
• Prescription drugs can affect sexual responsiveness.
• Multiple psychological factors, have multiple individual influences, including: 

• Fatigue and stress, sexual anxieties, excessive need to please a partner. 
• Internal conflict caused by religious teachings, guilt, internalized homophobia can contribute to dissatisfaction, as can relationship conflicts.

Anxiety and distress may also lead to potential erectile and orgasmic problems and premature ejaculation. Another form of changed sexual desire which can be harmful to the person is Hypersexuality.

As stated above, sexual health is intertwined with many other health-related areas and factors. We will now explore some of them.

3.2.2. Behaviours that increase vulnerability to disease (or “risk behaviours”)

• Substance use

Alcohol and drugs are commonly normatively perceived as enhancers or as ice-breakers, but the reality is often very different. Some people use alcohol to give themselves permission to be sexual, however, alcohol or drug use may lead to risky sexual situations, have inhibitive effects, or increase the risk of acquiring sexually transmitted infections. The latter can happen as a person under the influence of drugs or alcohol cannot always be fully aware of their needs and may change their sexual health boundaries, omit conversations on contraception and/or safer practices.

• Chemsex

Chemsex can be defined as engaging in sexual activities under the influence of specific recreational drugs, commonly to sustain, enhance, prolong, disinhibit, or facilitate the experience (Drysdale, 2021) or the use of drugs specifically for or during sex (Maxwell, Shahmanesh, & Gafos, 2019). The drugs usually included are various illegal stimulants which can be collectively called fourchems (Uholyeva & Pitoňák 2022). 

Alcohol, cannabis, and poppers are usually excluded from definitions of chemsex. It is typically substances like crystal methamphetamine, mephedrone (or other powerful stimulants), g-hydroxybutyrate (GHB)/γ-butyrolakton (GBL) or ketamine – collectively known as fourchems that are most typically associated with sexualised drug use. Chemsex practices increases number of sexual partners and is typically associate with higher vulnerability to disease. Chemsex may increase the risk of acquiring HIV or other STI and is more typical among men who have sex with men (MSM), but may or may not identify as gay, bisexual, heterosexual, etc. Participation in chemsex peaks between mid-thirties to early forties but is evident at all ages (Maxwell, Shahmanesh, & Gafos, 2019; Blomquist et al., 2020). The use of digital technologies and sexual dating apps significantly contributes to the spread of chemsex culture (Drysdale et al., 2020). Psychosocial interventions are effective, but they need to address both drug and sexual-related harms (Knight et al., 2019).

Talking about substance use and abuse is a valuable factor in having conversations about sexual health and consent as it is important to teach that everybody reacts differently to drugs/alcohol and how it might change the perception of reality. While consuming alcohol and/or drugs it might be harder to stay safe both physically (prevention of STIs transmissions and avoiding sexual violence) and mentally (being able to consent, keep boundaries, engage only in preferred activities), etc.

3.2.3. Sexually Transmitted Infections (STIs) and Sexually Transmitted Diseases (STDs)

Firstly, it is important to acknowledge the difference between STIs and STDs. STIs are infections that can be passed through sexual contact of two people, when mucous secretions, blood, saliva, semen and rubbing of skin are included in the practices. When untreated, some STIs can turn into STDs. For example, you can have a sexually transmitted infection in your body without having any symptoms and you can pass it through unprotected sexual contact. This infection might then develop physical symptoms into the person to whom it was passed, turning it thus into an STD. The most common STIs are: chlamydia, gonorrhoea, trichomoniasis, genital warts, genital herpes, pubic lice, syphilis. The most common STDs are hepatitis B & C, syphilis, and HIV. 

One STI that goes mostly undetected and that roughly 75% of sexually active people will have at some point in their life is the human papilloma virus (HPV), according to the Centre for Disease Control and Prevention (2021). This happens because HPV can be transmitted through protected sex too. However, according to the same centre mentioned above, 9/10 times it will go undetected, and your body will eliminate it within two years. Several vaccinations are available that can protect against certain strains of the HPV. Untested and untreated, some strains of HPV carry a high risk of developing cervical cancer (in female bodies) and genital warts (in both male and female bodies).

