This course offers a comprehensive, evidence-based exploration of human sexuality, sexual health, and well-being. Grounded in a sex-positive, intersectional framework, it draws on biology, psychology, sociology, public health, and clinical medicine to understand how sexuality shapes, and is shaped by, the full complexity of human experience.

Introduction and Foundations

Land Acknowledgement

The University of Waterloo is situated on the traditional territory of the Neutral, Anishinaabeg and Haudenosaunee peoples. The University is located on the Haldimand Tract, the land promised to the Six Nations that includes ten kilometres on each side of the Grand River. We acknowledge this territory as an ongoing act of respect and a commitment to understanding the history and present realities of Indigenous communities.

Approaching the Course: Self-Care

Sexual health material has the potential to evoke a wide range of emotional responses — including happiness, relief, excitement, embarrassment, sadness, anger, stress, or anxiety. This is entirely normal. Engaging thoughtfully with one’s own emotional responses is an important part of both personal well-being and professional development for those who will work in health-related fields. Self-care should be understood not as a luxury, but as a genuine priority and professional necessity.

Language and Inclusion

Language carries enormous power: it can affirm, include, harm, or exclude. This course commits to using inclusive language and acknowledges that language is constantly evolving. Students are encouraged to question terminology, including the language used in course materials, as part of collective learning. Making assumptions about other people — their identities, bodies, desires, or experiences — should be actively avoided.

A Sex-Positive Approach

This course takes a sex-positive approach to teaching sexual health. Sex positivity is not synonymous with sex promotion; rather, it is an educational and ethical stance that acknowledges sexuality as a natural and potentially healthy dimension of human experience.

What sex positivity means:

• Sexual activity can be healthy and pleasurable — yet is neither inherently moral nor immoral
• It promotes and celebrates the diversity of sexuality and bodies
• It supports the ability of individuals to make and respect personal choices regarding their own sexuality
• It avoids moralistic value judgements about consensual sexual behaviour
• It emphasizes comfort with one’s own body and sexuality, and respect for others'
• It advocates for comprehensive sexual health education for all people
• It is non-judgmental in its orientation

As the Sexuality Education Resource Centre (Manitoba) defines it: “Sex positivity is an important ideology that acknowledges and affirms each person’s right to experience and define their sexuality throughout their lifetime in whatever way they choose. Grounded in comprehensive sexuality and sexual health education, sex positivity is inclusive and respectful of a wide range of sexual experiences, expressions, consensual activities (including non-activity) and identities (including asexuality).”

Intersectionality

Intersectionality is a theoretical framework, developed by legal scholar Kimberlé Crenshaw, that examines how overlapping social identities — such as race, gender, sexuality, class, ability, and age — interact with systems of power and oppression to produce distinct, compounding experiences of privilege and disadvantage. In the context of sexual health, intersectionality helps us understand why health outcomes, access to care, and sexual experiences differ profoundly across populations.

Thinking Critically about Sexuality

We are continuously exposed to information about sex and sexuality through traditional media, social media, music, family, and friends — much of it contradictory, incomplete, or misleading. The core skill of critical thinking is scepticism: not accepting claims uncritically, especially when they come from authority figures, celebrities, or popular culture. Maintaining an open mind means being willing to revise one’s beliefs when confronted with good evidence.

What is Sexual Health and Well-Being?

Defining Human Sexuality

Human sexuality is a multidimensional phenomenon that encompasses:

• Biological dimensions: anatomy, hormones, reproductive organs, and physiology
• Psychological dimensions: erotic feelings, desires, fantasies, thoughts, and attractions
• Relational dimensions: intimate, romantic, and sexual relationships
• Social and cultural dimensions: gender roles, gender identities, gender expressions, and sexual orientations
• Moral and spiritual dimensions: personal values and ethical frameworks

As Rathus, Nevid, Fichner-Rathus & McKay (2016) write, “to study human sexuality is to study diversity” — human beings experience and express sexuality in deeply varied ways, and this diversity is central to individual and communal identity.

The study of human sexuality is inherently multidisciplinary, drawing on contributions from biologists, psychologists, sociologists, anthropologists, sexologists, theologians, medical researchers, and historians.

The WHO Definition of Sexual Health

The World Health Organization (WHO) offers the most widely accepted working definition of sexual health:

"…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled." (WHO, 2006)

This definition situates sexual health within a holistic model of well-being: it is inseparable from overall health and directly influences quality of life.

Sex-Positive vs. Sex-Negative Health Messaging

Traditional sexual health messaging has often focused narrowly on the prevention of negative outcomes — STIs and unintended pregnancy — at the expense of acknowledging pleasure, desire, and autonomy. Research by Brickman and Fitts Willoughby (2017) examined university students’ responses to sex-positive versus sex-negative sexual health text messages, finding that:

• Sex-positive messages were more believable and more persuasive than sex-negative messages
• The most effective messages combined a sex-positive stance with a gain frame (emphasizing positive outcomes of healthy behaviour)
• Gain-framed messages — describing the benefits of health-promoting behaviour (e.g., “Getting tested for STIs after each sexual relationship is responsible and leads to more trust from future partners”) — were rated more highly on understandability, believability, persuasiveness, and relevance than loss-framed messages

Prospect Theory (Kahneman & Tversky, 1979) explains this pattern: when presented with potential gains, people prefer safer choices; when confronted with potential losses, people often take risks. Sex-positive societies tend to focus on the gains of healthy sexual expression, while sex-negative societies emphasize the consequences of non-compliance.

Self-Efficacy in Sexual Health

Self-efficacy — the belief in one’s own ability to successfully perform a behaviour or meet a challenge — is a key predictor of health behaviour. In sexual health contexts, self-efficacy predicts whether individuals will seek testing, communicate with partners about sexual health, or use barrier methods consistently. This is distinct from self-esteem, which reflects one’s overall sense of worth or value. Self-efficacy is focused on doing; self-esteem is focused on being.

Anatomy and Physiology

The Vulva and Vagina

The vulva is the collective term for the external genital structures, including the labia majora, labia minora, clitoris, clitoral hood, urethral opening, and vaginal opening. A common misconception conflates the vulva with the vagina; the vagina is specifically the internal muscular canal that connects the vulvar opening to the cervix.

Vaginal secretions are a normal physiological occurrence and are composed of a combination of: secretions from the Bartholin’s and Skene’s glands; transudation (moisture seeping through vaginal walls in response to arousal); cervical mucus; cells shed from the vaginal lining; and products from the beneficial bacteria that comprise the vaginal microbiome. These secretions vary in consistency, volume, and scent across the menstrual cycle and life stages.

Vaginal lubrication occurs as part of the arousal response: increased blood flow to the pelvic region causes transudation through vaginal walls, producing a natural lubricant. The speed and volume of this response varies considerably from person to person and across situations. There is no universal baseline. If natural lubrication is insufficient for comfortable sexual activity, supplemental lubricants — available widely without prescription — are a practical and healthful option; water-based lubricants are compatible with all barrier methods.

Hymen mythology and “virginity”: The hymen is a thin, flexible membrane that partially covers the vaginal opening in many individuals. It does not “break” or “disappear” with first intercourse in most people — the tissue is elastic and resilient, and changes to it are not reliable indicators of sexual experience. Medical evidence has thoroughly discredited the concept of physical “virginity testing.” As Nina Dolvik Brochmann and Ellen Stokken Dahl argue in their TEDxOslo talk “The Virginity Fraud,” the notion that the hymen can prove or disprove sexual experience is both medically inaccurate and deeply harmful.

