genitourinary syndrome of menopause

Genitourinary Syndrome of Menopause (GSM)

Genitourinary Syndrome of Menopause (GSM) refers to a range of signs and symptoms that occur due to low levels of oestrogen in the vulva, vagina and urinary tract. This term replaced the previously used “vulvovaginal atrophy” in 2014, to provide a more all-encompassing description (and, more importantly, to recognise that no one likes to think of their genitals as atrophied). 

More than two thirds of people experiencing these symptoms don’t speak to a health professional, and many doctors do not routinely screen for this incredibly common and easily-treatable condition. I can count on my hands the number of postmenopausal patients I have seen who have answered “no” when asked if they have noticed troublesome vulvovaginal changes. Although these changes are frequently seen in people who have transitioned through menopause, they are not exclusively related to menopause and may be seen in any hypo-oestrogenic state – such as during lactation, and while taking hormonal medications and contraceptives.

The words we use during screening also matter – a patient recently mentioned to me that her Gynae had talked about vaginal dryness a few times, but she had never associated her experience of vulval ‘irritation’ and ‘burning’ with the word ‘dryness’, and therefore never realised that she was suffering from GSM until seeing these terms on social media.

Management is fairly straightforward in patients who have no history of previous breast cancer – but can be more nuanced when it comes to supporting patients who have undergone breast cancer treatment (who often experience menopause earlier and with more severe symptoms than those who have transitioned through natural menopause).

Multiple international guidelines recommend vaginal moisturisers and lubricants as first-line therapy; however, to treat the underlying cause, oestrogen may be required for symptomatic relief. Although systemic oestrogen can improve these symptoms, this is generally contra-indicated in anyone with a history of breast cancer. In contrast, data around the use of local/vaginal oestrogen is very reassuring, and vaginal oestrogen use is not associated with an increase in breast cancer recurrence or mortality in the majority of people. Observational data support the use of vaginal oestrogen in most patients with a history of breast cancer, with the exception of those using aromatase inhibitors where some studies have found an increased risk of recurrence (but not mortality), and guidelines encourage shared decision making with the patient, GP and oncologist.

As health providers, we have a role in screening but also adequately counseling patients on their treatment options and the latest evidence regarding the therapies available to them. Sexual health during menopause is an incredibly complex topic, with factors ranging from midlife relationship changes and career dynamics, to physical symptoms such as poor sleep, to psychological shifts particularly those around self-esteem.

By starting with the basics, and acknowledging the vulnerability it takes to seek help for sexual health concerns, we can ensure that people experiencing challenges during and beyond the menopause can continue to live fulfilled, pleasurable lives. 


  1. ACOG Clinical Consensus. Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer. December 2021, Number 2. 
  2. Agrawal P, Singh SM, Able C, Dumas K, Kohn J, Kohn TP, Clifton M. Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol. 2023 Sep 1;142(3):660-668. doi: 10.1097/AOG.0000000000005294
  3. Cathcart-Rake EJ and Ruddy KJ. Vaginal estrogen therapy for the genitourinary symptoms of menopause: Caution or reassurance? J Natl Cancer Inst 2022 Jul 20; [e-pub].
  4. Cold S et al. Systemic or vaginal hormone therapy after early breast cancer: A Danish observational cohort study. J Natl Cancer Inst 2022 Jul 20; [e-pub].
  5. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel Menopause. 2014 Oct;21(10):1063-8. 
  6. Kingsberg SA, Larkin L, Krychman M, Parish SJ, Bernick B, Mirkin S. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause. 2019 Feb;26(2):124-131. doi: 10.1097/GME.0000000000001194
  7. Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med. 2013 Jul;10(7):1790-9. doi: 10.1111/jsm.12190
  8. McVicker L, Labeit AM, Coupland CAC, Hicks B, Hughes C, McMenamin Ú, McIntosh SA, Murchie P, Cardwell CR. Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer. JAMA Oncol. 2024 Jan 1;10(1):103-108. doi: 10.1001/jamaoncol.2023.4508.
  9. Sund M, Garmo H, Andersson A, Margolin S, Ahlgren J, Valachis A. Estrogen therapy after breast cancer diagnosis and breast cancer mortality risk. Breast Cancer Res Treat. 2023 Apr;198(2):361-368. doi: 10.1007/s10549-023-06871-w.


