Dr T: A Guide to Sexual Health and Pleasure

By Tlaleng Mofokeng

‘Dr T’s voice – contemporary and thoroughly African – is vital in a country where too many women are taught to be ashamed of their bodies and their sexual desires, and too many men believe they should shame women.’ – SISONKE MSIMANG

The indomitable Dr Tlaleng Mofokeng – affectionately known as Dr T – is passionate about making sexual health and well-being services available to all, regardless of their sexual and gender identities and their economic status.

This updated edition of her bestselling book is filled with the specifics of sexual anatomy and health as well as advice and facts about pleasure and sexual rights, and includes additional resources along with new sections on coercive control as well as sex and pleasure during the time of COVID.

Dr T, with her typically honest and warm approach, makes the reader feel comfortable reading about topics that are not always discussed freely, providing ALL the information that demystifies sex and sexuality in a way that is entertaining and enlightening.

• Language: English
• Publisher: Pan Macmillan South Africa
• Release date: Jan 18, 2021
• ISBN: 9781770107717

Tlaleng Mofokeng

Dr Tlaleng Mofokeng obtained her medical degree (MBChB) from the University of KwaZulu-Natal in Durban and now runs a women’s health clinic, DISA, in Johannesburg. She is a thought leader and contributor to 5FM and Metro FM’s Sexual Health radio features, the ‘Let’s Talk About Sex’ columnist for the Sunday Times, and is internationally published in The Guardian, Teen Vogue and Project Syndicate. Dr T says that the field of sexual and reproductive health chose her during her community service year when she worked in the West Rand clinics in Johannesburg. Most of her patients were young women and, in true Dr T style, affirming of sexual pleasure, she made them feel comfortable to share their sexual health and relationship concerns. This ignited the spark in Dr T to pursue a career advocating for and defending sexual and reproductive rights and health for women and children.

Book preview

Updated edition with new content

Dr Tlaleng Mofokeng (MBChB)

MACMILLAN

Every effort has been made to ensure the accuracy of the medical information and advice contained in this book, but the onus is on the reader to consult with a medical professional to verify and clarify anything that they are not sure of. Remember that Google is not a doctor!

First published in 2019

This edition published in 2021 by Pan Macmillan South Africa

Private Bag X19,

Northlands

Johannesburg

2116

www.panmacmillan.co.za

ISBN 978-1-77010-770-0

eISBN 978-1-77010-771-7

© Tlaleng Mofokeng 2019, 2021

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of both the copyright owners and the publisher of this edition of the book.

Editing by Jane Bowman

Proofreading by Claire Heckrath and Sally Hines

Design and typesetting by Triple M Design

Illustrations sourced from iStock

Cover design by publicide

Author photographs by Zuzi Seoka

Make-up by Nikki Pitso

Hair by Unathi Ntakana

Dear readers

There are no words to describe the deep gratitude that I hold for all of you. Dr T: A Guide to Sexual Health and Pleasure has been a success from day one. I have lost count of the number of reprints that have been printed owing to your unwavering love and belief in the Pleasure Revolution. This book has been gifted and celebrated in so many countries around the world, way more than I could have hoped for. I have loved seeing your photos and artistic posts on social media as well as receiving updates on how your lives have changed and been enhanced by reading my book. I wish you joy and affirming experiences as you enjoy these updates. Ke a leboha.

Thank you especially to Letlhogonolo Mokgoroane of The Cheeky Natives, for your generosity and for trusting Dr T: A Guide to Sexual Health and Pleasure as the first book to be officially sold by The Cheeky Merchant. Thank you to all stockists, bookstores and supporters of my work. Your support is invaluable.

Yours in revolutionary pleasure

Dr T

December 2020

Contents

What Dr T is up to now

Introduction

About this book

Note for readers

Section 1: Sexual Health

Physiology

Vagina, vagina, vagina!

Let me tell you about the C.L.I.T.O.R.I.S.

Keep it tidy

Don’t panic! It might just be an ingrown hair!

Intersex

Penis, penis, penis!

Circumcision

The hormonal orchestra: Puberty

Menstrual Health

My first period

What is the menstrual cup?

