Handbook on

Sexuality for
HIV and AIDS
master trainers
TARSHI 2010
Copyright TARSHI and Saksham 2010
TARSHI 2010
Handbook on
Sexuality for
HIV and AIDS
master trainers
chapter 1 Why talk about sexuality? 4
chapter 2 About our bodies 9
chapter 3 Being sexual 20
chapter 4 Pregnancy and contraception 29
chapter 5 HIV and STIs 38
chapter 6 Safer sex 46
chapter 7 Abuse 50
Why talk
about
sexuality?
chapter 1
S
exuality in India is a very hush-hush issue, and
talking about it or even acknowledging that sex
happens is often considered taboo or wrong.
Our social system discourages sexual expression. This
can make sexuality, puberty and other experiences
confusing and embarrassing. And yet, sexuality is
a part of everyones life. It is an important, intimate
and extremely sensitive issue, which afects everyone,
regardless of gender or sexual orientation.
Most people do not have accurate sources of information
about sexuality. Often, they nd it very difcult to ask
any questions about it or talk about their problems and
doubts. This is especially difcult for young people,
who live in environments that discourage discussions
of such topics. People, who have sexually transmitted
infections (STIs) may not even know about these
infections, let alone know how to prevent them and how
get themselves treated before greater complications
arise.
Why do we need to talk about sexuality when
talking about HIV and AIDS?
The most important reason is that of the four diferent
ways by which HIV can be transmitted, the most
Handbook on sexuality for HIV and AIDS master trainers 6
common is through sexual intercourse. You cannot talk
about HIV and AIDS, therefore, without talking about
sex, sexuality and issues of sexual health. The silence
that arises from a sense of shame and embarrassment
about these issues is the leading cause of the spread of
STIs, sexual harassment and sexual abuse. This also
makes it difcult for people to seek help when it is
required.
If you are to help people stay uninfected with HIV,
you will be telling them about safer sex practices. This
means that you will need to talk about sex. If you are
comfortable talking about sexuality, people will also
feel comfortable to ask you questions and allay their
doubts. If you do not know enough or are uncomfortable
with these issues, you will not be able to provide people
with the information they need to actually practise safer
sex techniques in their own lives, or if you are a trainer,
you will not be able to efectively train others.
For a person living with HIV, being confronted with the
knowledge that one is infected with HIV also means
making many changes in ones life, including perhaps
some changes in sexual practices. For you to efectively
counsel your clients you need to be comfortable talking
with them about intimate matters of sexuality. Having
information about sexuality will make you more
condent about addressing your clients questions and
resolving their doubts.
Many people become sexually active in their teenage
years. Children who go to school are as prone to
experimenting and vulnerable to exploitation as those
who do not. Through unprotected sexual activity, people
are exposed to STIs (including HIV) and unwanted
pregnancies. Even people who are not sexually active are
vulnerable to sexual harassment and abuse. Accurate
information helps a person take responsible decisions,
Why talk about sexuality? 7
identify harassment and abuse when it happens,
know it is all right to say no to an uncomfortable
touch, and, in the event of harassment, ask for help.
As a professional working on HIV prevention and care,
you may have occasion to deal with young people.
Encourage them to ask you questions. The earlier they
have the right information, the sooner they can start
protecting themselves from HIV.
In any work dealing with HIV prevention and care,
it is important to keep in mind people of diverse
backgrounds and not only focus on some so-called high
risk groups. People can be sexually active regardless
of where they live, their educational qualications or
lack thereof, whether they have disabilities or not. For
example, because people with disabilities are not very
visible, they are often ignored and are vulnerable to
HIV infection because they are not informed about it
and thus are unable to protect themselves.
Everyone, regardless of gender, class, caste, colour,
size, sexual orientation, HIV status, etc. has the
right to:
Accurate information about sexuality
Make their own decisions about and express
their sexuality without fear of coercion,
discrimination or violence
Not be forced in any way into being sexual
Whats in this Handbook?
This Handbook on Sexuality provides accurate
information on some basic topics on sexuality. This
Handbook on sexuality for HIV and AIDS master trainers 8
material covers the common questions that people
have about sexual anatomy and physiology and kinds
of sexual activities. It also includes information on
unwanted consequences of sexual behaviour such as
unwanted pregnancy, infections and abuse and how
to prevent and deal with them. We hope that you will
nd them useful. If you are already familiar with these
topics, the Handbook will act as a refresher; if you do
not know much about these issues, the Handbook will
serve as a good starting point to learn more.
Remember that:
Decisions about sexuality depend on more than
just information. Sexuality is about emotions,
feelings, values and identity.
Talking openly about sexuality gives people
a sense of responsibility and makes them feel
trusted.
Talking openly also makes you a trusted person
they can approach for correct information.
About our
bodies
chapter 2
H
ow well do we know and understand our
bodies? Although some of us may learn about
our bodies at an early age, our knowledge
about our sexual organs and the reproductive system
is especially limited. People may be at danger of
contracting or transmitting infections because of their
ignorance about how the body works. Knowing the
names of our sexual organs and understanding the
functions of each are the rst steps towards greater
awareness. Also, knowing about how the sexual organs
work is important in understanding how to practise
safer sex and how to prevent HIV.
THE MANS BODY
Male Genitals
The male external sexual and reproductive organs are
the penis and the testicles. The penis does not have a
bone but is made of tissues, which become engorged or
erect when blood ows to it. This happens when a man is
aroused. Sometimes, a mans penis might become erect
during sleep, and most men have morning erections.
This is quite common and does not mean that the man
is over-sexed. Erections may also occur spontaneously,
without any sexual arousal.
About our bodies 11
The penis is slightly curved towards the tip. The size of
the penis has NO impact on a mans ability to produce
semen or to please his partner. At the tip, called the
glans, the penis is a bit more enlarged. The glans is
covered with an outer layer of skin, called foreskin.
When the penis is erect, the foreskin moves back so that
the tip of the penis is exposed. In some communities
and cultures, the foreskin is removed surgically during
childhood and the glans is exposed all the time. This
process of removing the foreskin is called circumcision.
This is a matter of preference and custom, and has
no impact on a mans ability to perform sexually.
Remember: the size of the penis cannot be increased
by exercise, massage or medicines that so-called sex
clinics provide.
The glans has an opening called the urethral meatus
for the discharge of urine and semen. The urethra is
a tube that functions as a passage for urine as well as
semen. Sometimes, before a man urinates, a few drops
of whitish uid (semen) come out of the penis. This is
common because both semen and urine come out of the
same passage. If there is semen in the passage, it will
come out before the urine does.
There are two testicles located below the root of the
penis. Sometimes referred to as balls, testicles may
not be of equal size and are extremely sensitive. They
produce sperm and hormones for the male body, of
which the best known is testosterone.
Semen carries millions of sperm. Each time a man
ejaculates he releases these sperm. One or maybe
sometimes two of these sperm can fuse with the female
egg and cause fertilization leading to pregnancy.
When a man is aroused sexually, a clear, sticky liquid
comes out of the penis. This is called pre-cum or pre-
ejaculate. The pre-cum also contains sperm, and, if it
Handbook on sexuality for HIV and AIDS master trainers 12
comes in contact with an egg, may lead to pregnancy.