As it was mentioned above, many times people who have an STIs, may not show any symptoms, which makes it easier to pass it on to another person. The easiest way to prevent this from happening is to get tested regularly and to have conversations around sexual health status with partners you are sexually active with. If the infection is symptomatic, it can become visible through: pain when peeing, unusual discharge from the vagina, penis or anus, skin changes around genitalia and anus, rash, and others (NHS – National Health Service, 2021). The most reliable way to prevent getting an STI is to use protection, such as condom for vaginal, oral, and anal sex at all times. 

However, some infections such as HIV may be present in the body of the infected individual and yet be invisible to testing, which is called diagnostic window. For example, HIV may be invisible to testing for 4-12 weeks after the contact whereas individuals may already be infectious. If there is a suspicion of potential risky sexual contact – it is then most safe to wait, abstain from new sexual contacts and get tested after this period.   

This is why it is important to acknowledge that STIs and STDs are part of your life if you are sexually active. STIs are not something to be afraid of but rather something that you should be informed about so everyone can care for themselves, prevent, and treat them and have a satisfying sexually healthy life. Getting tested and talking about the subject with partners are two practices that can help anyone achieve that. Another one could be talking to the doctor or regularly informing and educating oneself instead of perpetuating fear, misinformation or myths related to sexual health.

Young people can be especially vulnerable to STIs and STDs because they are sexually active and they also have higher tendency for behaviours that may make them more vulnerable due to their psychosocial and neurological development (Berenbaum, Beltz & Corley, 2015; Hazen, Schlozman & Beresin, 2008). This can happen out of lack of knowledge or the perpetuation of myths and misinformation around sexual health, which are consequences of making sexual and reproductive health a taboo subject.

• The Human Immunodeficiency Virus (HIV)

HIV is one of the most stigmatized STIs being fuelled by misinformation and the spread of fear instead of education. If untreated or undetected, the virus can develop into a life-threatening disease known as Acquired Immunodeficiency Syndrome (AIDS). However, when detected and treated by antiretroviral treatment (ART), the virus can become untrasmittable and the person can lead a happy and fulfilling life. HIV has become particularly widespread among MSM, who are regarded this way by epidemiologist who understand that MSM may identify variously (gay, bisexual, heterosexual, etc.). The reasons for why MSM are particularly more vulnerable to HIV are complex and they are most efficiently described in terms of so-called HIV syndemic – a synergistic influence of multiple epidemics, including frequent simultaneous infections or health conditions (e.g., with other STIs such as syphilis), but also other behavioural factors and societal conditions (Pitoňák, 2018). The syndemic factors include:

• Biological factors: 

• Unprotected anal intercourse (UAI) being a more common sexual practice among this group and, at the same time, UAI being a practice with higher chance of HIV transmission (Patel, et. al., 2014) approximately having 20 times higher chance of transmission compared to vaginal intercourse (Baggaley, White, & Boily, 2010). Yet it is important to recognize that as anal intercourse is gaining popularity among couples of various genders it is an important factor to be mentioned when informing about HIV prevention and transmission in general.
• MSM being a group with higher prevalence of HIV infection then automatically generating a higher risk for an individual man having sex with men to be infected when engaging sexually.

• Social and cultural factors:

• Societal stigmatization of non-heterosexual people and minority stress which cause non-heterosexual people having higher prevalence of mental health issues.
• Stigmatization also systemically disadvantages gays and lesbians, for example, in terms of their relationship-seeking practices (e.g., are their chances of meeting their partners or seeking their partners equal in cisheteronormative societies?) or via access to preventative tools such as PrEP or PEP (e.g., these may be difficult to access, expensive to pay for) or impact their socioeconomical status.
• Stigmatization of HIV/AIDS in general – information about the virus being shared with intention to cause fear and moralize against people, which may lead to less open communication and concealment behaviours and lower willingness to get tested (e.g., due to fear of shame etc.).