Smegma is a naturally occurring accumulation of shed skin cells, skin oils, and moisture that can collect beneath the foreskin of a penis or under the clitoral hood of a vulva. It is a normal physiological substance that can cause odour if not removed with regular hygiene; it requires no special treatment beyond routine bathing.

The Penis and Testicles

The penis is composed of the shaft, glans (head), and — in uncircumcised individuals — the foreskin (prepuce). Internally, it contains two corpora cavernosa and the corpus spongiosum, which engorge with blood during erection.

Common anatomical conditions of the penis:

• Hypospadias: a congenital condition in which the urethral opening is located on the underside of the penis rather than at the tip
• Peyronie’s disease: a condition in which scar tissue (plaque) forms inside the penis, causing curvature during erection and potentially causing pain or discomfort
• Phimosis: a condition in which the foreskin is too tight to retract comfortably; it may cause pain during erection or intercourse, and in some cases may require medical management including circumcision

Semen composition: Ejaculate is composed of: approximately 1% spermatozoa; approximately 30% fluid from the prostate gland; approximately 70% fluid from the seminal vesicles; and pre-ejaculatory fluid (Cowper’s fluid) that coats the urethra before ejaculation and neutralizes residual acidity.

Epididymal hypertension (colloquially referred to by various informal terms) is a temporary sensation of discomfort or aching in the testicles that can occur when a person experiences sexual arousal without reaching orgasm. This is a benign, self-limiting condition; it resolves on its own without any sexual activity. It is not a medical emergency and cannot justify pressure on any person to engage in sexual activity.

Intersex Variations

Intersex is an umbrella term for a range of naturally occurring variations in which a person is born with reproductive anatomy, chromosomes, hormones, or gonads that do not fit conventional binary definitions of male or female. It is a natural variation in human biology, not a disorder or medical problem.

Intersex characteristics may involve:

• Variation in external genitalia (e.g., enlarged clitoris, fused labia, or genitalia that do not clearly align with binary sex categories)
• Combinations of internal reproductive organs from both sexes
• Chromosomal configurations other than XX or XY (e.g., XXY, X, XXX, XYY, or mosaic chromosomes)
• Hormonal profiles that differ from typical male or female patterns

The frequency of intersex conditions depends on the criteria used: approximately 1 in 2,000 births if only external genital ambiguity is considered, rising to roughly 1 in 200 when chromosomal and hormonal variations are included.

Medical ethics and surgery: Historically — and still in some contexts today — physicians would choose a binary gender for intersex infants and perform “normalizing” surgery without the patient’s consent, often resulting in the wrong gender assignment and significant long-term harm. Contemporary medical ethics increasingly recommends deferring non-essential surgical interventions until the individual can meaningfully participate in decision-making, providing only procedures necessary for health (e.g., creating a functioning urethra), and being honest with intersex children and their families about these variations from the outset.

Talking with Children about Their Bodies

Using accurate anatomical language with children — vulva, vagina, penis, testicles — from an early age is associated with several protective outcomes: it reduces shame and stigma around bodies; it equips children to describe their own experiences clearly, including in situations involving inappropriate touch; and it normalizes open, factual communication about bodies. Euphemisms and avoidance can inadvertently communicate that bodies, and especially genitals, are shameful or unspeakable.

Teaching children about bodily autonomy — the right to decide who touches their body, and how — begins in infancy and early childhood, and is foundational to later consent education.

Relationships

Forms of Intimate Relationship

Intimate relationships span a wide spectrum of structures, intensities, and arrangements. Recognizing this diversity is part of a sex-positive and non-judgmental understanding of human connection. These include, but are not limited to: marriage and remarriage; long-term committed partnerships; cohabitation; living-apart-together (LAT) relationships; casual dating; casual sexual partnerships (sometimes called “friends with benefits”); one-time encounters; companionate relationships without a sexual dimension; online and long-distance relationships; and relationships that have ended through separation, divorce, or loss.

Social scripts — internalized frameworks acquired through repeated social interaction — shape how individuals understand, interpret, and navigate relationships. People learn these scripts from lived experience, traditional media, social media, and, significantly, from pornography, which often reflects highly unrealistic and non-representative models of sexual relationships.

Social Exchange Theory holds that the development and maintenance of relationships reflects an ongoing evaluation of the rewards and costs of staying in versus leaving the relationship, compared against perceived alternatives.

Monogamy and Mononormativity

Monogamy refers to having one intimate or sexual partner at a time (serial monogamy) or throughout one’s lifetime. Mononormativity is the cultural assumption that monogamy is the default or only legitimate relationship structure. Research suggests that rates of non-consensual non-monogamy (infidelity) within ostensibly monogamous relationships are substantial, indicating that the equation between monogamy and relationship norms is more complex in practice than it may appear in theory.

Consensually Non-Monogamous Relationships

Consensually non-monogamous (CNM) relationships include a range of ethical, agreed-upon alternatives to exclusive monogamy:

• Open relationships: a primary partnership in which both members have agreed that each may have sexual (though typically not deeply romantic) relationships with others
• Swinging: a consensual practice in which people in committed relationships engage in sexual activity with others, often in social contexts, for recreational purposes
• Polyamory: the practice of maintaining multiple intimate relationships — which may be emotional, romantic, and/or sexual — with the full knowledge and consent of all involved. Polyamory has been described as “consensual, ethical, and responsible non-monogamy”

Research by Hutzler, Giuliano, Herselman & Johnson (2016) found that approximately 4–5% of people in the United States practice some form of CNM. Despite common misconceptions, polyamorous individuals tend to practice safer sex more consistently, maintain higher communication skills, and report lower levels of jealousy than those unfamiliar with CNM. Both awareness of polyamory and personal acquaintance with polyamorous individuals predicted more positive attitudes, consistent with the Contact Hypothesis: direct or indirect contact with members of an out-group reduces prejudice over time.

Structural stigma — negative attitudes embedded in cultural norms, legal frameworks, and institutions — continues to create chronic stress for CNM individuals, which in turn has documented mental and physical health consequences.

BDSM and Consensual Kink

BDSM is an acronym that encompasses three overlapping sets of practices:

• BD — Bondage and Discipline
• DS — Dominance and Submission
• SM/S&M — Sadomasochism (sexual arousal from giving or receiving pain, restraint, or humiliation, within consensual parameters)

Academic Research on BDSM

The academic literature has consistently challenged the popular misconception that BDSM practitioners are psychologically disturbed or that their practices reflect past trauma or psychopathology.

Wismeijer & Van Assen (2013) conducted a large comparative study and found that BDSM practitioners were, relative to non-practitioners: less neurotic, more extraverted, more open to new experiences, more conscientious, less sensitive to rejection, and higher in subjective well-being. They concluded that BDSM is better understood as a recreational interest than as an expression of psychopathological processes.

Richters, de Visser, Rissel, Grulich & Smith (2008), using a national Australian survey, found that BDSM is simply a sexual interest or subculture attractive to a minority, and that for most practitioners it is not a pathological symptom of past abuse or difficulty with other aspects of sexuality.

Consent and Communication in BDSM Practice

One of the most frequently observed features of BDSM communities is their explicit, structured emphasis on consent and communication:

Consent in BDSM is understood as clear, continuous, coherent, and coercion-free. Before engaging in BDSM activities, participants typically negotiate and establish:

• Hard limits: activities a person will never consent to under any circumstances
• Soft limits: activities a person is hesitant about but may be willing to explore under certain conditions
• A safe word: a pre-agreed signal (often using a traffic-light system: “red” = stop immediately, “yellow” = slow down or check in, “green” = continue) that any participant can use at any time to pause or end an activity. Any participant may use a safe word.