STIs can also be spread through the pre-cum. Semen
is a sticky white liquid that comes out of the penis in
spurts during sex. This is called ejaculation. Semen
is not made of blood. It is made up of secretions from
several glands including the prostate gland and seminal
vesicles. The quantity and quality of semen produced
varies from person to person and in the same person at
diferent times.
Sometimes, semen may be released by the body in the
middle of the night, without the man or boy realising it.
This is called nocturnal emission, night fall or wet
dreams. This may start happening during puberty.
This can be very embarrassing and, sometimes, even
frightening for boys, but it is perfectly natural and
normal. These do not lead to any weakness or, as
people sometimes believe, the loss of semen. The body
does not stop producing semen unless there is a serious
infection.
THE WOMANS BODY
Breasts
Though both men and women have breasts, it is only
when women reach puberty that their breasts become
larger because of the hormones that are released in the
body. Womens breasts are made of fatty tissues.
When a baby is born, the milk ducts in its mothers
breasts become active and produce milk. This is called
lactation.
Lactation happens through the nipples at the tips of the
breasts. The dark area around each nipple is called the
areola. The nipples are very sensitive to touch. When
the nipples are touched, they become hard and stand
About our bodies 13
out. This is called nipple erection, and happens in both
men and women.
Some interesting facts about the breast are:
The shape and size of breasts change with age, as
well as when a woman is pregnant. Breasts are not
perfectly hemispherical.
The size of the breasts is not related to how
interested a woman is in sex, or her ability to give or
receive sexual pleasure.
Breasts are very sensitive. They respond well
to gentle touching; handling them roughly or
squeezing them, however, may lead to severe pain
for the woman.
Breasts are rarely equal in size. Usually, there is a
small diference in size between both breasts.
The size of the breasts cannot be increased except
through expensive surgeries.
Medical attention should be given to women with
unusual discharge from the nipples, or when they
notice lumps in the breasts that last for longer than
a month. (A majority of the lumps in the breasts are
not dangerous, but some of them can be symptoms
of breast cancer.)
A brassiere, or bra, is worn to support the breasts.
Most women use bras, but not everyone is aware of the
diference between the right and the wrong kind of bra.
The right kind of bra provides support and does not
make movement or breathing a problem.
A bra should be neither too tight nor too loose. Cotton
bras are better, especially in a warm climate. It is better
to take of ones bra at night in order to allow for better
blood circulation and breathing.
Handbook on sexuality for HIV and AIDS master trainers 14
Female Genitals
The vulva refers to the outer part of every womans
genitals. The vulva includes the outer lips, the inner lips,
the clitoris and the vagina. The size, shape and colour
of these organs may be diferent for diferent women.
The clitoris is a very small, pea-sized structure that lies
above the urinary opening. It is covered by a clitoral
hood, which is basically where the inner lips meet.
The clitoris is sensitive to touch. When stimulated, it
becomes rmer and slightly bigger.
The vagina is the passage that leads to the uterus. It is
muscular and elastic, and serves a number of functions.
It produces secretions that keep it healthy and clean.
During sex, when a woman is aroused, it produces
more secretions and she might feel wet. It is the passage
through which the menstrual blood ows out every
month. During delivery, the vaginal passage stretches
and allows the baby to come out. The rst one-third of
the vagina has the greatest number of nerve-endings
and ability to experience sensation.
In the vagina lies the hymen a collection of delicate
membranes which allow the menstrual blood to pass
through. The hymen may break due to several reasons
such as when the body is jolted or during exercises,
including running and jumping, or simply swabbing
the oor. Some girls are born without hymens. Not
having a hymen does not indicate that the woman has
had sexual intercourse.
THE MENSTRUAL CYCLE
Menstruation is an important part of the female
reproductive cycle. Periods, or menses, or the monthly
ow, is a part of the menstrual cycle. The menstrual
cycle is the time between two periods. This is usually
About our bodies 15
about 2729 days. Some people believe that when a
woman is having her period, she is ill or dirty. Regular
periods, however, are a sign that the womans body is
healthy. Although some women experience pain during
periods, this is not the same as being ill. The experience
of having periods is diferent for diferent women.
How Menstruation Occurs
Every 28 or 29 days, in most women, one of the ovaries
releases an ovum, or egg. The uterus prepares to receive
a fertilised egg by thickening the lining of its walls.
This is required in case fertilisation does occur (that
is, if sexual intercourse has taken place and the sperm
released has fused with the ovum). The thick lining
of the uterus then protects and nurtures the growing
baby. However, if fertilisation has not occurred, the
body sheds this lining through the vagina during
menstruation. Therefore, menstrual ow is more than
blood it is also the lining, clots and mucous. The
ow usually lasts from 2 to 8 days. The womans body
experiences hormonal changes at this time, which
sometimes afects energy levels and moods. This is
why, before and during a period, some women may feel
irritable, tired or even in pain.
What Can Be Used During Periods
Menstrual blood cannot be allowed to ow unabsorbed
because it is neither hygienic nor convenient or
comfortable. Most women, therefore, use sanitary
napkins, or pads, cloth, cotton or tampons for this
purpose. Sanitary napkins and tampons are the most
hygienic options of these. Towels, cloth and cotton may
be used but should be very clean. Otherwise, they may
cause discomfort and infection.
Sanitary Napkins: Sanitary napkins available in
Handbook on sexuality for HIV and AIDS master trainers 16
the market are usually thick cotton pads wrapped in
synthetic material. These may come with belts or with
a strip of sticky glue to place the pad rmly on to the
panties. Every packet of sanitary napkins comes with
instructions and is available in a range of prices. Some
women may nd that sanitary napkins cause allergies.
In such cases, sanitary napkins may be made at home,
using cloth, gauze and cotton (all of which are available
in a medical shop). Reusing the same cloth can be
unhygienic and may lead to allergies/infections.
Tampons: Tampons are usually as big as ones
index nger, thin and circular, and they have a string
attached to one end. They can be placed in the vaginal
passage. These are quite convenient, but it is important
for the woman to know how to use them. Squatting (as
on the Indian toilet) will make inserting the tampon
easier. The tampon has to be placed at the entrance of
the vagina. Then, with one nger at the end where the
string is attached, the woman can gently slide it into
the vaginal passage. The tampon must slide in at least
one inch inside the opening of the vagina. If it is not
placed correctly, it may feel uncomfortable when sitting
and walking. Common myths about the tampon include
that it may get lost in the body or damage the hymen,
but these are not true.
Menstrual Pain/Cramps
Some women may experience pain or heaviness in the
breasts, lower stomach and back, thighs and sometimes
feet before or during periods. This happens because
the uterus contracts and relaxes in order to help the
menstrual blood ow. Some of this discomfort can be
relieved by using a hot water bag. Massaging the lower
abdomen gently, light exercises such as walking and
continuing to do lighter daily activities also help to
prevent these cramps from occurring.
About our bodies 17
Although some pain is common, extreme pain should
be reported to a doctor. Excessive ow of menstrual
blood and irregular menstrual cycles (that is, when
periods do not occur every 2729 days but vary from
month to month in the same woman) are also causes of
medical concern.
Some interesting facts about menstruation
are:
Most women begin menstruation between the ages
of 9 and 15 years, and stop between 45 and 55 years.
When a woman stops menstruating permanently,
she is said to have reached menopause.