• U = U

An important factor to be mentioned when talking about HIV is a principle based on a concept of treatment as prevention (TasP) which postulates that ART is an effective form of treatment, limiting the virus’s presence in the bloodstream and other bodily fluids to the extent which makes it practically Undetectable. What is more important that despite the fact that modern technologies can detect even very low number of HIV particles in the body, the so called undetectable viral loads have been scientifically proven to effectively block the transmission chances to zero (0) and that is why it is equated with the word untransmittable. The meaning of this abbreviation is Undetectable = Untransmittable (Leahy, 2018). There is robust scientific evidence to demonstrate the validity of U=U concept, and it has become a tool for destigmatization.  U=U is valuable in prevention of further transmission of the virus because it lowers the stigma of living with HIV and also of learning more about it. Achieving and maintaining undetectable viral load depends on consistently taking the antiretroviral medication as prescribed (Eisinger, Dieffenbach, & Fauci, 2019).

• Pre-exposure prophylaxis (PrEP)

Pre-exposure prophylaxis is medicine (a type of ART therapy) that is taken by individuals who are not HIV positive in order to protect them against getting HIV from sexual contact or injection drug use. PrEP is typically taken by those individuals who would otherwise be more vulnerable to HIV infection without it and where traditional methods such as use of condoms may not represent a reliable-enough option (e.g., individuals may be aware of that they cannot or do not want to use condoms in all situations, such as situations of substance use). PrEP is typically a prescribed drug, but in some countries, it may be easily accessible. The use of PrEP is however always advisable under periodical check-ups. PrEP can stop HIV from taking hold and spreading throughout the body with very high efficacy (Desai et al., 2017). However, it does not offer protection from other STIs. Accessibility of PrEP is limited for some groups of people for example due to its price or process of getting it. 

• Barrier protection

Barrier protections are instruments that reduce the risk of transmission of STIs or STDs.

The most well-known and used one is the condom for penises. However, there are other protection methods such as the vaginal condom (for insertion into the vagina. See Figure 2) or the dental dam (it covers the vulva or anus, so it is useful for oral sex. See Figure 3). Unfortunately, these types of barrier protection are not as widely available, but you can definitely buy some in most sex-shops. You can read more about protection methods in the topics related to European Laws, under sexual and reproductive health.

Figure 2. Vaginal condom

Figure 3. Dental dam

Some of the most common reasons why  people have unprotected sex is lack of information about the form of spreading of STIs and STDs. It often happens that one of the partners refuses to use a condom for various reasons, which can make it difficult to communicate one’s own need for safety during sex. What you can do in these situations is talking to your partner about your own needs, boundaries and preferred protection methods and find a common solution that would make everyone involved feel safe. Couples sometimes consensually opt for not using condoms (for instance visit testing frequently, have stable relationships, use other contraceptives, etc.), but it always must be a result of shared decision.

• Types of contraceptive methods to prevent unintended pregnancy (NHS, 2021):

• Hormonal pills: pills containing hormones, most of them contain a combination of oestrogen and progesterone and can be used by people with a uterus as it prevents the release of the egg. The prescription is usually to take 1 pill a day (around the same hour every day) for 21 days a month. In the next 7 days when no pill is taken the bleeding should occur. After those 7 days starts another 21 days of taking pills every day. The pill can have a lot of side effects and also can interact with other medication, so it should be consulted properly with a gynaecologist and GP. Side effects can vary but the most common are increased risk of having vein thrombosis, acne, headaches, bloating, and fatigue, and mood swings (Teal & Edelman, 2021). Lot of people report also changes in the way they experience stuff, like different energy levels, loss of sexual libido and changes regarding the period. Taking pills should be always thought through while weighting the pros and cons carefully. If used correctly, the pill can have 99% of efficiency in preventing a pregnancy. Other types of hormonal pills are pills with progestogen, which are taken every day without a break. The other rules of usage (taking the pill around the same time a day) are the same and the efficiency is similar. The efficiency of hormonal pills might be affected when having stomach problems, vomiting or diarrhoea.
• Condoms: there are two types of condoms, which are a) external condoms to be placed on the erected penis and b) internal condoms, that are inserted inside of the vagina or anus. Both types of condoms, if used properly, prevent unwanted pregnancy as well as transmission of most STI. Condoms are the safest and most efficient method to keep you safe from the transmission of STIs through penetrative sex.