Toxic shock syndrome

PMS

Pain management

A quick anatomy lesson

Termination of pregnancy

Medical Conditions

Sexual dysfunction

Painful sex

Air trapping

Sex and allergy to latex

Sex and back injury or spinal disease

Sex and contraceptives

Sex and endometriosis

Sex and fibroids

Sex and hypertension

Sex and menopause

Sex and polycystic ovarian syndrome (PCOS)

Sex and sexually transmitted infections (STIs)

Sex and urinary tract infections (UTIs)

Sex and diabetes

Sex and cancer

Sex and cervical cancer

Sex and hormones

Abstinence

Bereavement

Pregnancy

Section 2: Sexual Pleasure

Why the interest in sex, Dr T?

Sexual consent

The Big O

Sexual fantasy

Communication during sex

#TeamLayATowel

Anal play

Girl on girl

Section 3: Sexual Rights

Advocating for sexual rights

More than the birds and the bees

Sex work is work

LGBTQIA+

Coercive control

Epilogue: Sex and pleasure during the time of COVID

A glossary with a difference

Health and wellness checklist

Acknowledgements

Selected references

Social and medical resources

What Dr T is up to now

In February 2020, I led a delegation to the UN headquarters in Geneva, Switzerland, from the South African Commission for Gender Equality (CGE), in my capacity as Commissioner, to the Office of the United Nations High Commissioner for Human Rights (OHCHR). We had been invited to deposit a country report, as well as oral submissions to the Pre-session Working Group of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) on the specific progress made by South Africa.

Because the CGE is a national human rights institution with a mandate to promote, protect, develop and advance gender equality, it utilises international human rights instruments, regional instruments and national human rights standards to hold itself, and in this case the country, accountable.

Although I had been to the OHCHR before, this was the first time I was going as a Commissioner and not as an independent activist doing civil society work. And this time I was accompanied by two colleagues from the CGE. The UN space can be intimidating and aside from its size, it is possible to go from complete silence in the open spaces while sessions are in progress, to a chorus of people speaking in so many different languages, clad in various cultural dress. And of course it’s important to maintain the typical ‘diplomat’ decorum despite feeling overwhelmed at times.

On previous visits, I’d often sat at the coffee shop overlooking the awe-inspiring Lake Geneva. There it is possible to meet, in a less formal manner, diplomats, mission staff and secretariat and, on all my other visits to the OHCHR, it was a popular space for my comrades and I to meet for a catch-up and strategy sessions.

It was in this same spot while overlooking the lake, that I had noticed an online UN notification that the applications for independent experts was open. I went through the list and, further down, the mandate of the Special Rapporteur on the ‘right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ was listed. Reading the mandate overview moved me and, by the time I finished reading it, I knew that on my way home, I would be summoning the ancestors to send me a signal. It felt every bit like it was the right time and I needed the universe to make way for it so I decided to apply and the rest is history. Well, first it took me three days to complete the application form and then send it through and then a few weeks of nervous waiting and then I received the news that I was shortlisted and that I would be one of the candidates to be interviewed. At the time, South Africa was deep in the coronavirus lockdown and it was starting to take its toll on my mind and spirit.

I recall letting go of any expectations immediately after the interview was over. I felt I had done the best I could and, on a personal note, it was one of the best experiences of an interview I had had in recent years. I had started to forget the whole process had even happened though, when the public notification was posted on the UN website and I emerged as one of two finalists and the preferred candidate to be appointed. The day of the announcement drew closer and as the moment approached, I called my mom, Ausi Aggie. When I called she told me she was putting her last load of washing on the washing line and I quickly reminded her to click on the UN Web TV link I had sent her on WhatsApp so she could follow the proceedings live. I had no idea if they would read out the candidates’ names or what to expect and I was a bit more anxious than I thought I would be. Ausi Aggie reminded me that nerves are good as it meant that I cared. As I heard the chair of the session resume with the agenda, the names were projected on the screen and my name was there, as the special procedures mandate holder to be confirmed and appointed. At its 44th session in July 2020, the United Nations Human Rights Council appointed me, Tlaleng Mofokeng, ngwana Qwa-Qwa, as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. To share that moment with Ausi Aggie, the person who literally made me, was incredibly special.

The UN Human Rights Council appoints Special Rapporteurs for a three-year renewable term for a specific issue, country or human rights theme, with these independent experts holding that official mandate to monitor violations and promote related rights. ‘Facilitating accountability for human rights realisation, Special Rapporteurs support rights advancement through country missions, government communications, public statements, and Council reports. To advance the right to health, the Special Rapporteur holds a mandate to examine efforts to implement the right to health through healthcare services, health promotion, and underlying determinants of health.’