Dr Steph Roche

General Practitioner with a special interest in Sexual & Reproductive Health

Qualifications: MBChB (UCT), PG Dip HIV Management (SA)


Tel: +27 35 772 6635

Social Media: Instagram: @knickersinanot

sex therapy

10 Things You Should Know About Sex Therapy

People in any form of relationship structure; whether it be monogamous couples, conscious/ethical non-monogamous or any form of polyamorous relationships seek relationship therapy for whole number of reasons, and sexual issues can be one of them.

Psychosexual therapy or as it’s commonly known, ‘sex therapy’ is recommended when people are experiencing sexual difficulties that are causing distress in their relationship/s.

Some common issues that may warrant sex therapy include varying sexual desire, sexual pain, difficulties with arousal, and any relationship problems related to sex. Sex therapy can also be helpful for those who want to improve their sexual satisfaction, sexual pleasure and overall relationship and is important to seek as soon as possible, as sexual difficulties can lead to feelings of frustration, anger, and disconnection if left unresolved.

A trained sex therapist can help identify and address the underlying issues contributing to their sexual difficulties, and work with them to develop a plan for improvement.

10 things you should know about sex therapy:

  1. Sex therapy is a type of therapy that addresses sexual issues and concerns, including those in relationships.
  2. It is a collaborative process between the therapist and the client/s.
  3. Sex therapy may involve individual and/or joint sessions, as well as homework assignments.
  4. Sex therapy is based on open communication and respect for both partners.
  5. Sex therapy can help couples improve their sexual satisfaction and overall relationship.
  6. Sex therapy is not just about fixing sexual problems, but also about improving intimacy and connection.
  7. Sex therapy is confidential and private.
  8. A qualified therapist who specializes in sex therapy should be licensed and formally trained in human sexuality.
  9. Couples should feel comfortable discussing intimate topics and should be willing to actively participate in therapy.
  10. Sex therapy for couples is not a quick fix or a magic solution to all relationship issues.

In addition, it is not about placing blame or finding faults in either partner, but rather a collaborative and non-judgmental process. It is not solely focused on physical intimacy, but also addresses emotional, psychological, and relational aspects of a couple’s sexual well-being.

A word of caution:

When seeking any form of sex therapy or couples/relationship therapy, it is important to consider your personal safety. By doing your homework on your therapist and making sure they are registered with a legislative body such as the Health Professions Council of South Africa (HPCSA), SA Council for Social Service Professions (SACSSP) or any other local or international ethical and legal body, as these organisations have ethical and legal rules which therapists must abide by.

Sadly, like any profession there are people who claim to be relationship or sex therapists who are not trained or registered with a governing body causing harm to people. Because of this it is important to check that they have qualifications of a therapist and are experienced in working with relationship and sexual issues.

As sex therapy involves discussing sensitive and intimate topics consent and respect for everyone’s comfort level are essential. Please bear in mind that this form of therapy does NOT involve intimate touch, performing sexual acts in the therapist’s room or with the therapist. Sex therapy is a ‘talk-therapy’, however you may be given homework to do on your own or with your partner/s.


Stephan Laverack

Counselling Psychologist

Qualifications: BA(Hons) Psychosocial (UEL, UK), MA Couns. Psych. (Wits)



Gender Affirming Voice and Communication Therapy for the Trans and Gender Diverse Population

Hi! I am Saskia (she/they), a speech therapist based in Cape Town.

I am thrilled to offer gender affirming voice and communication therapy as the main focus of my practice, SL Speech Therapy. 

Gender affirming speech therapy is a relatively new branch of speech therapy, especially in South Africa. As such, I offer online sessions so that I can make my service more accessible to South Africans not based in Cape Town.

How does it work?

Broadly speaking, gender affirming speech therapy falls under three main categories: ‘masculinising’, ‘feminising’ and ‘neutralising’. To understand a bit better how this works, I will describe some of the prominent differences between ‘masculine’ and ‘feminine’ voices. 

(Please note that the descriptions that follow, are based on studies done on cis people, and hopefully future studies will include gender diverse participants.)

Most people’s initial thought on these differences relate to ‘pitch’. Generally lower voices are perceived as more masculine and higher voices are perceived to be more feminine. Gender affirming speech therapy can assist individuals to either raise or lower their habitual pitch in a way that is healthy, and not damaging, to the vocal mechanism. However, pitch is only one component of voice, and even though it is often the most obvious one to people, it is not the most important component.