• External condoms are usually made out of latex, but can be also found from different materials in case of allergy to latex. Lubricants can be used with condoms, but should be water-based so they don’t affect the function of the condom. Condoms can be used only once. When you have sex again it is needed to use a new one. Condoms should be ideally stored in not too hot and sunny places, avoiding sharp objects, and used before expiration date. When unpacking a condom, it is good to be careful when opening it so it does not get pierced or damaged in other ways. Then, place it on top of the erected penis and roll it down to its base, making sure it holds good. You can check once in a while if the condom holds on well. Be careful to hold the condom from the base when pulling the penis out of the vagina/anus to avoid possible slipping., Condoms are 98% effective.
• Vaginal condoms work on the same principle as external condoms by creating a barrier on the inside so that the semen cannot reach the egg and cause a pregnancy. The condom should be inserted into the vagina before sex, making sure the penis does not touch it before. When opening the condom, be careful to not use your teeth or sharp object in order to avoid risk of tearing it. Place the smaller ring inside of the vagina and the bigger ring of the condom at the opening of the vagina. One of the risks when using a female condom is that the penis can slide in between the condom and the side of the vagina, or if the condom gets pushed too deep there is a possibility that it could get stuck into the vagina. Vaginal condoms are 95% effective.
• An IUD which is a small object placed into the uterus, can be either hormonal or non-hormonal. It has to be fitted in only by a gynaecologist. Each type of IUD has different specifics and can have its protective function against unwanted pregnancy for up to 5 years. This can be a convenient form of contraception for some people since it requires low effort and is highly effective in preventing pregnancy (99%). Yet some people might experience increased pain and heavy bleeding during periods when having intrauterine devices. IUD does not protect from STIs and STDs.
• Contraceptive patch: a sticky patch, looking similar to a plaster, which is releasing hormones to one’s body through the skin. It contains the same hormones as the pills (progesterone and oestrogen) and it is made to be used by people with a uterus. Use the patch as instructed on the package. One patch should be worn for approximately one week and then switched for a new one. Patches are also used in the cycle of 4 weeks, 3 weeks with patch (each week a new one) and one week patch free. It should be resistant to water and sweat so no restrictions in regime are needed. The possible side effects can be similar as with hormonal pills, including heightened blood pressure.
• Contraceptive diaphragm or cap is a silicone cap which is inserted into the vagina before sex. The cap covers the cervix and creates a barrier so that the sperm cannot enter the uterus and fertilize the egg. The cap has to stay inserted for at least 6 hours after sexual contact to be efficient, and it is recommended to be used together with spermicide gel making circa 94% of efficiency in preventing a pregnancy. The caps are of various sizes so it can take some time to find the right size and to learn how to use it properly. One cap can be used repeatedly for proximately 1-2 years.
• Vasectomy is a surgical procedure for people with testicles to cut or seal the tube with sperm and therefore prevent pregnancy. Vasectomies can be reversed again with surgical reconnection of the tubes, yet the procedure of the reverse surgery is not guaranteed to work, especially the longer it took since the vasectomy was done. First few weeks (8-12) after the procedure other contraceptive methods should be used because there might still be sperm in the tubes. After vasectomy, there will be ejaculation, but the semen won’t carry sperm. Some people can have problems with painful testicles after this procedure. 
• Female sterilization: for people with uterus it means blocking or sealing the fallopian tubes to prevent the eggs reaching the sperm and becoming fertilized. Most tubal ligation procedures cannot be reversed. If reversal is attempted, it requires major surgery and isn’t always effective.