It is this part, ‘The Special Rapporteur has been mandated to pay attention to the situation of vulnerable and marginalised groups, and has been further asked to apply a gender perspective and to pay special attention to the needs of children in the realization of the right to health’, that makes this role important for me in my advocacy work. There are relevant provisions important to the execution of duties in particular, General comment No. 14 of the Committee on Economic, Social and Cultural Rights (CESCR), the Durban Declaration and Programme of Action and General Comment No. 22 on the right to sexual and reproductive health, to name a few.

There are also technical guidances providing a human rights-based approach to the implementation of policies and programmes to reduce and eliminate preventable mortality and morbidity of children under five years of age and preventable maternal mortality and morbidity.

In October 2020, a few months after my appointment, I delivered the following statement to the UN General Assembly 75th session (UN GA75) outlining my vision for the next three years:

I endeavour to take dignity as the pivotal principle that permeates the right to health. As a Black African woman, I understand that people are not intrinsically vulnerable, but that these vulnerabilities are rather brought on by oppressive systems and the obstacles they face in the social, economic and political contexts they live in.

I envision to gain a deeper understanding on the negative impact of colonialism racism and the oppressive structures embedded in the global health architecture which disproportionately impacts Black people, indigenous peoples and people of colour communities, as well as those in developing countries.

The impact of criminalisation and need for zero discrimination regarding health-related issues such as drug use, sex work, lesbian and transgender and intersex persons, safe abortions, disability health, mental health and adolescent health are important areas of work I plan to take on, ensuring continuity and building on the solid work developed by previous mandate holders who successfully set up a clear framework for the right-to-health analysis on these and a number of issues.

My experience as a first responder over the years, on matters of gender-based violence and femicide and those violations against persons on the basis of their real or imputed sexual orientation or gender identity, continue to be of concern to me. I am further concerned by the insufficient to inexistent support for victims and survivors of gender-based violence and femicide in many countries in respect of their life and the integrity of their person.

I will pay particular attention to issues of health funding and financing, and the over-reliance on philanthropy and foreign aid in developing countries for essential health services including sexual and reproductive health. I will also address the human rights dimensions of the issues of neglected diseases, non-communicable diseases, co-morbidities, lifespan and quality of life, during my mandate.

I am also interested in climate change, migration and the impact on health planning and resources, especially on how innovation, digital technology and tele-health could, and should, be supported to increase access to health-related information and services.

Last but not least, I would like to continue the work developed previously regarding healthcare workers; they are essential to ensure availability, acceptability, accessibility and quality of healthcare services for all. I wish to elaborate on healthcare workers’ health, mental wellness, allowances, remunerations and fairness in the workplace so they can deliver quality health services.

This year has certainly been challenging as we face the ­COVID-19 crisis and cooperatively search for solutions. International cooperation and multilateralism are important for laying the groundwork for a robust, sustained and inclusive socio-­economic recovery around the world.

In order to mitigate and contain the spread of the pandemic globally and to support national and international economic and financial recovery, it is imperative that COVID-19 diagnosis and treatment goods, including any potential vaccine, are fully available, accessible and affordable to all.

As a Sexual and Reproductive Health and Rights (SRHR) expert, I was especially encouraged to see that the OHCHR mandates me to continue to pay attention to sexual and reproductive health as an integral element of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

I am driven by the ideal of restoration of dignity.

Introduction

‘Please be advised that the following feature is a PG16 due to the sexual content’ is the introduction ‘disclaimer’ I now open with! At the start of almost all my radio sexual health segments I contribute to, this is the tagline I have become accustomed to but I definitely didn’t ever think it would be.

In 2010, two years after graduating from medical school, I was working in the West Rand townships, on the outskirts of Johannesburg. As a response to the HIV epidemic, there was a public campaign across the country and the district I was working in was one of the hubs of activity to get more peer educators enrolled into a HIV prevention programme for the local community. This was at a time when our country, South Africa, was engaged in finding more creative ways of accessing the youth and getting them to sign up to do voluntary HIV testing. Much was being said about reducing risky behaviour and it was still very technical in its approach by ways of risk reduction in wider public health campaigns. Clinics were labelled ‘youth-friendly’ but there was not much focus on training a new crop of healthcare professionals who could incorporate sexuality, gender and sexual pleasure in the consultations with young people.

As a young 20-something-old, even I, with all the medical knowledge, felt that the approach that was being used stigmatised young people having sex and sex became something looked at as inherently diseased. This feeling was not just a feeling. Once I started doing research I found that many healthcare providers do not talk with their adolescent patients about sexual health issues during primary care visits. When these conversations do occur, they are usually very brief; in one study conversations with patients aged 12 to 17 lasted an average of 36 seconds.