Although the average length of the menstrual cycle
is 2729 days, menstrual cycles can fall within a
range of 21 to 35 days. Sometimes, a womans cycle
may become irregular; her periods may come earlier
or be delayed. This can happen because of illness,
mental tension, etc. This is very common with young
girls who have just started to menstruate.
A missed period can be caused by a number of
things, but most importantly, it is usually one of the
rst signs of pregnancy in a sexually active woman.
There is no single day in a menstrual cycle on which
the chance of becoming pregnant is 0%. Therefore,
even during periods, it is important to use a
condom while having sex. This is both to prevent an
unwanted pregnancy as well as to avoid infection.
Some women try to delay or hasten their periods
through medicines, due to sports events, functions
or trips. This should be avoided because it can be
harmful for the body and its natural rhythm.
Handbook on sexuality for HIV and AIDS master trainers 18
MAINTAINING GENITAL HYGIENE
Both men and women need to maintain a high degree
of cleanliness of the genital areas. Some of the ways to
do this include:
The genital area needs to be washed every day
with water. Soap and antiseptic are not required.
Deodorants should NOT be used. Lukewarm water
can be used, but hot water can be damaging.
The vagina has its own mechanism for cleaning, and
using external substances can damage the natural
defenses the body has to minor infections. Washing
with clean water is enough. Occasionally use a mild
cleansing agent like Lactacyd.
No sharp object should be inserted into the vagina.
In men, a sticky white substance called smegma
can accumulate under the foreskin of the penis. To
clean this, the foreskin must be gently moved back,
before washing the tip of the penis.
While washing after defecating, wash in a motion
away from the genitals from the front to the back.
This backward motion ensures that no bacteria or
infection gets transferred to the urinary tract in
front, especially in the case of women.
Underwear should be changed at least once a
day. Cotton underwear is preferable; the skin may
react to synthetic underwear, especially in a warm
climate.
Underwear must be washed carefully so that all the
detergent is removed. It should then be dried in the
sun. Sunlight is an excellent disinfectant.
Wearing very tight underwear and jeans may
damage sperm production in men.
About our bodies 19
A pair of clean scissors should be used to remove
pubic hair, to maintain hygiene. Bleach, hair
removers or any other chemicals should be used
judiciously on the genitals because the skin here is
very sensitive. It is always a good idea to do a patch
test on the forearm before nally deciding to use
a product. This is because, the sensitive skin of the
genitals may react and develop rashes or allergies
to chemicals found in hair removers and other
products. If so desired, pubic hair may be trimmed
carefully with a pair of scissors. It is equally OK if
one decides never to remove, wax or shave in the
genital area. All one has to do is ensure that it is
clean and dry from discharge, blood and sweat.
With accurate information about the body, you can
explain health messages more clearly. For example, in
case someone wants to know why women can continue
doing their daily activities while menstruating, you can
explain how the menstrual lining accumulates over a
period of time and is then shed as it is not required by
the body; it is not as if the woman is suddenly losing a lot
of blood and must rest. Similarly, you can explain why
using oils and massaging the penis in order to make it
grow in size is of no use as the penis is not a muscle that
can be strengthened with exercise or massage. When
you are talking about safer sex practices, knowing how
sexual organs function is very useful.
Being sexual
chapter 3
T
he decision to be sexual with another person
should ideally be a conscious one, taken by
adults, that is, those over the age of eighteen.
Unfortunately, even when the two people involved
are adults, they may not have all the information they
need in order to take such a decision. It is important
to understand what being sexual means. For most
people, the word sex usually indicates anal or vaginal
intercourse, but sex is not intercourse alone. It is both
emotional and physical, and can include a number of
activities such as kissing, holding hands, massaging
and masturbating.
For a sexual relationship to be an enriching and
enjoyable experience, people must:
Respect and treat each other as equals and be
honest with each other.
Be in a consenting relationship, that is, be able
to stop doing anything sexual that makes them
uncomfortable.
Use safe and efective ways to protect
themselves from physical and emotional harm,
unwanted pregnancies and STIs.
Handbook on sexuality for HIV and AIDS master trainers 22
Anyone can have sexual feelings teenagers, men,
women, girls, boys, transsexuals and even grandparents.
People and growing children with disabilities also
have sexual feelings, and for them this can become a
confusing and scary experience, because they may not
be able to express their sexuality like other people.
Similarly, people living with HIV also have sexual
feelings and a right to enjoy their own sexuality.
Sex can also, unfortunately, be a way of dominating,
hurting and exploiting another person. The right infor-
mation is necessary to protect oneself, both emotionally
and physically. It is also helpful in order to experience
sexual pleasure and well-being.
SEXUAL ACTIVITIES
Sexuality begins in the mind. People fantasise or
day-dream about many things, including sex. This is
perfectly natural and normal, because fantasies are a
valid way of understanding ones options and desires.
Fantasies are harmful only when translated into actions
that cause emotional or physical harm to other people
or to ones own self.
People may engage in sexual activities with them-
selves or with other people. Stimulating ones self by
touching, rubbing or massaging ones own body parts,
usually the genitals, for sexual satisfaction, is called
masturbation. Some people believe that masturbation
will cause one to go blind or weak, but these are a
few of the many myths that abound on masturbation.
Masturbation is only harmful if it interferes with the
performance of ones daily activities. Both men and
women masturbate, sometimes with their hands and
sometimes using objects. It is important to remember
to use clean hands and objects. Masturbation usually
Being sexual 23
results in orgasm. An orgasm is regarded as the height
of sexual pleasure. Both men and women have orgasms.
When a man reaches orgasm, it is usually accompanied
by ejaculation; women do not ejaculate like men but
also have orgasms. In fact, women can have more than
one orgasm during a sexual encounter.
Sexual activities performed with other people may
include vaginal intercourse, anal intercourse, oral sex,
etc. Vaginal intercourse occurs when a mans penis is
put into a womans vagina. Anal intercourse occurs
when a penis is put into someones anus. Oral sex is
when someones mouth is used on the penis, vagina
or anus of another person. Any sexual activity that
involves the exchange of bodily uids such as semen or
vaginal uids carries a risk of transmission of HIV. Both
vaginal and anal intercourse are high-risk activities, in
terms of STIs including HIV, and should be performed
with some protection such as a condom. These are not
the only ways to be sexual. There are a number of other
ways to express oneself sexually including hugging,
cuddling, stimulating diferent body parts, and so on.
There are no right or wrong ways of having sex. What
one person likes, may be quite boring or even disgusting
for another. What is important is whether the people
engaged in the sexual activity are doing it with consent;
whether you think their sexual practices are ok or not,
is of no consequence.
Sexuality cannot be increased or decreased. Sex
clinics and quacks prey on peoples lack of knowledge
and try to lure them into believing that their sexual
potency can be increased by using certain tablets,
sprays and lotions, which are not of any real use. People
experiencing sexual problems should go to a qualied
professional.
Handbook on sexuality for HIV and AIDS master trainers 24
SEXUAL AND GENDER IDENTITIES
So far, we have talked broadly in terms of heterosexual
relationships (that is, sexual relations between men and
women). However, people may have diferent sexual
identities. A person might be attracted to members of
the same gender, or another gender, or both. These are
matters of sexual preference or orientation.
People who are attracted to people of the same gender
are called homosexuals. Women who are attracted
to other women are called lesbians. Men who are
attracted to other men are called gay. Heterosexuals
are people who are attracted to people of the opposite
gender, that is, men attracted to women, and women
attracted to men. Bisexuals are people who are attracted
to people of both genders, that is, a man or woman who
is attracted to both men and women.