Have you ever heard a deep voice that is still clearly feminine, or a high voice that is still distinctly masculine? This would be due to the other vocal characteristics (such as resonance, intonation patterns, articulation and vocal quality) allowing you to perceive the voice as masculine or feminine, despite the pitch being high or low.

This brings us to the next component of voice, resonance. Resonance describes how a voice is filtered and enhanced as it travels along the open chambers of the vocal tract (the lungs, trachea, pharynx, oral and nasal cavities). Resonance gives a voice depth and timber. It is each person’s unique body and habits around resonance that makes their voice distinct, allowing us to distinguish one voice from another and recognise those of the people we know. In masculine bodies, the open spaces along the vocal tract are bigger and the resonance is mainly in the chest. This results in masculine voices sounding “rich”, “dark” or “gravelly” in quality. 

In contrast, the open spaces along the vocal tract are smaller in the feminine body, and the resonance is focused more in the head and mouth. This results in a voice quality that is “clear”, “bright” or “crisp”. Resonance is a major factor in how a voice is perceived in terms of gender. 

Gender affirming speech therapy teaches the individual how to adapt and refocus their resonance, so as to align with their identity.

Another important component in voice is intonation. Intonation patterns refers to how a voice rises and falls during speech, to add emphasis, meaning and emotion to the utterance. Masculine voices tend to use more downward inflections (voice going down) and tend to use volume to emphasise something. Feminine intonation patterns incorporate more upwards inflections (voice going up) and words are emphasised by going up in pitch (more than increasing volume).

Other characteristics include articulation styles (masculine voices produce syllable and words distinctly separately from each other, whereas feminine voices let words and syllables blend into one another), vocal quality (how clear, smooth, breathy or rough a voice sounds) and nonverbal communication such as gesture, body language and facial expressions.

A note on testosterone and voice

Individuals on testosterone generally experience a drop in their pitch. While this can be very gender affirming, some clients are still not completely happy with their voices and feel that they do not sound “masculine enough” or that while they have a deeper voice they sound more like a boy than a man. This is because the other components such as resonance and intonation patterns have not changed. Speech therapy can help the client to adapt the other characteristics of their voice so as to match the new deeper pitch.

Of course in some cases someone wants a deeper pitch but they do not wish to, or are unable to take testosterone for whatever reason. A speech therapist can still assist in these cases with safely habitualising a deepening your pitch, with or without testosterone.

Why is gender affirming voice therapy important?

Voice and communication are essential aspects of a person’s identity. It conveys who we are, how we feel, and what we want to say to the world. For many transgender and non-binary individuals, voice and communication can be a huge source of dysphoria, distress, and discrimination. They may feel that their voice does not match their gender identity or expression, or that their voice gets in the way of them being their authentic self. Sadly, safety is also a concern for many of my clients. People can behave unpredictably and aggressively in the face of gender diversity. If for example, a stranger notices that a femme presenting person has a masculine voice (or visa versa) – they could potentially respond with discrimination or even violence.

Gender affirming voice and communication therapy can have significant benefits for transgender and nonbinary individuals. It can improve their self-esteem, well-being, social relationships, and quality of life. It can also reduce their risk of vocal injury or vocal abuse. It can empower them to express their authentic self and live more fully.

My approach

Although therapy broadly works to ‘masculinise’, ‘feminise’ or ‘neutralise’ a voice, I do not believe in a one-size-fits-all approach. The aim is not to give the client a new voice or to copy someone else’s voice. Rather, we aim to find the clients own authentic voice.
Therefore my approach is a gentle and playful journey of self-discovery, and I encourage my clients to play around within the components and discover what brings them euphoria and connection. 

It is also important to me to not reinforce binary stereotypes, I do not believe that there is a right or wrong way for anyone to sound, or that someone’s voice should ‘match’ their physical expression of gender.

The logistics

The speech therapist works collaboratively with the individual to assess their current voice and communication skills, identify their goals and expectations, develop a personalised treatment plan, and monitor their progress and outcomes.