The community term for the space in which BDSM activities occur is a “scene” — a pre-negotiated encounter with clearly established parameters.

Aftercare refers to the care that participants provide to one another following BDSM activity. Certain forms of intense physical or psychological play can be both physically demanding and emotionally activating; aftercare provides time to return to baseline, check in on one another’s well-being, and transition out of the roles and intensity of the scene.

BDSM Terminology

Common roles and identities within BDSM include:

• Dominant (Dom): the person who takes the leading or authoritative role in a scene
• Submissive (Sub): the person who yields or surrenders authority within the negotiated parameters of a scene
• Switch: a person who comfortably takes either a dominant or submissive role in different relationships or situations
• Top: the person performing an action; authority dynamics are not necessarily implied
• Bottom: the person receiving an action; authority dynamics are not necessarily implied

Kink is a broader term encompassing a wide range of sexual interests, practices, and relationship structures that diverge from societal norms. Not all kink involves pain or power exchange. The kink community, sometimes called the leather community, typically values privacy, discretion, and a commitment to SSC principles (Safe, Sane, and Consensual) or the alternative RACK framework (Risk-Aware Consensual Kink).

DSM-5 clinical distinction: The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5, APA 2013) formally distinguishes between a paraphilia — an atypical sexual interest — and a paraphilic disorder, which additionally requires that the interest cause the individual significant personal distress or involve non-consenting persons. BDSM practiced consensually between adults who experience no distress does not, by this definition, constitute a disorder.

50 Shades of Grey (2011 novel; 2015 film) introduced BDSM to mainstream audiences but is widely considered by practitioners and researchers to be a highly inaccurate representation: it depicts numerous consent violations and unhealthy power dynamics that are contrary to the values and practices of actual BDSM communities.

Age Dynamics and Social Scripts in Relationships

Social norms around the appropriate ages of partners in romantic relationships are pervasive and often unexamined. These scripts intersect with gender identity, economic power, and cultural expectations in ways worth critically examining. The question of what constitutes “appropriate” age difference is shaped by power differentials and context.

Relationship Agreements and Infidelity

What counts as “cheating” is not universally defined and varies significantly across relationships. Different couples define infidelity differently — some relationships would consider emotional intimacy with a third party a violation; others would not. Explicit communication about expectations, boundaries, and agreements is fundamental to navigating this complexity. Esther Perel’s work on infidelity challenges conventional narratives and invites a more nuanced examination of what people seek in relationships and why infidelity occurs.

Menstruation and Menopause

Menstruation: An Overview

Menstruation is the shedding of the endometrial lining of the uterus, occurring approximately monthly in people with uteruses who are not pregnant and have not reached menopause. The menstrual cycle has four phases:

1. Menstrual phase: the uterine lining is shed, typically over 3–7 days
2. Follicular phase: follicle-stimulating hormone (FSH) stimulates ovarian follicles; estrogen levels rise and begin rebuilding the endometrium
3. Ovulation: a mature egg is released from the ovary, typically around day 14 of a 28-day cycle
4. Luteal phase: the corpus luteum produces progesterone, maintaining the endometrial lining in preparation for potential fertilization; if fertilization does not occur, progesterone drops and the cycle begins again

The average cycle is 28 days, but normal cycles range widely from approximately 21 to 35 days.

Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

Premenstrual syndrome (PMS) refers to a constellation of physical and emotional symptoms occurring in the luteal phase that resolve with menstruation. Common symptoms include bloating, breast tenderness, fatigue, mood changes, irritability, and headaches.

Premenstrual dysphoric disorder (PMDD) is a more severe form affecting a minority of menstruating individuals, characterized by significant mood disturbances (including depression and anxiety) that cause meaningful disruption to daily functioning.

Menstrual Taboo and Menstrual Equity

Menstruation remains heavily stigmatized in many cultural contexts worldwide. This stigma has real consequences: menstruating individuals may be excluded from social participation, educational settings, and places of worship; lack of access to menstrual products and sanitation infrastructure undermines educational opportunity and health outcomes, particularly in low- and middle-income countries.

The WHO and UNFPA (2021) jointly expanded the definition of menstrual health beyond hygiene management to encompass a full rights-based framework: “a state of complete physical, mental, and social well-being … in relation to the menstrual cycle,” including access to products, sanitation, accurate information, safe spaces, and freedom from stigma. Globally, an estimated 500 million people lack adequate access to menstrual products and facilities (UNICEF/WHO WASH data). In Canada, the federal goods and services tax on menstrual products was removed in 2015; Scotland (2020) and New Zealand (2021) have legislated free product access in schools and public facilities.

Menstrual Hygiene Day (May 28) is a global advocacy platform working to break silence and shame around menstruation, raise awareness of menstrual hygiene management (MHM), and engage governments and international bodies to increase political priority for access to menstrual products and sanitation.

“Queer Periods” (Chrisler, 2016) documents the experiences of transgender, non-binary, and gender-diverse individuals with menstruation — highlighting how the cultural gendering of menstruation (as exclusively a “women’s” experience) causes particular harm to individuals who menstruate but do not identify as women, and vice versa.

Menopause

Menopause is defined as the permanent cessation of menstruation, confirmed retrospectively after 12 consecutive months without a menstrual period. The average age of menopause in North America is approximately 51 years.

Perimenopause is the transitional period leading up to menopause, which may begin years earlier and is characterized by irregular menstrual cycles and fluctuating hormone levels.

Common experiences of menopause include:

• Vasomotor symptoms: hot flashes and night sweats (caused by declining estrogen affecting the hypothalamic thermostat)
• Vaginal atrophy and dryness (due to reduced estrogen, affecting mucosal tissues)
• Sleep disturbances
• Mood changes
• Changes in sexual desire and arousal

Treatment options range from hormone therapy (estrogen and/or progesterone) for moderate to severe vasomotor symptoms, to non-hormonal interventions and lubricants for vaginal dryness. Medical decisions about menopause management should be individualized and made in collaboration with a healthcare provider.

The Menstrual Movement

The menstrual movement is a global advocacy effort to: destigmatize menstruation; achieve menstrual equity (ensuring all people have access to menstrual products and education); push for policy change (e.g., eliminating “tampon taxes” on menstrual products); and challenge the silence and shame that have historically surrounded this normal biological process.

2SLGBTQI+ Health Care

Language and Terminology

Understanding the terminology used by and for 2SLGBTQI+ communities is essential for respectful, effective, and inclusive healthcare and social interaction. Language evolves; what follows represents current commonly used definitions.