By the end of the first few months of working at the clinic as the resident medical officer, I noticed there were more young women and men waiting in the car park for me than there were in the clinic. The conversations we started having were casual. None of them were acutely ill so once the initial ‘icebreaking’ was done, we swiftly move on and chatted about girlfriends and boyfriends, how to break up with someone, how to say no to sex when you feel you are not ready, sexual pleasure, what the different parts of the vulva are and the list goes on! A young woman asked me if it was true that masturbation caused one to lose the ability to be sexual and to have pleasurable sex in the future. Another asked if it was normal to have vaginal dryness. Their preference for the car park consultations persisted for as long as I worked at the clinic and became something I looked forward to. I often joke and say I’m not sure when exactly I became the sex doctor but those young people had a big part to play in what has become my life’s work.

I do not recall ever feeling awkward or shy to talk about sex or sexual health-related topics and for that I have my mother to credit. She was always open about sex and relationships and would often have ‘sex talks’ in a very nonchalant manner. She made me comfortable with my own sexuality and thus the ability to share knowledge in a non-judgemental manner. Those young people felt comfortable talking to me about their sexual health and because I looked like them, I spoke like them and I used the same slang as they did, it was easy for them to connect with me.

I found myself at the end of my contract with the clinic and realised I had to find a way to reach as many young people as I could. I needed to be able to reach them where they were at any given time and research has shown that digital media, including social networking sites, apps and text messaging services, are increasingly being used to reach adolescents with sexual health interventions, and studies have demonstrated efficacy in improving knowledge and behaviour across a range of sexual health outcomes. In South Africa, recent data shows that digital media and access to mobile phones is growing exponentially, with an expected mobile internet penetration of 52.3% in 2016 with figures set to increase to 77.8% in 2021.

So this is how my journey started; with a cellphone and mobile data. I was soon contributing as a sexual health expert across multiple platforms such as radio, television, print and social media, on both a local and global scale. My Twitter account today is constantly buzzing with requests for information and referrals for sexual and reproductive care services. And I also contribute to the Sunday Times and have been published in a range of media houses including The Guardian, Cosmopolitan SA, Teen Vogue, Women24 and I am the resident sexual health expert on one of the top three biggest national radio stations, Metro FM, with a previous weekly slot at the regional station, KayaFM, for three years.

It is not always easy knowing how to measure the impact of an initiative, working alone, mostly on digital platforms, but what started off as an extramural activity quickly became a recognisable brand of health communication. In 2016, I was given an award by the Bill and Melinda Gates Foundation, the 120 Under 40: The New Generation of Family Planning Leaders, for my work as a health communicator. And in 2017 I was invited to partake in a webinar hosted by the Johns Hopkins Bloomberg School of Public Health, where I shared my experiences and the ways I use digital media to build a strong brand in the public health field. It meant so much being recognised by my peers for the value of my work.

In 2018, I expanded to becoming host and associate producer of a television show ‘Sex Talk with Dr T’ on the Moja Love channel on DSTV. I embarked on the project to showcase what sex positivity looks like as well as bring evidence-based and inclusive programming, while being deliberate in ensuring inclusion of gender and sexualities beyond the heteronormative. The educational aspect of the edutainment covered topics such as sex work decriminalisation and interviewing sex worker advocacy groups on human rights law, health and law reform.

My approach and goal is to elevate sexual pleasure to its rightful place alongside sexual health and sexual rights. Another platform that I use is on a podcast entitled ‘PodSexEd’ which is a series of conversations between myself and a friend where we discuss issues such as menstrual hygiene, sex toys, our experiences within the feminist/advocacy spaces and dedicate entire episodes to the clitoris and discussions around pleasure and masturbation. My weekly Q and A column in the Sunday Times also reaches thousands of people, via a more ‘traditional’ platform.

One of the most common negative comments I receive in terms of my work is whether we are making it easy for young people to have sex. A large body of research has found no evidence that providing young people with sexual and reproductive health information and education results in increased sexual risk-taking. In fact, comprehensive life skills-based sexuality education helps young people gain the knowledge and skills to make conscious, healthy and respectful choices about relationships and sexuality.

And as such, recommended by the American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care, advocacy programmes should not only focus on reproductive development, the prevention of STIs, and unintended pregnancy, but they also should teach about forms of sexual expression, healthy sexual and nonsexual relationships, gender identity and sexual orientation and questioning, communication, recognising and preventing sexual violence, consent, and decision making.