All these terms are categories, and people cannot be
put into boxes and stored away. Sometimes these terms
are useful to describe diferent ways of being. They are
also useful as a political tool against discrimination.
However, just as some people nd them useful to
organize themselves into groups, some others would
rather not identify themselves for fear of harassment
and discrimination.
There are many men and women in India who are
homosexual but are forced to live in arranged marriages.
Many of them are too scared to reveal their sexual
orientation. There are also many men who have sex
with other men but do not identify as homosexual or
gay for diferent reasons. Therefore, for more efective
HIV prevention work, the term MSM men who have
sex with men was coined to describe a behaviour but
not an identity.
Being sexual 25
COMMONLY ASKED QUESTIONS
1
Can gays and lesbians be cured?
Since lesbian, gay and bisexual people are not mentally
ill or abnormal they dont need to be cured. These are
not abnormalities or perversions; they are orientations
or preferences, just like being left-handed or right-
handed. All people, whether they are hetero, homo or
bi, have a right to live with dignity and in accordance
with their preferences. Attempts to treat them may
succeed in temporarily changing sexual behaviour but
also can lead to emotional and other problems.
What causes homosexuality?
That question is as difcult to answer as what causes
heterosexuality? No one knows for sure. Some foolishly
suggest that maybe a person turned lesbian because she
had a bad experience with a man, or a man became gay
because a woman mistreated him. If this were truly the
case, then there should be many more lesbian and gay
people, wouldnt there?!
Why do some homosexuals feel they have to
announce their orientation to the world?
Society encourages and conditions most people to be
heterosexual. People who are diferent from the norm
are often discriminated against. This discrimination may
be blatant or subtle. Common ways of discriminating
against people include: making fun of them, thinking
of them in stereotypical ways (for example, all gay men
are efeminate or all lesbians are masculine), isolating
them, and not seeing them as full human beings.

1 Taken from The Blue Book, TARSHI, 1999.
Handbook on sexuality for HIV and AIDS master trainers 26
Many people say they dont have a problem with
homosexuality as long as it is not aunted. By this they
mean that homosexual people should not talk about their
partners or show any signs of sexual expression, and so
if they dont hide their orientation, they are thought to
be aunting their sexuality. When heterosexual people
do the same thing (talk about their relationships or
publicly demonstrate afection) it is not considered
aunting. Because of these discriminatory reactions
many lesbian, gay and bisexual people actually have to
hide their sexuality, rather than express it freely.
So, what are they like?
Lesbian, gay and bisexual people do not t the stereo-
types that people have of them. They cannot be identied
on the basis of mannerisms or physical characteristics.
People who are lesbian, gay or bisexual come in as many
diferent shapes, colors and sizes as do people who are
heterosexual. Lesbian, gay and bisexual people are
diferent from one another just like heterosexual people
are diferent from one another. They have diferent
personalities, likes, dislikes, strengths and weaknesses,
like everyone else.
How does one know if they are Gay or
Bisexual?
Usually it is in the teenage years that people begin
discovering and becoming conscious of their sexuality.
This is also the time of crushes and infatuations and of
being confused about ones sexuality. Someone who
is heterosexual may have very intense feelings for and
be strongly attracted to someone of their own gender,
and someone who is homosexual may feel this way
for someone of the opposite gender. Thats ne. These
things happen. Isolated experiences do not determine
Being sexual 27
ones sexuality or change it. Also, one may have
been heterosexual for a large part of their lives before
becoming gay (or the other way around!). This is also
possible and may be very difcult for some or extremely
liberating for others. If you are confused about your
sexuality, or know someone who is, it helps to talk and
nd out more. Ignoring something or suppressing it will
not make it go away.
Do homosexuals feel that they belong to the
opposite sex really?
Most lesbian, gay and bisexual people are comfortable
with their own biological sex; they dont wish to belong
to the opposite sex and are not transgender (unhappy
with and feeling trapped in ones biological sex,
wanting to change it).
People may also express their gender diferently. A
person may even be confused about, or not identify with
their own gender. A transgender person is someone,
who does not identity with the gender they were given
at birth. This person may be born biologically female
but feel more like a man, or be born biologically male
but feel more like a woman. Transsexual people are
those who take steps to change the body to conform
to the gender that they identify with. This can be done
by means of surgery, hormonal treatments and other
medical procedures. A person born biologically male,
who identies as a woman and undergoes body altering
procedures is a transwoman. A person born biologically
female, who identies as a man and undergoes body
altering procedures is a transman. Transgender and
transsexual people may be heterosexual, homosexual
or bisexual.
An intersex person is one born with ambiguous genitals
that cannot easily be classied as male or female. Some
Handbook on sexuality for HIV and AIDS master trainers 28
intersex people do not want to be either man or woman,
and may feel comfortable identifying as intersex, while
many others identify as men or women. They may be
heterosexual, bisexual or homosexual.
In India, we also have hijras who dene themselves as
people of the third gender. Despite the common belief
that they are intersex, many hijras are biological males
who have voluntarily undergone castration and joined
the hijra community. Because of the lack of educational
and employment opportunities, many of them resort
to begging and to sex work. Hijra sex workers have sex
with men and are vulnerable to being infected with HIV
and other STIs. Because of the discrimination they face,
they are often unable and unwilling to access public
health facilities.
All people, regardless of gender identity and sexual
orientation, are at risk for HIV, based on what they do,
not who they are. Therefore, when spreading awareness
about STIs and HIV, counsellors and other professionals
need to be open and approachable by people of diferent
identities and to be able to answer questions honestly,
and provide information without judgment.
Pregnancy
and
contraception
chapter 4
I
nformation about conception as well as contra-
ception is important in the context of HIV. The
only contraceptive method that also ofers
protection from HIV is the condom. No other methods
of contraception have this dual function. Therefore,
when people are choosing a contraceptive method they
need to be aware of this. Also, certain commonly used
contraceptives may have side efects that may further
compromise the health of a woman living with HIV.
There may be instances when the issue is not about
contraception but instead is about conception. People
living with HIV also have the right to have children.
While this is true, we must also remember that in India
there is a lot of family pressure on couples to bear a
child. For sero-concordant couples where both partners
are living with HIV, the risks of re-infection must be
explained in case they want to have unprotected sex
to result in a pregnancy. In case of sero-discordant
couples where one of the partners is HIV positive, the
risks of transmission of HIV to the other partner need
to be clearly understood. It also needs to be clearly
explained that mother to child transmission can
occur during pregnancy, labour, delivery and through
breastfeeding, and that though there are ways to
minimize this, there are no guarantees that the child
will be born free of HIV.
pregnancy and contraception 31
Also putting an HIV negative woman who is married to
a positive man at risk of infection by insisting that she
conceive so that she can produce an heir to the family is
a gross violation of her rights.
HOW PREGNANCY OCCURS
Every month, a womans ovaries release one ovum (or
egg) into the fallopian tubes that connect to her uterus.
A mans semen contains millions of sperm. When a
man ejaculates in or near the vagina, his semen travels
through the vagina and the uterus to the fallopian
tubes. The ovum and the sperm meet, or fuse, in the
fallopian tube and form a fertilised egg. This is known
as fertilisation. The egg then moves into the uterus,
where it attaches itself to the uterine lining. It grows in
the uterus for about 38 weeks before emerging into the
world as a baby. Pregnancy begins at conception and
lasts until the delivery of the baby.