Gender Identity and Expression

• Gender: a person’s understanding and experience of themselves in relation to their body, identity, and expression. Gender is distinct from biological sex.
• Assigned sex: the classification of a person at birth, typically based on external genitalia
• Assigned gender: the assumptions, expectations, and norms of behaviour that follow from a person’s assigned sex
• Gender binary: a system — rooted in Western colonial frameworks — that permits only two genders (man and woman). Many cultures, past and present, have recognized and celebrated more diverse gender categories.
• Transgender: a person who does not identify with the gender they were assigned at birth
• Cisgender: a person whose gender identity aligns with the gender they were assigned at birth
• Non-binary: a person who identifies outside the binary of “male” and “female,” some or all of the time
• Genderqueer: an umbrella term for gender identities outside of, or beyond, the binary
• Gender non-conforming: a person whose gender expression does not match societal expectations for their gender identity
• Agender: a person who does not identify with any gender
• Gender variant: an umbrella term for identities and expressions that diverge from social or cultural expectations
• Two-Spirit (2S): a term used in some Indigenous communities, referring to a person who embodies both masculine and feminine spiritual qualities. Two-Spirit is a culturally specific term and should not be applied outside Indigenous contexts; its inclusion at the front of the 2SLGBTQI+ acronym reflects its historical and spiritual significance.
• Transition: the processes through which a transgender person may align their social presentation and/or body with their gender identity. Transitions may be social (new name, pronouns, clothing) and/or medical (hormones, surgeries). There is no single or “correct” way to transition; not all trans people wish to or are able to pursue all aspects of transition.
• Cisnormativity/Cissexism: the assumption that everyone’s gender identity aligns with their assigned sex, such that genitals are conflated with gender identity

Sexual Orientation and Attraction

• Lesbian: a woman who is primarily attracted to women
• Gay: most commonly describes men attracted to men, though the term is used more broadly
• Bisexual: a person attracted to people of the same gender as themselves and to people of other genders
• Pansexual: a person attracted to people regardless of gender
• Asexual (ace): a person who experiences little to no sexual attraction to others; asexual individuals may still experience romantic attraction
• Aromantic (aro): a person who experiences little to no romantic attraction; aromantic individuals may still experience sexual attraction
• Demisexual: a person who experiences sexual attraction only after forming a significant emotional bond
• Sapiosexual: a person who is primarily attracted to intelligence
• Panromantic: a person who experiences romantic attraction to people of any gender
• Queer: an umbrella term reclaimed by many 2SLGBTQI+ individuals to describe non-normative sexual orientations and gender identities. As a formerly derogatory slur now reclaimed as a positive identity term, its use by allies should be approached carefully; the full acronym (2SLGBTQI+) is preferred in ally contexts.
• Questioning: the state of exploring or being uncertain about one’s sexual orientation or gender identity; this process has no set timeline

Structural Concepts

• Gender binary: a Western colonial construct that enforces exactly two mutually exclusive gender categories
• Fluidity: the concept that gender identity and/or sexual orientation may shift or evolve over a person’s lifetime
• Heteronormativity/Heterosexism: the assumption that heterosexuality is the norm or default
• Homophobia: systemic and interpersonal prejudice, discrimination, and violence directed at people perceived to be gay or lesbian
• Transphobia: systemic and interpersonal prejudice, discrimination, and violence directed at transgender and gender-diverse people

2SLGBTQI+ Health Disparities

Strong and well-documented links exist between stigma, chronic stress, and adverse health outcomes. People who identify as 2SLGBTQI+ face disproportionate exposure to stigma — from peers, families, healthcare systems, and structural institutions — which translates into measurable mental and physical health disparities.

Bonvicini (2017), reviewing LGBT healthcare disparities in the American context, found:

• Many LGBT individuals report negative healthcare experiences, including homophobia and unequal treatment
• Trans and gender-non-conforming individuals — particularly those who are also BIPOC (Black, Indigenous, and People of Colour) — face disproportionate rates of outright refusal of medical care
• Medical and nursing education includes almost no training on LGBT health needs, creating providers who may be unprepared to deliver competent, affirming care
• LGBT individuals often avoid the healthcare system altogether following negative first experiences, leading to delayed diagnosis and worsening health outcomes
• First interactions with the healthcare system — including non-clinical staff at reception, billing, and security — matter enormously; inclusive, respectful environments require change at every level

Inclusive healthcare practices include: using a patient’s chosen name rather than legal name; asking about pronouns; designing intake forms that do not assume binary gender or heterosexual orientation; and ensuring clinical staff receive ongoing education about 2SLGBTQI+ health needs and implicit bias.

Trans Health Resources

• Trans PULSE Project (Ontario): a community-based research project documenting the health impacts of social exclusion and discrimination on trans people. Findings underscore the critical importance of family support: lack of parental support was found to significantly increase vulnerability to mental health challenges, homelessness, and other serious harms.
• Rainbow Health Ontario: an organization working to improve the capacity of the healthcare system to support 2SLGBTQI+ communities through education, research, and advocacy.
• The University of Waterloo has implemented systems allowing students to use a chosen/preferred name across university systems — an important step toward inclusion for trans, non-binary, and gender-diverse students.

Sexual Health and Cancer

The Intersection of Sexual Health and Illness

Physical health conditions — illness, injury, aging, and the side effects of medical treatments — can significantly affect sexual health and well-being. This connection is frequently underdiscussed in clinical settings, in part because conversations about sex are difficult for many people even when they are healthy; illness adds additional layers of vulnerability, changed body image, altered roles, and fear.

Cancer and its treatments can affect sexual health and well-being through:

Direct treatment effects:

• Removal of body parts involved in reproduction or sexual function (e.g., breasts, testicles, ovaries, uterus, portions of the intestine)
• Nerve damage affecting sensation in the genitals and other erogenous areas
• Loss of sensation or hypersensitivity in affected areas
• Damage to mucous membranes in the mouth, vagina, anus, or urethra
• Vaginal dryness and atrophy of genital tissues
• Skin changes from radiation, including transformation of soft tissue to scar tissue
• Reduced blood flow to pelvic organs
• Abrupt onset of surgically- or chemically-induced menopause

Systemic effects:

• Hormonal changes (from anti-hormone therapies, surgical removal of hormone-producing organs)
• Loss of energy, chronic fatigue, and pain
• Erectile dysfunction; changes in ejaculation
• Altered capacity to reach orgasm
• Infertility
• Changes in libido
• Urinary or bowel incontinence
• Various forms of sexual dysfunction

Psychosocial effects:

• Altered body image and sexual self-esteem
• Fear of cancer recurrence during sexual activity
• Role changes within relationships (partner becoming caregiver)
• Dating challenges post-diagnosis
• Heightened risk of depression and anxiety disorders in cancer survivors

What Can Be Done?

For patients managing the sexual health effects of cancer and its treatment, options include:

• Communication with healthcare providers (patients may need to advocate for themselves, as providers often do not initiate these conversations)
• Vaginal moisturizers and lubricants for dryness
• Topical or systemic hormone therapy where appropriate (estrogen creams, testosterone)
• Erectile aids (e.g., phosphodiesterase inhibitors, vacuum devices, penile implants)
• Pelvic floor physiotherapy (see Week 10)
• Sensate focus exercises — structured, progressive exercises often assigned by sex therapists, designed to help couples rebuild intimacy and communication without performance pressure (see below)
• Masturbation as a tool for self-exploration and reconnection with one’s own changing body
• Sex toys designed to enhance arousal and circulation
• Egg and sperm freezing prior to treatments that may cause infertility
• Counselling, sex therapy, and psychoeducation
• Online communities and peer support networks for cancer survivors

Cancer Screenings

Cervical Cancer and Pap Tests

Cervical cancer is caused by certain high-risk strains of Human Papillomavirus (HPV). Most HPV infections resolve on their own without causing any disease; a small proportion of people infected with high-risk strains will develop cervical cell abnormalities that, if undetected, may progress to cancer over many years.

A Pap test (cervical smear) involves collecting cells from the cervix with a small brush; these cells are examined for abnormalities. According to Ontario guidelines updated in 2013:

• Cervical screening should begin at age 21 for anyone with a cervix who is or has been sexually active (including any form of genital contact)
• Screening frequency is every three years (changed from annually), as cervical cancer before age 21 is extremely rare (approximately 1 in one million)
• Abnormal results may indicate cell changes (very common, often self-resolving) or early cancer; follow-up testing (including colposcopy and biopsy) may be recommended
• An HPV test is approximately 90–95% effective and can be based on self-collection

Pap tests do not screen for STIs such as chlamydia or gonorrhea — these require separate testing.