It is with this in mind that my work is dedicated to ensuring that programmes and health systems link sexual health, sexual rights and sexual pleasure and to translate this into sex positive communication and access to inclusive sexual healthcare in order to support young people make healthy transitions into adulthood.

Dr T

Johannesburg

June 2019

About this book

I wrote this book, A Guide to Sexual Health and Pleasure, with the intention of helping you, the reader, navigate different aspects of sexual and reproductive health, pleasure and rights. The experiences I have had as a young woman, the many conversations I’ve had with women, specifically my mother, Ausi Aggie, my medical training, as well the 12 years of practice, have all prepared me for this moment.

I draw on and find the courage to be myself from my experiences with my mother. I am truly only able to do this work, confidently and boldly, because of the way my mother affirmed my inquisitiveness as a child. She taught me vital life lessons and gave me information about sex, relationships and my body, in a way that made me trust her as a resource. But I realised growing up that not all young people had a care­giver or parent who was as affirming, delicate and informative as my mother was to me and so I hope this book is a resource for many young people, caregivers, parents and anyone working with young people. My aim is to promote wellness in order to achieve the maximal point possible for pleasure.

The first section of the book, Sexual Health, deals with health and wellness and covers common medical conditions and provides information to assist you in understanding your own anatomy and bodily functions. You may be interested in a certain aspect because of a personal connection or because you have always wondered about certain anatomy or a specific illness. Whatever your reason or interest, the section provides all the details which, once understood, will alleviate anxiety caused by simply not knowing. It busts some common myths by providing accurate information to assist in making informed decisions about your health and pleasure.

The second section, Sexual Pleasure, is a dedication to the Pleasure Revolution. Sexual pleasure is the missing link in many sexual health discussions and even in the medical field, women’s pleasure is under-researched, with the development for safe and effective pleasure-enhancing biomedical and pharmaceutical solutions also lagging. The Pleasure Revolution is about understanding the many ways that sex happens, it is about consent and what it takes to have fulfilling sexual experiences. The unshackling of women’s bodies, sexual desires and pleasure is the revolution for many women across the world and we need to be bold in reclaiming our sexual pleasure and sexual expression.

The last section of the book, Sexual Rights, contains important elements that must be respected and protected. I share my perspectives and show how in some aspects, as a society, we seem progressive yet when it comes to those who do not fit the mould, be it in their gender or sexual identity or in occupations such as sex work, we ourselves can be contributing to an unjust and unequal society.

I’ve included references to my work and experiences that some ­people may recognise from an article, a radio show or a television interview. As much as I have shared those details with you, I have brought all of myself to this book and had a wonderful journey going down memory lane to revisit my own experiences.

When women are able to hold conversations and negotiate the type of sex they want, including the use of condoms, toys and fantasy play, within respectful exchanges, the chances of good and affirming sexual experiences are greater. It is my wish that you find A Guide to Sexual Health and Pleasure informative and that you keep it as a reference tool that you keep going back to and it can assist in getting the best out of your consultation when you are face-to-face with your healthcare provider.

Enjoy!

Note for readers

I decided to use ‘she’ and ‘women’ but I am talking to all of you and the book is all inclusive! So that includes ‘him’, ‘men’, ‘people’, etc., etc.

I have included a few helpful (unfortunately not juicy as this isn’t THAT kind of book!) pics and graphics to give you a bit more to think about and to orientate yourself.

I have sounded out some of the tricky anatomical words for you in the Sexual Health section. Not in a proper ‘phonetic’ kind of way, more of a ‘as-you-hear-it’ kind of way.

Look out for the ‘Tips’ that pop up every now and again. Denoted by 

Go to the back of the book for names, places and links to various medical and social services if you need advice and help. That’s what they are there for!

Section 1

Sexual Health

Physiology

Vagina, vagina, vagina!

When last did you look at your vagina? Occasional stolen eye contact while grooming or bathing doesn’t count. When last, if ever, did you take a mirror and just look? Okay, indulge me for a few moments. Put the book down, get into a comfortable position and take a good look. (Pro tip: selfie mode on your phone camera works just as well as a mirror!) I mean really look at it, the detail of the labia, the different openings on the vulva and get familiar with what your normal is.

Maybe you blushed or laughed so much that the tears made it hard for you to focus or maybe you only managed to stare at the pubic hair, but one thing is for certain we all have very different relationships with our vaginas and for as