Conception occurs when a single sperm fuses with an
ovum. The semen and the pre-ejaculate, or pre-cum,
contain millions of sperm. The rst sign of pregnancy is
a missed period but the only way to be sure is to have a
pregnancy test conducted by a gynaecologist.
AVOIDING UNWANTED
PREGNANCIES CONTRACEPTIVES
A sexually active couple may not want to have children
or may want to delay having children. In order to do this,
they need to use contraceptives. Using contraception is
a sign of being responsible. In addition, a contraceptive
method like condom usage also ofers the additional
benet of protection from STIs including HIV.
Handbook on sexuality for HIV and AIDS master trainers 32
Accurate knowledge about contraceptives, therefore,
will help people make responsible, informed decisions
about their own and their partners lives.
There are several methods of contraception. Some of
these methods involve the use of devices and some do
not. Some of these are reliable and some are not very
reliable.
The common methods of contraception that do not
require the use of any devices include abstinence, the
rhythm method and the withdrawal method. These
methods are not reliable.
Abstinence is not having sex at all.
The rhythm method is the practice of couples timing
intercourse for the days when the woman is supposed to
be the least fertile. Ovulation (when the ovary releases
the egg) usually occurs 14 days before a womans next
period. The life-span of an egg is 24 hours (1 day) and
that of a sperm is 72 hours (3 days). Therefore, four days
before and four days after the 14th day of the menstrual
cycle is considered to be the most fertile period with the
greatest chances of conception occurring if a woman
has sex. However, a woman may ovulate at any time
during her menstrual cycle or the cycle may change
because of stress or other factors. Therefore, this is an
unreliable method of contraception.
The withdrawal method is when the man takes his
penis out of the vagina just before he ejaculates.
However, because the pre-cum also contains sperm, the
woman can become pregnant.
There are several methods of contraception, both for
men and women, that involve the use of devices.
pregnancy and contraception 33
CONTRACEPTIVES FOR MEN
Condoms: Condoms are the most efective method of
contraception. A condom is a thin, latex sheath, which
is worn on the penis. This sheath prevents the exchange
of bodily uids such as semen, the pre-ejaculatory
uid and the vaginal uids. Condoms are, therefore,
also an efective safeguard against HIV and other STIs.
Condoms should be used in every sexual act, whether it
is with a woman, a man, a transgender or transsexual
person for oral, anal and vaginal sex. Condoms should
be worn as soon as a man has an erection and every time
a couple has sex. Condoms are not reusable. Condoms
have an expiry date after which they are inefective, so
it is important to check this date on the package.
How does one wear a condom?
Gently tear open the condom package. Do not unroll
the condom. At the closed end of the condom, there
is a protuberance, like a teat or nipple. Pinch this teat
so that all the air comes out of it and while holding it
pinched, roll the condom on to the erect penis all the
way to the end. It is necessary to remove the air from
the teat so as to create an empty space into which
the ejaculated semen can ow or else the condom
may burst. After sex, when the man pulls away from
his partner, he needs to hold the condom against his
penis so that the semen does not ow out. He needs to
then slip it of, knot the open end, wrap the condom
in a piece of paper and dispose of it. Do not ush the
condom in the toilet as it may simply oat there and
can also clog the drain.
Handbook on sexuality for HIV and AIDS master trainers 34
CONTRACEPTIVES FOR WOMEN
Female Condoms: These are condoms that can be
placed inside the vagina before sex or foreplay begins.
This gives them an advantage over male condoms, which
can only be placed on an already erect penis. These
also allow women to exercise greater control over their
sexual health. However, these are not as freely available
as male condoms, and can be quite expensive.
Oral Contraceptive Pills (OCPs): OCPs are
hormone-based pills that have to be taken regularly, even
if the woman is not having sex every day. Diferent kinds
of OCPs are available now, with diferent concentrations
of hormones to suit diferent women. Some women may
experience side-efects from such pills but most do not.
An OCP should ideally be prescribed by a gynaecologist
after a routine check-up to determine which pill will
suit the womans body type and medical history.
Emergency Contraception (The Morning-After
Pill): The emergency contraceptive pill is a higher
dosage of the OCP, designed for a situation in which
regular contraception fails. It must be taken by the
woman within 72 hours of intercourse, in order to avoid
pregnancy. In some women, this can cause bleeding and
spotting for a week after the pill is taken. This method
must not be used in place of regular contraceptives,
but only as an emergency measure. The high dosages
of chemicals can harm a womans body if the pill is
taken frequently. Unfortunately, many young women
are resorting to overuse of this form of contraception
which gives them a false sense of security with respect
to unwanted pregnancy but does not protect from HIV.
Only condoms ofer protection from HIV.
pregnancy and contraception 35
Pessaries: A pessary is a tablet that can be placed
within the vagina 15 minutes before intercourse. This
tablet produces foam, which contains a chemical
that destroys the sperm. However, the efect of this
chemical lasts for half an hour only. The packet comes
with instructions for use, which should be followed
carefully.
Intra-Uterine Devices (IUDs): IUDs are devices
that have to be placed within the uterus by a qualied
doctor. An IUD is most commonly T-shaped and, once
inserted in the uterus, can be efective for as long as ve
years and more. This device prevents the fertilisation
of the ovum by the sperm and the implantation on
the uterine lining. A woman using an IUD must check
regularly after her period to make sure that it is still
placed properly as it may become displaced during
menstruation. This can be done by feeling for the two
threads attached to the lower end of the IUD. The strings
in no way afect sexual intercourse and cannot be felt
by the penis. This device is usually recommended only
for women who have already had two children because
there is a risk of infection. An untreated infection,
caused by an IUD, can lead to infertility.
Using a combination of methods for protection (for
example, a condom and a pessary) is more reliable than
using one method alone.
Permanent Contraception
The methods discussed earlier are temporary methods.
That means that once their use is stopped, conception
can occur. There are also forms of contraception that
can permanently prevent conception. Sterilisation is a
permanent way of preventing conception. In the case of
men, sterilisation is referred to as a vasectomy whereas
Handbook on sexuality for HIV and AIDS master trainers 36
for women, it is called tubal ligation, or tubectomy.
These procedures should be performed only by trained
professionals. A vasectomy is a simpler and easier
procedure than a tubectomy. Both these procedures are
mostly irreversible and should be undertaken with full
understanding of the consequences. These procedures
do not afect future sexual enjoyment.
ABORTION
Pregnancy can occur even if precautions are taken.
Often, in such a situation, a woman may choose to
terminate the pregnancy, that is, have an abortion.
Having an abortion can be a difcult and painful
decision. It is a subject that few people talk about.
Therefore, it is even more important to have the right
information about abortion.
An abortion is the termination of a pregnancy. This can
occur spontaneously in some cases; it is then called
a miscarriage or a spontaneous abortion. The other
kind of abortion is when a pregnancy is intentionally
terminated and it is called an induced abortion. An
induced abortion can be performed in two ways: it can
be medically induced, in which case the gynaecologist
prescribes drugs, or it can be surgical, in which case the
foetus is removed from the uterus through an operation.