The HPV vaccine (available for all genders) provides highly effective protection against the most cancer-causing strains of HPV and is a critical component of cervical cancer prevention.

Indigenous communities and cervical cancer: Research by Maar et al. documents disproportionately high rates of cervical cancer and cervical cancer mortality among Indigenous women in Canada, driven by systemic barriers to screening access and follow-up. Cultural safety, trust-building, community-centred education, and self-collection HPV testing are identified as key strategies for addressing this disparity. The legacy of colonialism — including the harm done in residential schools and Indian hospitals — continues to shape healthcare access and trust in Indigenous communities.

Breast Cancer

Breast cancer is the most commonly diagnosed cancer among people with breast tissue in Canada (approximately 27,400 diagnoses per year). Early detection substantially improves treatment outcomes. Screening methods include:

• Breast self-examination: regular self-check for changes in texture, shape, or the presence of lumps
• Clinical breast examination: physical examination by a healthcare provider
• Mammography: low-dose X-ray; the Canadian Cancer Society recommends mammography every two years for individuals aged 50–74
• Breast thermography: infrared imaging that detects abnormal vascular patterns associated with early-stage cancer

Prostate Cancer

Prostate cancer is the most commonly diagnosed cancer among people with prostates in Canada. Risk increases with age and is typically diagnosed after 50. Early-stage prostate cancer often produces no symptoms. Screening includes:

• Prostate-specific antigen (PSA) test: a blood test measuring PSA levels; elevated levels may warrant further investigation
• Digital rectal examination: palpation of the prostate through the rectal wall to assess size, shape, and the presence of irregularities Both tests together are recommended beginning around age 45–50.

Testicular Cancer

Testicular cancer is the most commonly diagnosed cancer in people with testicles between ages 15 and 29. Regular testicular self-examination is recommended: individuals should familiarise themselves with the typical feel of their testicles and report any new lumps, changes in size or consistency, or discomfort to a healthcare provider promptly. Early detection dramatically improves outcomes.

Sexual Health after Heart Attack and Stroke

Sexual activity involves cardiovascular exertion comparable to climbing two flights of stairs — a level of activity that is generally safe to resume a number of weeks after a cardiac event, according to the Heart and Stroke Foundation of Canada. Specific timelines should be confirmed with a cardiologist. Practical guidance includes:

• Starting slowly, with lower-intensity forms of intimacy first
• Avoiding sexual activity in extreme temperatures, immediately after a large meal, or after consuming alcohol
• Communicating openly with partner(s) about fears and needs
• Seeking support from healthcare providers if fear of recurrence is affecting intimacy

Following stroke, sexual functioning may be affected by neurological damage, fatigue, depression, communication difficulties, and physical limitations. A gradual, flexible approach to intimacy — one that expands the definition of sex beyond penetration to encompass a range of intimate contact — is often recommended.

Sexually Transmitted Infections (STIs)

Categories of STIs

Sexually transmitted infections are classified into three categories based on the type of pathogen involved:

1. Bacterial STIs — caused by bacteria, which are living, single-celled organisms that remain separate from the host’s cells. Bacterial STIs can generally be treated and cured with appropriate antibiotics. Examples include: chlamydia, gonorrhea, and syphilis.

2. Viral STIs — caused by viruses, which integrate into host cells. Because they “hide” within healthy cells, viral STIs are difficult or impossible to cure; management focuses on antiviral treatment to suppress symptoms and reduce transmission risk. Examples include: HIV, herpes (HSV-1 and HSV-2), Human Papillomavirus (HPV), and hepatitis B.

3. Parasitic STIs — caused by parasites (organisms that live on or within a host). Examples include: pubic lice (Phthirus pubis) and scabies.

A Note on Antibiotic Resistance

Gonorrhea (Neisseria gonorrhoeae) represents an increasingly serious public health concern. The World Health Organization has classified antibiotic-resistant gonorrhea as one of the three most urgent antimicrobial resistance threats globally. Multiple strains are now resistant to previously effective antibiotics, severely limiting treatment options.

STI Epidemiology

The WHO estimates that hundreds of millions of new STI infections occur worldwide each year. In Canada, rates of several STIs — including chlamydia and syphilis — have been increasing in recent years. Reported statistics consistently underestimate true prevalence, as many people are never tested and as STIs often present without symptoms.

Key epidemiological context:

• The average age of first sexual intercourse in Canada has remained relatively stable at approximately 16–17 years
• The average age of marriage and first committed relationship is increasing
• Use of long-acting reversible contraception (LARC — e.g., oral contraceptives, patch, ring, hormonal IUD) has increased, while condom use has declined — meaning pregnancy prevention practices have improved but STI protection has not kept pace

Prevention and Barrier Methods

Condoms (both external/male and internal/female types) and dental dams remain the most effective barrier methods for reducing STI transmission risk during sexual activity. Correct and consistent use is essential.

Common Mistakes in Condom Use

1. Improper storage (must be kept at a consistent, moderate temperature, away from direct sunlight and heat)
2. Using an expired condom
3. Not pinching the tip of the condom prior to application (to leave space for ejaculate)
4. Not holding the condom base when withdrawing after sexual activity

Condom Availability in Schools

Research cited in this course (Society for Adolescent Health and Medicine) supports condom availability programs in secondary schools, noting that providing access to condoms does not increase the likelihood of sexual initiation among young people, but does increase rates of barrier method use among those who are already sexually active, thereby reducing unintended pregnancy and STI transmission.

Communicating about Sexual Health

Open communication with partners before sexual activity is a core component of sexual health and consent. This includes discussing:

• Consent and the nature of the intended sexual activity
• STI testing history and results
• Birth control preferences
• Relationship expectations

Stigma and STIs

STIs carry disproportionate social stigma, which compounds the medical implications with emotional and psychological consequences. Stigma creates barriers to testing, disclosure, and treatment. It is important to recognize that anyone who is sexually active can contract an STI — this reflects biological reality, not moral judgment. Education and destigmatization are the most effective tools for reducing both transmission rates and harm.

Canadian STI surveillance (PHAC): Chlamydia is consistently the most commonly reported STI in Canada, disproportionately affecting youth aged 15–24. Rates of gonorrhea more than doubled between 2014 and 2019, and antimicrobial resistance (Neisseria gonorrhoeae) is classified by both WHO and PHAC as a critical public health threat. Infectious syphilis has experienced a significant resurgence, including a troubling rise in congenital syphilis (transmission from gestating parent to fetus), which had been near-eliminated. Current statistics are published in the PHAC Report on Sexually Transmitted and Blood-Borne Infections in Canada (canada.ca/phac).

Public Health Waterloo Region provides free, confidential STI testing and can assist with anonymous partner notification to help limit transmission without requiring individuals to contact partners themselves.

Birth Control

Historical and Legal Context

People have attempted to prevent unwanted pregnancy throughout recorded human history. In Canada, contraception was legal until the late 19th century, when it was criminalized; it was not fully relegalized until 1969. The 1920s saw the beginning of organized advocacy for birth control legalization. Today, a wide range of contraceptive methods is available, and access remains an ongoing area of advocacy and public health work.

Typical Use vs. Perfect Use

Every contraceptive method has two efficacy rates:

• Perfect use: the failure rate when the method is used correctly and consistently every time
• Typical use: the failure rate in real-world conditions, accounting for inconsistent or incorrect use

The gap between perfect use and typical use is largest for methods requiring regular user action (e.g., the oral contraceptive pill, where typical use failure rates are considerably higher than perfect use). Long-acting reversible contraceptives (LARCs), which do not require daily or per-encounter action, have smaller gaps between perfect and typical use.

