Helen Asquith is a London-based doctor working towards a career in international public health. She has travelled widely, observing doctors and hospitals around the world. Her streetwise view of medicine led me to ask her to write some advice on sexual health in dangerous places. Some of the advice below is a little unorthodox because it is aimed at solving problems when there are no professional solutions around. If you have access to medical help, though, you should always consult a doctor about any sexual health problems as soon as possible.
/PREVENTING SEXUALLY TRANSMITTED DISEASES (STDs)
High rates of sexually transmitted infections and war zones go hand in hand. There are two main methods to stop infection in the first place:
Abstinence – former US President George W. Bush advocated this for Africa, but it’s not always feasible.
Condoms – the only form of contraception that prevents STDs.
A responsible sexually active adult should also have regular STD checks, especially when they change partners. Many STDs do not always cause symptoms, but you might pass infection on to a partner who develops serious complications, including infertility.
Perhaps you feel that you do not have sex often enough to warrant this? Don’t kid yourself! If you have sex with one person who has had sex with 20 people, you are effectively taking on that person’s risk.
/COMMON STDs
While this is not an exhaustive list, it covers some of the infections most likely to cross your path, describing their symptoms and what course of action to take.
If you have had unprotected sex and develop any of the symptoms listed, you should (if possible) go immediately to a reputable health centre for an STD test.
Sexually acquired infections
If you think you have one of the infections listed below, you should never have sex without a condom.
Non-sexually acquired genito-urinary conditions
/URINARY TRACT INFECTIONS
Does it burn when you pee? Are you bursting for the loo, only to find that a pathetic trickle of liquid fire (perhaps laced with blood) is all you can produce? Are you sometimes worried that you won’t make it to the loo in time?
These are the symptoms of a urinary tract infection (UTI), such as cystitis, the bane of many women. Hot climates, lack of sufficient drinking water and dehydration make it even more likely to occur. Here are some tips on how to prevent and treat infection.
• Stock up on over-the-counter cystitis remedies before you go abroad. You can even ask your GP to give you an advance prescription of appropriate antibiotics.
• Keep well hydrated, especially in hot climates.
• Always pee after sex. Normal urine is sterile and will wash away bacteria that have managed to work their way up the urethra during sex. This really works.
• If you feel a UTI coming on, start drinking even more water, or cranberry juice if it is to hand. Take a sachet of cystitis relief if you have one.
If you haven’t stocked up on antibiotics in advance but think you need them, it’s best to consult a doctor. If that’s not possible, you might be able to buy them without prescription from street pharmacies. Try to get local advice on which ones are reputable. Antibiotics useful for UTI include:
• Cefalexin – 500 mg twice daily for three days
• Amoxicillin – 500 mg three times a day for three days
• Co-amoxiclav (Augmentin) – 250 mg three times a day for three days
Warning: Do not take these antibiotics if you are allergic to penicillin. Ask a doctor back home what you can and can’t take if you are allergic, and ask him to provide some for you. Always read the label and always take the full course of the drug.
If you develop fever, abdominal pain or back pain, or feel unwell, you should seek medical attention immediately as you may be developing a kidney infection.
/CONTRACEPTION
The contraception you use at home might not be the best for your trip. Asking yourself the following questions before you leave might stave off difficulties or disasters down the line.
Are you planning to have sex on your travels?
If so, take a supply of condoms. This is the only form of contraception that can protect you from sexually transmitted infections.
Are you on the pill?
If so, consider switching to a longer-term form of contraception (see chart opposite).
Do you use contraception for medical reasons (e.g. regulating periods or skin conditions)?
In this case, you probably need to stay with the pill, but check that you have enough to last your trip.
Will your GP prescribe enough pills to last the trip?
If not, you need to find out if you can obtain more pills at your destination. If your brand is not available, find out in advance what the equivalents are in other countries.
/WHICH CONTRACEPTIVE METHOD IS BEST FOR YOU?
If using any method other than condoms, you will need to consult a doctor before you start a new one.
For more detailed advice on contraceptive options, please visit the website www.patient.co.uk
/THE CONTRACEPTIVE PILL
The pill works by preventing ovulation. Taking a pill on seven consecutive days is sufficient to prevent ovulation. In addition, omitting more than seven days of the pill (i.e. lengthening the ‘withdrawal bleed’) allows ovulation to occur.
It is important to note that the ‘withdrawal bleed’ you get with the pill is not a true period. It occurs because of the hormone-free seven days between packets. Some pill brands require the user to stop taking a pill for a week. Other brands include a week of dummy pills so that the routine of pill-taking is not interrupted.
Types of contraception
Why have a hormone-free period at all? There are two reasons:
• To reduce a woman’s exposure to the hormones which, over a long period of time, are known to increase the risk of deep-vein thrombosis and certain cancers.
• To mimic the natural menstrual cycle.