The surgical procedure is referred to as medical
termination of pregnancy or MTP. This has been legal
in India since 1971. As of mid 2010, an MTP may only
be conducted up to twenty weeks of pregnancy, but the
earlier it is done, the less risky it is.
An MTP must be performed by a qualied gynaecologist
because there are risks of infection and even death. If the
abortion takes place within the rst twelve weeks of the
pregnancy, the risk is relatively low. It can become very
pregnancy and contraception 37
risky even lift-threatening if done later; therefore,
the Indian Penal Code prescribes that TWO qualied
doctors should be present if this becomes necessary. A
woman should never be compelled or forced to undergo
an abortion.
It is illegal in India to check for the sex of the foetus
during pregnancy. In a country like India, because of
the higher value given to sons, many people do not want
to have daughters. This is one of the leading reasons for
women carrying a female foetus to be forced into or
choosing to terminate the pregnancy, leading to sex-
selective abortions.
Women living with HIV have the right to decide if,
when and how many children they want. This means
that a woman living with HIV has the right to not have
children if that is what she wants and therefore has
the right to safe abortion if she wants to terminate a
pregnancy. It also means that if she wants to carry a
pregnancy to term, she has the right to accessible and
afordable healthcare that optimizes the outcome for
herself as well as her future children.
HIV AND STIs
Sexually transmitted infections (STIs) were previously
known as sexually transmitted diseases (STDs). These
are infections that are spread from one person to another
mainly through sexual contact. Some of them, such as
HIV and syphilis can also be spread from a woman to
her child during pregnancy and delivery. Infection with
certain STIs can also increase the chances of being
infected by HIV and if already infected, of transmitting
it. Lets look at HIV and other STIs more closely.
HIV and
STIs
chapter 5
H
uman Immuno-deciency Virus, or HIV, is a
virus that weakens the bodys immune system
by afecting the helpful cells that assist the
body to ght infections. This can eventually lead to the
body becoming increasingly unable to resist infections
and developing the condition of Acquired Immune
Deciency Syndrome or AIDS.
The current UNAIDS estimate of the number of people
in India living with HIV is 2.31 million. HIV has spread
to all groups of people from all walks of life and anyone
can be afected by it.
HIV can spread in four ways:
1 By having unprotected sex with a person
with HIV. This is the most common way that HIV
spreads. In many cases, people living with HIV
themselves may not know that they have the virus.
That is why it is important to practice safer sex.
2 By sharing needles, razors, etc. If the blood of
a person living with HIV enters another persons
bloodstream, the infection may be passed on. The
use of disposable needles and sterilised medical
equipment is, therefore, vital.
3 Through infected blood and blood products.
This includes organ and tissue transplants, and
Handbook on sexuality for HIV and AIDS master trainers 40
simple blood transfusions in hospitals or outside.
4 From mother to child. If a woman is HIV
positive, the child may acquire the virus during
pregnancy, delivery or through breastfeeding.
HIV often remains hidden in the body. There are no
external signs of HIV. The only way to detect HIV is
through special blood tests that are carried out in
hospitals or ICTCs (Integrated Counselling and Testing
Centres).
With new developments in the eld of medicine, people
can now live productive and enjoyable lives. People
living with HIV do not necessarily develop AIDS.
People who have developed AIDS can, with the proper
treatment regime, continue to live for many more years.
However, people living with HIV or with AIDS, need
to take good care of themselves, eating proper meals,
exercising and resting enough.
It is unrealistic to expect that a person living with HIV
will not have sex. People living with HIV also need to
practice safer sex for two reasons. One, is so that they
do not transmit the infection. Two, to protect themselves
from acquiring another strain of the HIV virus that may
cause more damage to their body. It is important that
this be explained to people so that they are able to take
better care of themselves and their partner.
HIV can be transmitted through even a single act of
unprotected sex. As you know, often people may not
be aware that they are infected with HIV. So, very
often, people do not know whether the person they are
having sex with has the virus or not. It is therefore very
important to practice safer sex at all times so as to avoid
chances of getting infected.
HIV and STIs 41
STIs
STIs are caused by bacteria, viruses, and parasites
transmitted through the genitals or other parts of the
body. These are infections that are primarily spread
through sexual contact with another person who has an
STI. However, sometimes they are also spread through
a non-sexual route. So, STIs can be caused by sex with
infected persons, lack of hygiene, certain medication,
and sharing a needle with an infected person. The
infection may afect the genitals as well as other parts of
the body. It is important to note that in women, STIs are
often asymptomatic and that based on their biological
and social realities, women are more susceptible to
STIs than men. Having an STI increases the risk of HIV
transmission.
The most common signs and symptoms of infections
are:
Burning sensation while urinating (please note that
this is diferent from the slight burning that occurs
when one does not drink enough water)
Itching, redness or rash in the genital area or mouth
(especially if oral sex has occurred)
Sores on the genitals
Unusual discharge from the genitals
Bleeding between menstrual cycles (for women)
Foul smell from the genitals
Lower abdominal pain
Discomfort during sex
Noticing these symptoms early is vital because though
some STIs are curable with simple antibiotics, others
Handbook on sexuality for HIV and AIDS master trainers 42
can lead to complications such as:
Infertility: This refers to the inability to produce
sperm or eggs.
Ectopic Pregnancy: A pregnancy that occurs outside
the uterus usually in the fallopian tube. It is very
rare and usually impossible for this to be viable
(that is, to lead to childbirth without complications)
and should be treated as a medical emergency that
can lead to death,
Pelvic Inammatory Disease (PID): A broad term
that refers to bacterial, parasitic, viral or fungal
infections in the uterus, fallopian tubes or the
ovaries. This can lead to a scarring of the organs,
and further complications, including ectopic
pregnancies, chronic pelvic pain and infertility.
Epididymitis: An inammation of the testicles,
which can be mildly or very painful. It should be
treated by a doctor as soon as possible.
Some kinds of cancers, especially cervical and colon
cancer.
COMMON STIs AND THEIR
SYMPTOMS
Gonorrhea: Gonorrhea is caused by a bacterium.
It can infect the vagina, penis, cervix, urethra, anus
or throat. It is spread through oral, vaginal or anal
sex. If symptoms do occur they can include unusual
discharge from the penis/ vagina, pain when urinating,
or painful bowel movements. It increases the risk of
contracting HIV. If untreated, gonorrhea can lead to
pelvic inammation, infertility (in men) and death. It
can also afect the foetus of a pregnant woman who has
the infection. Gonorrhea can be prevented with safer
HIV and STIs 43
sex practices and treated with antibiotics in the early
stages.
Chlamydia: Chlamydia is also a bacterial infection
that is caused by unprotected vaginal, oral or anal
sex. It may be passed on to an infant from an infected
mother during childbirth and result in other infections
in the infant. Chlamydia is often not recognised
because infected people do not always experience any
symptoms. Symptoms can be an abnormal discharge or
a burning sensation while urinating in both men and
women. Although chlamydia is usually curable with
antibiotics, it can have serious consequences such as
pelvic inammatory disease, chronic pain in the pelvic
region, ectopic pregnancy, epididimytis and infertility.
Syphilis: A bacterial STI that is transmitted through
direct contact with sores that the infection produces on
the vagina, penis, rectum, anus, lips or mouth. Syphilis
also increases the risk of HIV infection. Syphilis occurs
in three stages. In the rst stage, red sores may appear
on any area that was touched during sex, including the
genitals, tongue and throat. In the second stage, fever,
sore throat, headache, loss of appetite and joint ache
may follow, as well as rashes on palms and on soles
of feet. There is often a period of hiding between the
second and the third stage, during which everything
may seem all right for as long as a number of years.