Why People Use Birth Control

The decision to use birth control is multifaceted:

• Preventing unintended pregnancy
• Regulating or suppressing menstruation
• Reducing menstrual pain or heavy bleeding
• Managing skin conditions (e.g., hormonal acne)
• Reducing premenstrual symptoms
• Managing polycystic ovary syndrome (PCOS) or endometriosis symptoms
• Personal choice and body autonomy

Overview of Contraceptive Methods

Hormonal Methods

Combined oral contraceptive pill (“the pill”): contains synthetic estrogen and progestogen; prevents ovulation, thickens cervical mucus, and thins the uterine lining. Must be taken daily at approximately the same time. Typical use efficacy: ~91%.

Progestogen-only pill (“mini-pill”): contains only progestogen; must be taken at the same time each day (shorter window than combined pill). Suitable for individuals who cannot use estrogen.

The patch (Evra): worn on the skin, changed weekly (three weeks on, one week off); releases estrogen and progestogen transdermally.

The vaginal ring (NuvaRing): a flexible ring inserted into the vagina for three weeks at a time; releases estrogen and progestogen locally.

The contraceptive injection (Depo-Provera): a progestogen injection administered every three months by a healthcare provider; highly effective with no daily action required.

Intrauterine devices (IUDs):

• Hormonal IUDs (e.g., Mirena, Kyleena): release small amounts of progestogen locally; reduce menstrual flow and may eliminate periods; effective for 3–8 years depending on brand
• Copper IUDs (e.g., Flexi-T, Mona Lisa): non-hormonal; the copper creates a hostile environment for sperm; effective for 3–10+ years and can also be used as emergency contraception

Implant (Nexplanon): a small rod inserted under the skin of the upper arm; releases progestogen for up to 3 years.

Barrier Methods

External condom: worn over the penis or sex toy; the only widely available contraceptive that provides simultaneous protection against both pregnancy and STIs.

Internal condom: inserted into the vagina or anus; provides similar dual protection. Can be inserted in advance.

Dental dam: a thin sheet used as a barrier during oral-vaginal or oral-anal contact; reduces STI transmission risk.

Diaphragm / cervical cap: inserted into the vagina before sexual activity to cover the cervix; used with spermicide.

Fertility Awareness Methods (FAMs)

Track the menstrual cycle using temperature, cervical mucus consistency, and calendar tracking to identify fertile days and avoid unprotected intercourse on those days. Effectiveness depends heavily on correct use, regular cycles, and motivation. These methods provide no protection against STIs.

Emergency Contraception

Emergency contraception pills (ECPs) — commonly known by brand names such as Plan B or Next Choice — are used after unprotected intercourse to reduce the probability of pregnancy. They work primarily by preventing or delaying ovulation and may affect fertilization; they do not cause abortion of an established pregnancy. A single dose costs approximately $27–$40 and is available without prescription in Canada (though it is often stored behind the pharmacy counter, requiring a request). Ella (ulipristal acetate) is a prescription-only ECP effective up to five days post-intercourse. Copper IUDs are the most effective form of emergency contraception (>99%) when inserted within five days of unprotected intercourse.

Postpartum Contraception

During the first six weeks following childbirth, only non-hormonal methods are recommended (condoms, copper IUD). Lactational amenorrhoea — the natural suppression of ovulation during exclusive, frequent breastfeeding/chestfeeding — can function as contraception when practiced in full according to established criteria, achieving efficacy comparable to hormonal methods during the first six months postpartum.

Abortion

Abortion is legal across Canada and is considered by law to be a medical procedure that is the sole decision of the pregnant person. Options in Canada include:

• Surgical abortion: a clinical procedure available in most urban centres, covered by provincial health plans (e.g., OHIP in Ontario)
• Medical abortion (abortion pill / mifepristone + misoprostol): approved by Health Canada in 2015 and increasingly available across the country, including in Waterloo Region. Can be used up to approximately 9 weeks of gestation. Works by blocking progesterone to end the pregnancy, followed by a second medication to facilitate expulsion. Covered by OHIP.

When a person discovers they are pregnant, they have three options: terminate the pregnancy; continue the pregnancy and parent; or continue the pregnancy and place the child for adoption. Each decision involves complex personal, social, financial, and health considerations, and deserves access to non-judgmental counselling and support.

Male Hormonal Contraception

Research into hormonal contraception for individuals who produce sperm is ongoing. Clinical trials of hormonal male contraceptives have shown high efficacy but have raised questions about side effect profiles. Research by Tschann et al. examines men’s attitudes toward and willingness to use male hormonal contraception, finding that willingness is associated with relationship type, attitudes toward contraceptive responsibility, and sexual scripting — culturally learned norms about who is “supposed” to manage contraception.

Theory of Planned Behaviour suggests that intention is the strongest predictor of behaviour: preparatory behaviours (carrying condoms, taking contraceptives) depend on intention, which is shaped by attitudes, social norms, and perceived control. The Prototype-Willingness Model adds that spontaneous, socially influenced decisions (as opposed to deliberate, planned ones) are also important predictors of actual contraceptive behaviour.

Pregnancy

Language of Pregnancy

• Prenatal: occurring before birth
• Intrapartum: occurring during labour and delivery
• Postpartum: occurring after childbirth
• Gestation: the period of development from fertilization to birth (typically approximately 40 weeks)
• Trimester: a three-month period of pregnancy; a full-term pregnancy has three trimesters

Approximately 40% of pregnancies are unplanned — a figure that does not mean those pregnancies are unwanted. Assumptions about how people feel about their pregnancies should be avoided. The language used to describe pregnancy has significant emotional and social weight; terms like “a mistake” or “an accident” can be harmful even when used casually.

Sex During Pregnancy

There are several widespread misconceptions about sexual activity during pregnancy:

• Penile-vaginal intercourse does not harm the fetus, which is protected by the uterine walls, amniotic fluid, and the cervical mucus plug
• Orgasm does not cause miscarriage in healthy pregnancies; uterine contractions from orgasm are mild and self-limiting
• Sex during pregnancy may be an important source of intimacy, connection, and pleasure for many pregnant people and their partners
• Sexual desire, comfort, and interests commonly change across the three trimesters; the first trimester is often associated with reduced desire due to nausea, fatigue, and hormonal shifts; many people report increased desire in the second trimester

The only circumstances in which a healthcare provider might recommend refraining from penetrative sex during pregnancy typically involve placenta previa (placenta covering the cervical opening) or premature labour risk.

The Social Experience of Pregnancy

The discourse of pregnancy — how society talks about it — is overwhelmingly positive in assumption: congratulations, excitement, and wonder are the expected responses. This creates an environment where individuals whose experiences are ambivalent, unwanted, or complicated by health or social circumstances may feel silenced.

In the second trimester, as pregnancies become visibly apparent, pregnant people often experience unwanted physical contact (touching the abdomen without consent), unsolicited commentary on their bodies, and hyper-gendering that can be particularly distressing for transgender and non-binary individuals.

Racism, Health, and Pregnancy Outcomes

Bower et al. (2018) documented that Black women in the United States who reported experiencing racism in the year before delivery had a significantly elevated risk of preterm birth — a finding that reflects the physiological toll of racism-related stress on pregnancy outcomes. Chronic exposure to racism activates the hypothalamic-pituitary-adrenal (HPA) axis, producing elevated cortisol and inflammatory responses that directly affect pregnancy biology.