Vaginal ring is a soft plastic ring which is placed into the vagina, and which releases oestrogen and progesterone to prevent pregnancy. Ring works for one month, when placed correctly inside of the vagina. If the ring comes out, it can be washed with warm water and placed inside again. It is more than 99% effective.

3.2.4. Sexual health and our body

Sexual health is also dependent on how we relate to our own body – to our body image -> You can read more about it in the topic on sexual maturation. Body image of a person can be greatly influenced when some forms of eating disorders are present, or the distorted body image can enhance restrictive dieting, extreme training, or other dietary behaviours. Both body image and eating disorders are vastly influenced by social media (Hogan & Strasburger, 2008). Negative body image can also lead to desire for body modifications such as having a lean figure, getting a tattoo, piercing or other decorative attribute, but it can be also expressed through clothing, with usage of anti-aging products or undergoing plastic surgeries, (Antonova et al., 2019; Song, & Kim, 2005).

• Sex should not hurt

Pain signals that something is wrong. It can be caused by insufficient lubrication or perhaps stress. When sex hurts (and it is not a part of consensual BDSM practice), we should stop or slow down. If the cause is stress or fear, which is very common especially when having sex for the first time or with a new person, it is important to communicate this with your partner and do things that calm and relax the muscles. If the cause is insufficient lubrication, it is possible to use a lubricating gel. This is especially necessary during anal sex. Pain during sex can also have more serious causes such as vaginismus, endometriosis, or phimosis. In such cases, it is important to contact an expert – gynaecologist or urologist.

• Breast cancer 

Even though breast cancer among teenagers is extremely rare, the risk for adolescents and young adults is getting higher, so it might be good to mention preventive self-examination or sources of information for future use (mammogram and health insurance coverage), talk about the most common symptoms like new lump(s) in the breast or underarm, change of shape and size of the breast, swelling and other, self-examination is ideal to do once a month.

• How to self-examine (more precise instructions can be find here)

• Best time to self-examine is 1-2 weeks after period
• Visually check your breasts in front of the mirror while standing, both with your hands down and above your head to see any possible changes
• Then when laying down flat on your back, with light pressure in your two or three fingers go around the breast tissue with circular motion, both on the surface and bit deeper and notice any lumps or hardness.

• Testicular cancer 

It affects young people from 15 years old so it is important to inform teenagers about it. The typical symptoms are painless swelling or lump in one of the testicles, any change in shape or texture of the testicles, change of firmness of testicle. Best preventive measure is also self-examination, preferably done once a month. 

• How to self-examine (more precise instructions can be find here):

• Hold the top of one testicle between your thumb and point finger and hold the bottom with your other hand.
• Gently roll the testicle with a light grip feeling for hard lumps or bumps.

• Genital mutilation 

Usually, female genital mutilation can be defined as procedure of removing healthy external genitalia from girls/women for socio-cultural reasons in countries outside of Europe, often without their approval or full understanding of the consequences of the procedures. The genital mutilation can in worst cases lead even to sudden death. Other immediate effects can be severe bleeding, intensive pain, infection, injuries of neighbouring organs, urine retention and a huge shock. Long term effects can be forming of cysts, formation of abscess, long lasting infections, and many others. There it has also huge negative impact on pleasure and sexual life of the people who undergone this intervention (WHO, 1998). Psychological effects are commonly occurring after such procedure, mainly Post-Traumatic Stress Disorder (PTSD) and affective disorders, yet this area needs more research since the majority was focusing only on physical effects. Involving information about genital mutilation can be part of discussion about cultural/beauty standards in different cultures and how they harm healthy bodies (Mulongo, Hollins, & McAndrew ,2014). 