In the third stage, the infection afects the brain, the
spinal cord, skin, bones, nerves, eyes, etc. Symptoms
of syphilis should be taken very seriously and treated
because without treatment, it can lead to death.
Trichomoniasis: Trichomoniasis is caused by a
small parasite, and is a disease that usually afects
women more than men. Common symptoms include
an inammation of the genitals, a burning sensation,
discomfort during intercourse and urination, a yellow-
Handbook on sexuality for HIV and AIDS master trainers 44
green and smelly discharge, and lower abdominal
pain. Symptoms surface within 28 days of exposure
to the parasite. Men who are afected may experience
an irritation inside the penis, mild discharge and
slight burning after urination or ejaculation. Although
Trichomoniasis is curable, it increases the risk of
contracting cancer and HIV, and should be taken very
seriously.
Hepatitis B and C: Hepatitis B is an incurable disease
that attacks the liver. It is transmitted through the blood
of an infected person, through sharing needles, from
a mother to a child during childbirth and by having
sex with an infected person. Early symptoms include
muscle pains, fever, fatigue, loss of appetite, headache
and dizziness; however, an infected person may not
have any symptoms at all. Over a period of time, as the
disease becomes worse, symptoms may include dark
urine, a perpetually loose stomach, yellowing around
the eyes and the skin, and tenderness in the liver area
(below the ribs on the right side). Hepatitis B can lead
to liver cancer and liver failure. Safer sex practices and
a Hepatitis B vaccine are the only ways to prevent this
disease.
Hepatitis C is an infection acquired similarly through
unprotected sex and blood transfer from an infected
person. But unlike Hepatitis B, there is no vaccine for
Hepatitis C and no cure. Symptoms include yellowing
of the eyes and skin, headaches, muscle aches, dark
urine, tiredness, loss of appetite, nausea and vomiting,
generalized itching. Medications and treatments can
help with symptoms.
Human Papillomavirus (HPV) and Genital
Warts: There are over 70 types of HPV. Some types may
cause genital warts. These are called low-risk types of
HPV. It is very common among people who are sexually
HIV and STIs 45
active. When HPV infects the genital area, it afects the
vulva, vagina, cervix, rectum, anus, penis, or scrotum.
Genital warts are small, esh coloured and look like
small cauliower orets on the genitals, anus, and in
some cases in the mouth and/or throat. These warts can
be itchy and grow in clusters. Genital warts if untreated
can disappear, stay the same, or grow in size and in
number. They can cause sores and bleeding which
can increase the risk of HIV infection. Some types of
HPV may cause cell changes that sometimes lead to
cervical and other cancers. These are called high-risk
types of HPV. Cell changes of high-risk HPV strains can
be detected through Pap tests for women. Many other
forms of HPV can be asymptomatic. Most types of HPV
seem to have no harmful efects at all.
Genital Herpes: Herpes is a viral STI caused by the
herpes simplex virus (HSV). There are two subtypes:
HSV-1 and HSV-2. Herpes spreads through skin contact
with an infected individual. The virus can be spread
through contact with blisters and sores during an
outbreak as well as when there are no symptoms. For
those with symptoms, they include painful blisters or
sores on the genitals, around the buttocks or thighs,
or mouth, fever, swollen glands. There is no cure.
People can experience outbreaks of sores that will
vary in severity and frequency from one person to
another. Symptoms can be treated with oral or topical
medications.
The way to prevent becoming infected with an STI is
to practice safer sex which we will look at in the next
chapter. In case of symptoms, early treatment must be
sought. Most STIs, except HIV, hepatitis B, genital herpes
and genital warts are easily treatable. It is advisable
that both partners be treated so that re-infection does
not occur.
Safer sex
chapter 6
B
eing safe requires making the right choices to
protect oneself from unwanted pregnancies,
STIs such as HIV, sexual harassment and
abuse. Safe measures against unwanted pregnancy
have already been described in the chapter about
contraceptives
SAFER SEX PRACTICES
Protection against STIs can seem complicated. Some
STIs, particularly HIV, may have no external or visible
signs. There is no way of knowing if a person is infected,
and in some cases, they may themselves not know.
It is important for people to have information about
the level of risk involved in diferent sexual activities.
There is no risk if there is no contact with the semen,
pre-ejaculatory uid, vaginal uid or blood of another
person.
No Risk Activities
Masturbation and Mutual Masturbation (when two
people masturbate each other): These acts are not
risky as long as there is no broken skin on which
vaginal secretions, pre-ejaculate, or semen fall.
Handbook on sexuality for HIV and AIDS master trainers 48
Touching, hugging, body massage, body rubbing
Kissing, deep kissing: Not risky as long as no blood
is exchanged through mouth sores, ulcers in the
mouth, cuts, etc.
Low-Risk Activities
Oral sex on a man with a condom: The condom
should be worn as soon as the penis is erect.
Remember, the pre-ejaculate may carry infections.
Oral sex on a woman with a barrier: This barrier
could be a square piece of a cut, open and unused
condom, or a thin cling lm (the kind in which
sandwiches are wrapped), or a dental dam (the kind
used by dentists). The barrier should be about 5
inches, square and placed on the vulva before oral
sex is performed.
Some Risk
Deep kissing: Only if blood is exchanged (through
bleeding gums, sores, etc.)
Oral sex without a condom or barrier: Oral sex
accompanied by ejaculation in the mouth is more
risky than when ejaculation is not in the mouth.
Vaginal or anal intercourse with a condom:
Intercourse with a condom is not 100% safe because
condoms do sometimes break or slip of.
Getting semen, vaginal secretions or blood into the
mouth or on broken skin can be unsafe.
High Risk
Vaginal intercourse without a condom: The vaginal
secretions and semen may contain HIV. The
Safer sex 49
membranes of the vagina are permeable to HIV as
is the opening of the urethra in the penis. If an HIV
positive woman is menstruating, her blood also
contains HIV.
Anal intercourse without a condom: The lining of
the anus and the rectum is extremely delicate, far
more than the lining of the vagina. The anus does
not produce the uids that the vagina does during
intercourse. It is also a narrower passage. Anal
sex without adequate lubrication can lead to cuts
and tears in the lining. It is risky for the receptive
partner because the infected semen can easily pass
into the anal bloodstream. It is also risky for the
insertive partner as the blood in the anus can enter
his body through the membranes in the urethra.
Anal sex could also be a route of transmission for
hepatitis and other STIs.
Some people argue that using protection is selsh but
this is not true. It is smart and a healthy way to protect
oneself and ones partner. Substances such as drugs
and alcohol can impair judgment, reduce control and
encourage people to take risks that they would not if
they were fully in control of themselves. For instance,
if drunk one may agree to have sex with a stranger or
forget to use a condom.
Abuse
chapter 7
S
afety also refers to emotional safety.
Professionals working in the eld of HIV must be
aware that issues of power are often manifested
in the sexual parts of peoples lives. Abuse is an ugly
part of many peoples lives. Those who are most afected
by it are women and children (both girls and boys),
though men are also abused. Abuse can be physical,
sexual, emotional or a combination of all three. Fear,
embarrassment, low self-esteem, shame and other such
feelings can prevent people from telling other people,
counsellors or friends about such situations.