In the U.S. in 2013, the infant mortality rate for non-Hispanic Black infants was more than twice that of white infants. These disparities are not explained by individual health behaviours; they are driven by structural racism in the healthcare system and broader society. Public advocacy by prominent Black women — including their experiences of being dismissed or disbelieved by healthcare providers during labour — has raised awareness of the systemic nature of these disparities.

Healthcare Providers in Pregnancy

Family Physician

Many family physicians provide care through some or all stages of pregnancy. In Ontario, it is relatively uncommon for a family physician to manage a full pregnancy as primary care provider; this role is more typically fulfilled by an obstetrician or midwife.

Obstetrician/Gynaecologist (OB/GYN)

An obstetrician is a physician with specialized training in pregnancy, labour, delivery, and postpartum care (and gynaecological health). In Canada, an OB/GYN requires eight years of residency training after medical school. Referral is necessary. Obstetricians can order inductions, perform assisted vaginal deliveries (using forceps or vacuum), and perform Cesarean sections.

Midwife

In Ontario, midwifery is a regulated, publicly funded healthcare profession. Midwives provide primary care for healthy, low-risk pregnancies, including prenatal, labour, delivery, and postpartum care for both parent and infant up to six weeks post-birth. They can prescribe medications and order lab tests. Midwives uphold three core philosophical tenets:

1. Choice of birthplace: clients may choose to give birth at home, in hospital, or in a birth centre; midwives have hospital privileges
2. Informed choice: genuine shared decision-making, distinct from “implied consent” models
3. Continuity of care: clients see no more than four midwives throughout their care

Doula

A doula provides non-clinical supportive care during and after birth — emotional, informational, and physical support — but does not provide medical care. Birth doulas support the pregnant person during labour; postpartum doulas support families following birth. Doulas are paid privately and do not replace clinical care providers.

The Medicalization of Birth

Historically, birth was attended primarily by midwives — many of whom were BIPOC, possessed extensive experiential knowledge, and were embedded in their communities. Beginning in the 19th and 20th centuries, birth was progressively medicalized and moved into hospitals, and knowledge was transferred from community-based practitioners (many of whom were women and/or BIPOC) to predominantly male physicians. This shift had implications for birth outcomes, the experiences of birthing individuals, and the devaluation of community-based knowledge. Contemporary maternity care represents a renegotiation of these histories.

Pregnancy, Disability, and Access

People with disabilities — including physical, developmental, intellectual, cognitive, and invisible disabilities — are full sexual beings who experience desire, form relationships, and may become pregnant. Assumptions to the contrary — that people with disabilities are asexual, childlike, or should not parent — are not only incorrect but actively harmful. Sunnybrook Hospital’s Accessible Care Pregnancy Clinic in Toronto is the first in North America dedicated to providing integrated prenatal care for people with disabilities.

Key principle: neurodiversity — the view that neurological differences represent natural human variation rather than deficits — informs an affirmative approach to disability in reproductive and sexual health contexts.

Supporting Our Sexual Health

Pelvic Floor Physiotherapy

The pelvic floor is a group of muscles and connective tissues that form the base of the pelvis, supporting the bladder, bowel, and — in individuals with a uterus — the uterus. Pelvic floor muscles are also directly involved in sexual function: they contribute to arousal, orgasm, vaginal and penile sensation, and ejaculatory control.

Pelvic floor physiotherapy (pelvic health physiotherapy) is a specialized area of physiotherapy addressing dysfunctions of the pelvic floor musculature. Conditions treated include:

• Pelvic pain
• Vaginismus (involuntary contraction of vaginal muscles that prevents or restricts penetration)
• Dyspareunia (painful intercourse)
• Urinary or fecal incontinence
• Pelvic organ prolapse
• Recovery from childbirth
• Sexual dysfunction

Pelvic health physiotherapy is relevant to people of all genders and ages, not only to those who have given birth.

Mindfulness and Sexual Well-Being

Mindfulness — the intentional, non-judgmental awareness of present-moment experience — has been applied with significant benefit in sexual health contexts. Modern life imposes chronic distraction: stress, technology, multitasking, and anxiety fragment attention and pull people out of embodied presence. Mindfulness counteracts this by training attention toward immediate sensory experience.

In the context of sexual activity, mindfulness-based approaches encourage:

• Attention to physical sensation rather than performance evaluation
• Awareness of partner sensations, sounds, and presence
• Non-judgmental observation of intrusive thoughts, followed by gentle redirection of attention to the present experience
• Reduction of self-monitoring (preoccupation with appearance, performance, partner satisfaction)
• Freedom from the pressure to achieve a particular outcome (e.g., orgasm) as the sole measure of “successful” sexual activity

Mindfulness can be integrated into nearly any sexual health concern and does not require a spiritual framework — it is, at its simplest, a practice of sustained, compassionate attention.

Sensate Focus

Sensate focus is a structured behavioural technique developed in the context of sex therapy, often attributed to Masters and Johnson. It consists of a graduated series of exercises designed to:

1. Establish mutual responsibility between partners for addressing sexual needs
2. Provide education about sexual function and response
3. Foster willingness to shift attitudes about sex
4. Reduce sexual performance anxiety
5. Improve communication about what feels pleasurable
6. Identify and address unhelpful behavioural patterns or role dynamics
7. Build a mutually satisfying sexual relationship

Sensate focus exercises typically begin with non-genital touching, with explicit instruction to avoid penetration and focus on sensation rather than arousal. Partners take turns exploring each other’s bodies, communicating about what feels pleasant, gradually expanding to include genital and breast touch over subsequent sessions. The deliberate removal of pressure to “perform” or achieve particular outcomes allows couples to reconnect with pleasure, intimacy, and communication.

Sexual Fantasy and Masturbation

Masturbation

Masturbation is the self-stimulation of one’s genitals or other erogenous areas for sexual pleasure. It is a normal, common, and generally healthy sexual behaviour across the lifespan.

Why People Masturbate

People masturbate for a wide range of reasons:

• Physical pleasure and sexual release
• Relaxation and stress relief
• Help with sleep
• Self-exploration — learning one’s own body, preferences, and arousal patterns
• Relief of menstrual cramps or other discomfort
• As a supplement or alternative to partnered sexual activity
• Managing differences in sexual desire between partners
• Curiosity and practice

There is no “normal” frequency of masturbation. Frequency varies enormously across individuals and across the lifespan; some people masturbate frequently, others rarely or never, and both are perfectly normal.

Health Aspects

Masturbation has been associated with several health benefits:

• Orgasm releases endorphins and oxytocin, which can elevate mood and reduce stress
• Regular ejaculation may support prostate health
• Self-stimulation supports body awareness and sexual self-efficacy
• Masturbation is the form of sexual activity with zero risk of STI transmission or unintended pregnancy

The historical (and now thoroughly debunked) notion that masturbation causes physical harm — including blindness or insanity, claims that proliferated in the 18th and 19th centuries — has no basis in medical evidence.

“Procrasturbation” and Recreational Use

The colloquial term “procrasturbation” has emerged to describe masturbation used as a form of procrastination. While playful, the term reflects a genuine phenomenon: like many pleasurable activities, masturbation can be used as avoidance behaviour. Context and whether the behaviour is causing distress or functional impairment are more relevant than frequency per se.

Mutual Masturbation

Mutual masturbation — engaging in self-stimulation in the presence of, or simultaneously with, a partner — is a form of sexual activity that can be intimate, pleasurable, and lower-risk with respect to STI transmission compared to other forms of sexual contact. It also serves as a way for partners to communicate their preferences and responses directly.