-> You can read more about these topics in sexual maturation section

3.2.5. Mental health topics

Mental health problems in sexual minorities and gender diverse people first need to be put in context of historical (however at some places still prevalent) pathologizing and medicalizing of “homosexuality” or “transsexualism” which introduced persisting forms of stigma that may complicate even the contemporary affirmative and destigmatizing conversations regarding mental health and well-being of LGBTQ+ youth and adults. Up until the publication of tenth edition of International Classification of Diseases in 1990, “homosexuality” could have been pathologized per se, whereas it was only in 2019 when obsolete and stigmatizing “transsexualism” was substituted by “gender incongruence” that allows for depathologizing of normal human gender diversity. 

However, despite this recent depathologization, which clearly shows that there is nothing ill or wrong about being LGBTQ+ person, research on well-being and mental health among LGBTQ+ people continue to prove that life in a world that upholds various cisheteronormative forms of marginalizing, discrimination and stigma constitutes additional challenges that may cause additional psychological distress and lead to health disparities. These additional challenges are often encapsulated within a term minority stress (including stigma, discrimination, family disapproval, social rejection, violence and other forms of victimization and marginalization), For example, international research demonstrates that the likelihood of sexual assault, dating violence, and bullying is much higher among LGBTQ+ students compared to their heterosexual peers (Pitoňák, 2017; Plöderl, & Tremblay, 2015). As a consequence of this minority stress, international research continues to substantiate that LGBTQ+ individuals face additional and significant distress that may translate into severalfold higher levels of anxiety or depression, severalfold higher suicidal ideation and attempts of suicide, more frequent substance use, as well as higher rate of missing school, for example, due to their safety concerns. In addition, fear of discrimination within their families and health care system, causes many LGBTQ+ people to avoid seeking appropriate care. 

The importance of awareness about mental health impacts of stigma, marginalizing and  discrimination, however, do not end with knowing their ill-effects. We also need to be aware of strategies that may help diminish their effects. For example, schools may introduce policies that embrace diversity and inclusion within the school environment and make sure that this policy is clearly heard by all (e.g., including potential bullies). Research has, for example proven that students in  those schools that introduced such policies had lower suicidality compared to those in schools without such policies (Hatzenbuhler, 2011). 

-> You can read more in the topic  Identity: Sexual diversity.

– 3.3. SITUATIONS OF DISCRIMINATION RELATED TO THE TOPIC –

Many stereotypes and prejudicial misconceptions may be hurtful, including:

• Expectations of men being always ready for sex.
• Gay men cannot form stable and caring relationships and are only interested in casual sex.
• Well behaved girls are not interested in sex. 

Is the lecture and information about HIV always linked to the debate about LGBTQ+ people? This is an example of the stigmatization of LGBTQ+ people, especially the gay community.

• Gay and queer LGBTQ+ people being associated automatically with higher rates of STDs 
• Stigma around medication, such as PrEP – e.g., treating people who want to use it as people who want to be irresponsible in their sexual behaviours. 
• Shaming people for living a rich sexual life.

3.4. BEST PRACTICES

3.4.1. Tips regarding sexual health in general

Recognize and accept that individuals experience different rates of physical, emotional, sexual and social development.

You do not have to worry about telling your kids something you think they are not old enough for. If they ask you then it is a good time to answer their questions truthfully and in an age appropriate way.

Remember that sexual health does not equal absence of disease, it is far more complex as it also encompasses emotions and psychological well-being, including stress factors and societal norms towards sexuality. Speak about range of various behaviours within sexual expression and give information about what sexually healthy actions and choices can mean.

When speaking about sexual health, include definition of and discussion about peer influence and how it can affect one’s sexual behaviour and how societal gender norms influence it too. Practice decision making about own boundaries and sexual health and how making rational decisions may look like. Activity on practicing assertive communication, refusal and negotiation can be performed too (Women, U. N., & UNICEF, 2018).