People living with HIV may be at an added risk of abuse,
especially if their family members are not supportive of
them.
Abuse can occur within relationships, both within
marriage as well as live-in relationships. There are
some warning signs to look out for. A relationship is
unhealthy when one partner:
makes all the decisions
controls what the other partner wears and does
acts possessive, that is, tells the other partner who to
talk to and who not to
Handbook on sexuality for HIV and AIDS master trainers 52
makes the other feel inferior, thereby reducing self-
esteem
insults the other partner
gets violent or threatens to get violent, etc.
Abuse in a relationship does not have to be physical or
violent. It may include insults, name-calling, shouting,
etc. Often, abusive relationships start with such minor
ofences and then build up to more extreme violence.
In more extreme cases, there may be physical or sexual
violence that results in injury.
It is not easy for a person whose partner is being violent
to talk about it. Sometimes, especially when violence
occurs in a marriage, it is very difcult to leave the
relationship because of lack of support from the family
and the community. In some cases, particularly among
young people, they may not have told anyone about their
relationship at all. This is true also of violence in same-
sex relationships and with people with disabilities, who
cannot speak up. While no one can interfere in someone
elses life, sometimes just talking about violence may
encourage people experiencing violence to break their
silence.
Abuse occurs in all sections of society, among educated
as well as uneducated people. One way of dealing with
violence is to help the person undergoing it to develop
a safety plan. This involves planning what to do to
protect ones safety and life, where to go in case the
person needs to leave the house, and what resources
are available for support. It can include storing away
important documents and valuables, such as marriage
certicates, bank account information, medical records,
passports and school records for children, jewellery and
spare keys, etc.
Abuse 53
A person undergoing violence cannot and should not
be forced to leave a violent relationship. Only they can
decide when they are ready to leave. Often, people facing
violence may not believe they are being abused; so it is
important to support them without being forceful.
Equally importantly, a person living in an abusive
relationship should not be forced to go back to the
abusive relationship if they do not wish to do so. Often,
friends and family members put pressure on the person
being abused using children, societal attitudes, possible
heartbreak of parents etc as excuses to force the woman
back into the abusive home. For a professional to do
this, it is highly unethical to push someone into danger
knowingly. This can drive the person to take extreme
steps such as harming herself or committing suicide. In
situations of extreme violence, the woman may even be
killed by her abuser.
People who are abusive and violent may have a number
of excuses for their behaviour; however, even a troubled
past is no excuse for hurting another person. It takes a
lot of work to change abusive patterns.
SEXUAL ABUSE AND SEXUAL
HARASSMENT
Sexual harassment is any unwelcome attention or
action of a sexual nature. It can occur in a number of
ways. It can happen without touching, in the form of
a lewd SMS, unwanted sexual jokes or letters, sexual
comments, touching, whistling, leering or following
people around. Unwanted touching, patting, brushing
or exhibiting the genitals are also forms of sexual
harassment. Sometimes, demands may be made for
sexual favours. These may be stated or unstated, but
bargained for, by withholding marks, recommendation
Handbook on sexuality for HIV and AIDS master trainers 54
letters, promotions, etc. Sexual harassment can occur
in school, college, the workplace, or out on the streets.
Sexual abuse is any sexual activity that one does not
want. Some people think that sexual abuse occurs only
with actual physical contact or violence. This is not true.
The threat of violence and abuse is as frightening, and
as much a method of controlling someone, as violence
itself. Sexual abuse is most often committed by a person
known to the victim.
Sexual abuse and harassment can happen in any
setting, to people of any gender. It may be as mild as
whistling at someone in the street and as extreme as
forced intercourse or rape. Sexual abuse can also occur
at home. Trusted people and even family members may
be abusers.
There is no excuse for abuse. Sometimes, after an
incident of rape, people make comments like, She
asked for it or She was wearing such a short dress.
No one asks for it. What one wears, where one goes,
what time one returns home at night none of these are
a justication to abuse someone. It is never the victims
fault. It is the abuser who is wrong, and an abusers
actions should not be defended by such explanations.
Children both boys and girls are also vulnerable to
sexual abuse. Child sexual abuse is any sexual activity,
which may or may not involve direct physical contact
with the child, by which a person uses a child for sexual
gratication. This happens most frequently within
homes. When a child is sexually abused by a relative,
it is called incest. It can also occur in classrooms, in
school corridors by older students, on the streets and
elsewhere. Child sexual abuse can have a terrible impact
on childrens lives, damaging self-esteem and the ability
to trust other people. It can also afect a childs mental
health and long-term emotional well-being.
Abuse 55
Open communication, therefore, between parents and
children must be encouraged. Talking to them freely
and without shame about the body and its functions
makes sure that children know what a bad touch is. It
makes them aware that there are personal zones of the
body, and that it is not okay for people to touch them
if it makes them uncomfortable. Parents should also
not insist that their child hug and kiss all uncles and
aunties if their child does not want to. Children do not
make up stories of sexual abuse. If a child talks about a
bad touch, she/he is not making up stories and should
be taken very seriously.
People with disabilities, especially children with
special needs, are also vulnerable to sexual abuse and
consequent HIV infection. This is because, due to their
disabilities, they may have to depend on caregivers
for basic care, such as bathing, dressing and using
the toilet. The ofender has more occasions for private
access to the person. Lack of information about
sexuality may mean that the child/person with special
needs may not know what appropriate behaviour is and
what is not. People with special needs may be unable to
escape unwanted sexual advances or to talk about what
has happened to them.
People who are facing abuse are at added risk of HIV as
they are not in a position to negotiate for safer sex and
may be forced to have unprotected sex. In the course
of your work, while talking with people about sexuality
and HIV, you may come across people who have been
or are still being abused. Talk to them with compassion
and do not add to their feelings of shame. In case they
are still in a situation of abuse, as in the case of domestic
violence, refer them to people who are specialized in
dealing with such issues. You may want to familiarize
yourself with NGOs, special cells or centres, and other
specialists in your town or city.
TARSHI
www.tarshi.net
TARSHI (Talking About Reproductive and Sexual Health
Issues) is a registered NGO based in New Delhi, India.
TARSHI believes that all people have the right to sexual
well being and to a self-afrming and enjoyable sexuality.
It works towards expanding sexual and reproductive
choices in peoples lives in an efort to enable them
to enjoy lives of dignity, freedom from fear, infection
and reproductive and sexual health problems. TARSHI
runs a helpline (011-26472229), conducts trainings and
institutes, develops publications, and participates in
public awareness, education and advocacy. TARSHIs
work is supported by Mama Cash.
SAKSHAM
www.tissgfatmr7.com
Saksham is part of the Global Fund (Global Fund to
ght AIDS, Tuberculosis and Malaria) Round 7, HIV
and AIDS programme in India that aims to strengthen
human and institutional capacities of the National
Health System to better meet the goals of the National
AIDS Control Programme. It is a unique partnership
between 41 academic institutions spread over 25 states
of India. It works closely with the National AIDS Control
Organization, State AIDS Control Societies, non-
government organizations, representatives of Positive
Peoples Networks and corporate agencies to enhance
the overall quality of HIV and AIDS counselling and
counselling training programs in India.
T ARSHI T ARSHI