Sex Toys

Sexual aids and devices — including vibrators, stimulators, and accessories for various body parts — are widely used by people of all genders, in both solo and partnered contexts. They are particularly relevant for:

• Individuals with disabilities or limited mobility for whom other forms of stimulation may be less accessible
• Augmenting sexual pleasure when fatigue or low energy is a factor
• Exploring new forms of stimulation in partnered activity

Communication with partner(s) about the introduction of sexual aids is important, as is normalizing their use without shame.

Pornography

Pornography is widely consumed and has complex effects on sexual health and relationships. Potential considerations include:

• Can be a source of arousal and pleasure
• Can provide exposure to sexual diversity (though often selectively and unrealistically)
• May generate unrealistic expectations about bodies, sexual performance, duration, and responses when consumed without critical reflection
• The gap between pornographic depictions and typical real-world sexual experience can be a source of disappointment, confusion, or inadequacy if the distinction is not made explicit

Critical media literacy — understanding how to interpret pornographic content as produced, performed, and not representative of typical sexual encounters — is an essential component of contemporary sexual health education.

Sexual Fantasy

Sexual fantasy is defined as any thought, mental image, or imagined scenario that is experienced as erotic or sexually arousing to the individual. Fantasy is extremely common: the vast majority of people experience sexual fantasies, though their content, frequency, and role in sexual arousal vary considerably.

Key Points about Fantasy

• People may fantasize during masturbation, during sexual activity with partner(s), or entirely outside of any sexual activity
• Fantasizing about someone other than one’s partner during partnered sexual activity is common and does not necessarily indicate dissatisfaction or disloyalty
• Fantasy and behaviour are not equivalent: fantasy is unconstrained by social norms, physical reality, laws, or interpersonal consequences — behaviour is not. Having a fantasy does not mean one wishes to enact it.
• Fantasies involving non-consensual scenarios, power exchange, or taboo content are common in the general population and do not, in themselves, indicate pathology or a wish to replicate these scenarios in reality
• Sharing fantasies with a partner is a personal choice; doing so can increase intimacy but also shifts power dynamics within the relationship

Fantasy Content

Research on sexual fantasy content indicates enormous diversity. Common fantasy themes include: people known and unknown to the fantasizer; past or current partners; celebrities and public figures; imagined or fictional characters; scenarios involving power exchange or novel contexts.

A small number of individuals experience primary erotic attraction to fictional or animated characters — an orientation sometimes termed fictosexuality or fictoromanticism. Sexual attraction to inanimate objects (object sexuality) is also documented, though uncommon.

Asexuality, Masturbation, and Fantasy

Prevalence and recognition: Bogaert (2004, Journal of Sex Research) provided one of the first population-based estimates of asexuality, finding approximately 1% of a large UK sample reported having never felt sexually attracted to anyone. Asexuality is increasingly recognised in academic literature as a stable sexual orientation, analogous to heterosexuality or homosexuality, rather than a disorder. The DSM-5 distinguishes asexuality from Hypoactive Sexual Desire Disorder (HSDD): asexual individuals do not typically experience distress about their lack of sexual attraction; their orientation is ego-syntonic (consistent with their sense of self). This distinction was empirically developed by Brotto & Yule (2011, Archives of Sexual Behavior).

Yule et al. (2017) studied sexual fantasy and masturbation among people who identify as asexual, finding:

• Asexual individuals may masturbate and experience sexual fantasies, though less frequently than allosexual (non-asexual) individuals
• When asexual individuals do masturbate, they are more likely to focus on physical sensation than on fantasy imagery
• Asexual individuals are more likely to report having never had a sexual fantasy, and when they do fantasize, the fantasies are more likely to not involve other people
• Analloeroticism is a term used for individuals who experience little or no sexual attraction to others but who may still have a sex drive or engage in masturbation

Pleasure Education and Building Community

Pleasure as a Legitimate Goal of Sexual Health Education

Contemporary sexual health education in most of Canada focuses primarily on risk avoidance: STI prevention, pregnancy, and consent. While these are critical, this approach systematically omits pleasure, desire, and positive motivation from the sexual health curriculum.

Research and advocacy from scholars like journalist/educator Jess Philips and others argue:

• Young people — particularly girls — are frequently taught about the dangers associated with male-presenting sexual activity, but rarely about their own entitlement to pleasure
• Teaching only about risk and prevention can implicitly communicate that sex is inherently dangerous or negative, failing to equip young people with the frameworks to recognize and seek enjoyable, respectful sexual experiences
• “If someone is never taught that sex is something they should enjoy, they might be more willing to accept pain and discomfort as a typical experience.”
• Research shows the top three topics young people actually want to learn about in sexual health education are: (1) healthy relationships, (2) HIV/AIDS, and (3) sexual pleasure — yet current curricula rarely address the third

A comprehensive sexual health education includes both risk-reduction strategies and affirmative content about desire, pleasure, consent, and healthy sexual relationships.

Sexting

Sexting — the electronic transmission of sexually suggestive or explicit messages, images, or video — is a common practice among adults and increasingly among adolescents. Relevant considerations include:

• Sexting can be a form of consensual sexual expression between people of appropriate ages
• Peer pressure and coercion around sexting exist and must be addressed through consent education
• The non-consensual distribution of intimate images (sometimes called “image-based abuse” or “non-consensual pornography”) is a serious harm and a criminal offence in Canada
• Digital literacy and understanding of permanence and consent in digital communication are essential skills

Technoference

Technoference refers to the interference of digital technology — smartphones, tablets, social media — in face-to-face interpersonal interactions, including intimate and sexual encounters. The intrusion of technology into intimate space can reduce presence, connection, and pleasure, and warrants conscious and mutual boundary-setting between partners.

Building a Caring Community

Sexual health does not exist in isolation from the broader social world. Individuals can actively contribute to a healthier sexual culture through the following practices:

Being an Ally and an Advocate

• Allyship is an ongoing practice, not a fixed identity: it involves continuous learning, self-examination of privilege, and active work to amplify the voices and rights of marginalized groups
• Advocacy — speaking and writing in support of individuals or causes — is something anyone can practice in everyday contexts

Practical Actions

• Challenge language and behaviour that is homophobic, transphobic, racist, ableist, or otherwise discriminatory in interpersonal settings
• Use and normalize sharing pronouns (in introductions, email signatures, social media profiles)
• Avoid ableist language: terms that are derogatory to people with disabilities (whether or not used in that context)
• Introduce oneself using pronouns and create environments where others can share theirs
• Continue self-education about groups and communities different from one’s own
• Be an active bystander: intervene in situations of harassment, discrimination, or violence, within the bounds of personal safety
• Leverage privilege in service of equity: recognize that privilege exists and use it actively, not merely passively

Resources

• Hollaback!: a global movement providing bystander intervention training for harassment in public spaces and online
• University of Waterloo Human Rights, Equity and Inclusion office and Sexual Violence Prevention and Response (SVPRO) provide training, support, and advocacy resources
• The Truth and Reconciliation Commission of Canada report (2015) provides the foundational account of the history and ongoing legacy of residential schools, and calls to action for reconciliation

Closing: Sexual Health as an Ongoing Practice

Sexual health is not a destination but a lifelong process of learning, communication, and self-awareness. It is inseparable from mental health, physical health, relationships, identity, and community. A sex-positive, evidence-based, and intersectional approach recognizes that sexual health looks different for every individual, and that supporting the sexual well-being of all people requires attention to both personal behaviour and the structural conditions — of education, healthcare, law, and culture — that shape individual choices and experiences.

Course: SMF 213 — Sexual Health & Well-Being | University of Waterloo | Winter 2021 | Term code: 1211