It is recommended to start with discussing our body health in general – how we can take care of our sexual health and highlight positive sides of it – we can feel pleasure, etc.

3.4.3. Tips regarding mental health

Allow students to explore and understand the importance of their needs, rights and how these affect their well-being. State what mental health means and describe some factors which can lead to poor mental health. Include discussing possible ways to prevent and support mental health of oneself and others, while also discussing psychosocial support and mental health care and how to get it (FHI360 Open Doors Project, 2019).

3.5. REFERENCES

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APA (n.d.). Masturbation. Available from https://dictionary.apa.org/masturbation

Antonova, N., Merenkov, A., Gurarii, A., & Grunt, E. (2019, May). Body Image: Body Modification Practices. In 2019 International Conference on Pedagogy, Communication and Sociology (ICPCS 2019) (pp. 289-292). Atlantis Press.

Baggaley, R. F., White, R. G., & Boily, M. C. (2010). HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention. International journal of epidemiology, 39(4), 1048-1063. https://doi.org/10.1093/ije/dyq057

Berenbaum, S. A., Beltz, A. M., & Corley, R. (2015). The importance of puberty for adolescent development: conceptualization and measurement. Advances in child development and behaviour, 48, 53-92.

Blomquist, P. B., Mohammed, H., Mikhail, A., Weatherburn, P., Reid, D., Wayal, S., … & Mercer, C. H. (2020). Characteristics and sexual health service use of MSM engaging in chemsex: results from a large online survey in England. Sexually transmitted infections, 96(8), 590-595.

Centres for Disease Control and Prevention (2021). Sexually Transmitted Infections Prevalence, Incidence, and Cost Estimates in the United States. Available from https://www.cdc.gov/std/statistics/prevalence-2020-at-a-glance.htm

Desai, M., Field, N., Grant, R., & McCormack, S. (2017). Recent advances in pre-exposure prophylaxis for HIV. BMJ, j5011. doi:10.1136/bmj.j5011

Drysdale, K. (2021). ‘Scene’as a critical framing device: Extending analysis of chemsex cultures. Sexualities, 1363460721995467.

Drysdale, K., Bryant, J., Hopwood, M., Dowsett, G. W., Holt, M., Lea, T., … & Treloar, C. (2020). Destabilising the ‘problem’of chemsex: Diversity in settings, relations and practices revealed in Australian gay and bisexual men’s crystal methamphetamine use. International Journal of Drug Policy, 78, 102697.

Eisinger, R. W., Dieffenbach, C. W., & Fauci, A. S. (2019). HIV Viral Load and Transmissibility of HIV Infection. JAMA, 321(5), 451. doi:10.1001/jama.2018.21167.

FHI360 Open Doors Project (2019). Gender, sexuality, and sexual orientation. Training manual. Available from https://www.fhi360.org/sites/default/files/media/documents/resource-zambia-open-doors-gss-training-manual.pdf

Hatzenbuehler, M. L. (2011). The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth. PEDIATRICS. 127: 896-903.

Hazen, E., Schlozman, S., & Beresin, E. (2008). Adolescent psychological development: a review. Pediatrics in review, 29(5), 161-168.

Hogan, M. J., & Strasburger, V. C. (2008). Body image, eating disorders, and the media. Adolesc Med State Art Rev, 19(3), 521-546.

Knight, R., Karamouzian, M., Carson, A., Edward, J., Carrieri, P., Shoveller, J., … & Fast, D. (2019). Interventions to address substance use and sexual risk among gay, bisexual and other men who have sex with men who use methamphetamine: a systematic review. Drug and Alcohol Dependence, 194, 410-429.

Leahy, B. (2018). Language used to convey HIV infection risk is important. The Lancet HIV, 5(6), e272. https://doi.org/10.1016/S2352-3018(18)30103-6

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