It is a common misconception that missed pills towards the end of the packet do not matter as a ‘period’ will soon follow. In fact, the opposite is the case: during the bleed, hormone levels are at their lowest and ovulation is more likely. If unprotected sex has occurred in that time, pregnancy might result.
Missing a pill
If you forget to take a pill, what you should do depends on the type of pill you are taking. Ideally, you should find out in advance by reading the leaflet that comes with the pills.
Ovulation and pregnancy may occur if you miss pills, especially if the omission occurs at the beginning or end of the packet. In order to prevent pregnancy, you should use condoms for a week after the missed pill.
Running out of pills
If you run out of pills in a foreign country, one option is to switch to condoms. However, you may be able to buy an equivalent to your current pill (i.e. one containing similar hormone levels) but with a different international trade name. A useful website on which to look this up is the IPPF Directory of Hormonal Contraceptives (http://contraceptive.ippf.org).
Kathleen McCaul came out to Iraq with me from Oxford University to work at the Baghdad Bulletin. We were both as wide-eyed and naive as each other. She had an amazing ability to use that innocence to win her one exclusive interview after another. That access to the top corridors of power also made her vulnerable. At meetings that were supposed to be professional interviews sex-starved politicians, lawyers and soldiers, buoyed by the excitement of talking to their first girl in months and armed with an illicit bottle of booze, thought she was ripe for the picking. She had to learn how to bat them off with her eyelids:
‘I guess the first way to prevent yourself getting pregnant is by not having sex. But in stressful situations with not much other than work to do, an affair is a good way of letting off steam and doesn’t give you such a hangover as whisky, although it can have more serious consequences if you aren’t careful.
‘Not getting pregnant is p
retty straightforward. Use a condom. Always carry condoms with you. Many of the countries mentioned in this book are rife with HIV. You want to come back with good stories, not a lethal STD.
‘If something does go wrong, the morning-after pill is readily available practically everywhere – even up a mountain. You might get a few odd looks when you ask for it, but don’t let that put you off.
‘I think a greater danger than getting pregnant is getting trapped in a relationship that is furtive and ultimately unsustainable in conservative countries. It hasn’t ever, in my experience, ended happily. How do you avoid it? Don’t stay up late talking when there is a power cut. Don’t go on trips to remote, romantic places in the countryside. Don’t pick apart your personal stories and histories on walks in deserted gardens.
‘Avoid married men, especially if they are married to their cousins. Avoid men with girlfriends. Avoid your translator. Above all, avoid your boss, especially if their father happens to be a head mullah or something like that.’
/EMERGENCY CONTRACEPTION
The morning-after-pill is available in the UK and many other countries as an advance prescription. This means that you can hold up to three packets of the emergency pill in anticipation of a burst condom or accidental lapse in contraception. It is available for purchase from certain pharmacies both in store and online, and in the UK is also available free from family planning clinics and GPs at the doctor’s discretion.
Warning: Do not use the morning-after pill as a regular method of contraception. It is a heavy dose of hormones that can cause side effects in some women.
/DEALING WITH PERIODS
In most places you can buy anything you need in the way of sanitary towels or tampons from a pharmacy, but if you are in a place with no pharmacy, there are some other options. Ask women locally for advice. My experience has been that people who live with less modern amenities tend to be very open in talking about the mechanics of the body – periods, pee and lots of diarrhoea! It is a good idea to pack your own toilet roll or baby wipes. In many places there will be only water to wash yourself after a trip to the loo, and it can get messy if you are not practised.
Delaying a period
There are bound to be times when it is more inconvenient than usual to have a period, so it’s worth knowing how to delay one. There is no failsafe way of doing it, but you could try one of two methods.
1. Running packets of the contraceptive pill together
This method is more effective if you have been established on the pill for a while. Check with your doctor or nurse about the best way to do this with your brand of pill. For most pill types, you can run up to three pill packets together without a break. This is known as tricycling.
Fixed-dose pill (all the active pills in the packet are the same): Simply take up to three packets one after the other without the pill-free interval.
Phasic pill (two or three different types of active pills in one packet): Running packets together can result in breakthrough bleeding, but this will not reduce the efficacy of the contraception. Consult your nurse or doctor for advice.
Packets containing seven dummy pills (in a packet of 28): If you know for sure which the dummy pills are, you can throw them away and start the next packet of real pills. If you are unsure, read the instructions or check with your doctor or a pharmacist.
2. Taking norethisterone
This is a synthetic hormone similar to naturally occurring sex hormones. It is available only on prescription and is not guaranteed 100 per cent effective. If you want to try it, you should consult your doctor before your trip to check that it is suitable for you and to issue a prescription.
The usual dosage is 5 mg of norethisterone three times daily, starting three days before the anticipated onset of a period. Menstruation will occur 2–3 days after you stop taking it.
Note that norethisterone is not a form of contraception.
Perhaps inevitably, there are some risks involved in taking norethisterone. The main one is the risk of developing deep-vein thrombosis (DVT). You should not take this medication if you are at high risk or have a strong family history of DVT. Other side effects of norethisterone include migraine. Always read the label and consult a doctor before taking this.
Sanitary protection
What do you do if your bag containing all your spare stuff for periods gets stolen? What if you run out of tampons in the remoter parts of some Muslim countries, where they are as hard to find as hen’s teeth?
Since the ancient Egyptians invented the first tampons – made from softened papyrus – life for women has become considerably easier. Hippocrates recorded in the 5th century BC that Greek women were improvising with lint wrapped around bits of wood – sounds scratchy! The modern tampon with handy applicator was actually invented in 1929 by a man, Dr Earle Haas. He called his trademarked device Tampax, but then sold the company to a lady called Gertrude Tendrich, who made all the money.
The great lesson from all this is that women survived for millennia without the modern conveniences we take for granted. Indeed, in many of the wilder places you might be visiting today, women make do with very little. And so can you. The key thing is to do it safely and cleanly, planning in advance if possible.
Sanitary towels are by far the most common period product available globally, although many forms in remote places seem more akin to mattresses than pads. As many a maiden in distress will know, alternatives can easily be fashioned out of toilet paper, cloth or kitchen roll.
Tampons are generally harder to find, but fashioning alternatives to them is not impossible, as the women in ancient Egypt demonstrated. Anecdotes from adventurous ladies caught in extremis recommend the temporary use of alternatives such as a rolled-up wad of toilet paper or kitchen roll (verdict: rather dry). Or a rolled-up wad of clean medical dressing.
I lived with a similar ad hoc method to this for four months in Basra. It worked, but I blessed the BBC girl who gave me all her leftover goodies when she was heading back up to Baghdad. I probably could have found tampons if I’d asked locally, but given that my translator was a man… I was a wimp.
However, a few notes of warning are necessary:
• Always use clean materials.
• These improvised items are harder to remove than a normal tampon.
• Keep them in for a shorter time and replace with a proper tampon as soon as possible.
• They are unlikely to be sterile, therefore increasing the risk of toxic shock syndrome (potentially a very serious infection).
Can you use two tampons at once? Officially, the manufacturers of Tampax® advise against this. However, for heavy flow, many women have used this method without mishap.
How long can a tampon stay in? The official answer to this is eight hours. The longer the tampon remains inside, the greater the risk of developing toxic shock or pelvic infection. For legal reasons, we cannot advocate exceeding this limit. However, anyone who has slept longer than eight hours in a night will know that there is some flexibility in terms of time. Use your judgement.
The Mooncup® is a great alternative to tampons and pads, and is endorsed by several seasoned travellers of my acquaintance. This reusable menstrual cup is made of soft, non-latex, medical-grade silicone and is inserted in the vagina a bit lower than a tampon. Once in place, it collects many hours of menstrual fluid, which can simply be emptied into toilets. It is easily disinfected with boiling water.
Proponents of the Mooncup® argue that it is more economical, comfortable and environmentally friendly than any other method. If you’re new to it, give it a trial run before departure. It can be bought only online from www.mooncup.co.uk or www.mooncup.com in the USA.
If you are still not sure about anything you have read here, you can find further information in The Oxford Handbook of Genitourinary Medicine, HIV and AIDS (OUP, 2005). There are also several useful websites:
GP Notebook: www.gpnotebook.com
NHS Choices: www.nhs.uk
Pa
tient UK: www.patient.co.uk
WHQW: www.womhealth.org.au
/SAFETY FOR GIRLS
Some attention is good. Flirting is fantastic, in all sorts of ways, not least for getting things you might not otherwise have had access to. It might even get you the occasional free drink. Oops! But it can also lead to problems. Where sexual appetites are high or long unsatisfied, or if you are the only girl in a team of men, flirting can be misread as interest. Even worse, it can shout ‘I am here for the taking’ to the wrong sort of man.
Sometimes there is nothing you can do about unwanted attention. There’s no protecting yourself from being sexually harassed by a man who wants to get you into bed, or from a man who does not respect you. But in the highly charged world you currently find yourself in, it’s a good idea to stay within the safe, anodyne zones of flirtation. In a war zone, trust me, that means barely anywhere.
Samantha Bolton observes: ‘Flirtation can be useful for getting onto supposedly full planes, etc. Tell the rebels or whoever you are negotiating with that you are married. Carry a ring that can work as a wedding ring when required.’
Sadly, rape is often a weapon of war, and is not restricted just to the battlefield. It slips onto the streets, into the villages and, for many women, into their homes.
As a visitor, you can try to avoid it by not walking into dodgy areas, by not drawing attention to yourself with your behaviour or jewellery. If you get a bad feeling, run – and remember the self-defence advice on Self-Defence Moves. A surprise, quick and targeted attack on your attacker could well scare him off.
How to Avoid Being Killed in a War Zone Page 17