The length of the gender affirming voice therapy journey is different for everyone and depends on multiple factors, but generally takes between 4-8 months for most. Sessions are ideally weekly, but every two weeks is also an option for those who struggle with affordability of weekly sessions. Between every session clients will be voice exercises to practise and become familiar with. For optimal progress, clients should get into a routine of doing the exercises daily to allow them to form new vocal habits.

To refer a client or if you would like to connect with me:

You can send me an email or whatsapp me using the details below.

You can also follow me on Instagram @sl_speech_therapy where I share tips, resources, and stories about gender affirming voice and communication therapy.


Saskia Lilienfeld

Speech Therapist


Whatsapp: 079 966 3554


Kegels aren't always a good idea

Kegels: Friend Or Foe?

Kegels in layman’s language refers to the process of activating the Kegel muscles (pelvic floor muscles) to generate tension and increase strength.

What are Kegel/pelvic floor muscles?

Pelvic floor muscles are muscles that are located at the floor of the pelvis. You can think of your pelvis as a bowl and the pelvic floor muscles as a hammock from the pubic bone in the front to the tailbone at the back.

In an individual with a vagina, three holes pierce through these muscles namely, the urethra from bladder, the vagina and the anus. In an individual with a penis two holes pierce through namely, the urethra through the penis and the anus. There can also be variation in anatomy when there has been reconstructive surgery in this area.

What is the function of the pelvic floor muscles?

Control of the sphincters around the urethra and anal openings to prevent leakage of urine and bowel, as well as controlling the process of urination and passage of stool.

They have a sexual function, helping you to achieve and maintain erections and play a role in orgasm.

Support of the pelvic organs namely bladder, uterus and rectum during activities of daily living.

Provide stability to the pelvis and lower back as they are part of the ‘core’ support in this area

When are the Kegel/pelvic floor muscles your friend?

i.e. When should you consider doing Kegel exercises:

Post prostatectomy: During the procedure of removing the prostate gland, the muscles that are just below the bladder but above the prostate are removed as part of the procedure. These muscles, when intact, work automatically to maintain urinary continence. After the procedure, to maintain urinary continence, the pelvic floor muscles immediately below where the prostate gland used to be can be trained by voluntary control to generate tension in them to maintain or improve urinary continence.

During orgasm: During orgasm the pelvic floor muscles can go into explosive pleasurable contractions. When these muscles are weak the intensity of the orgasm will be reduced. Strengthening the pelvic floor muscles helps to achieve stronger orgasms.

Post partum: The pelvic floor muscles can be weakened by pregnancy itself and/or the mode of delivery (particularly vaginal delivery). Individuals can complain of struggling with bladder control, struggling to hold in gas voluntarily, feeling that the ability to ‘grip’ a penetrative object in the vagina is decreased, or a feeling that the pelvic organs are ‘sagging through the vagina’ (pelvic organ prolapse). When the pelvic floor muscles are underactive they need to be activated by generating more tension to provide better support.

When are Kegel/pelvic floor muscles your foe?

i.e. When should you consider avoiding Kegel exercises:

During sexual intimacy: one might have difficulty progressing in the sexual response cycle, for example, difficulty in getting aroused. Your pelvic floor muscles could be having excessive tension and not allow for the relaxation that encourages blood engorgement in the clitoris or penis. Here activating the Kegel muscles would lead to further frustration.

Vaginismus is a medical condition where an individual with a vagina struggles with any kind of penetration, and at worst cannot achieve penetration through at all. This can be penetration with a penis, a sex toy, a tampon, or a medical device e.g. a speculum or vaginal examination. Doing Kegels here would definitely be your foe and make things worse.

Dyspareunia refers to painful sex. Here penetration is achieved but it is painful. Your pelvic floor muscles are likely to be tight with increased tension so they need to be relaxed. Doing Kegels would only make things worse.

Tight (overactive) pelvic floor muscles during orgasm: in individuals with penises, during orgasm as the pelvic floor muscles explosively contract, it can cause an ascension of one of the testes into the pubic area resulting in excruciating pain. Kegels in this instance are not advisable.

Your pelvic floor is part of an integrated system

It should be noted that the pelvic floor is part of an integrated system. This means that dysfunction in another area of the system could be driving the perceived tightness or weakness of the pelvic floor. Working on the affected tissues in another area can have a positive resultant effect on the client’s primary complaint, for example, dyspareunia (painful sex).

It is therefore advisable to seek help from a physiotherapist who works in pelvic floor rehabilitation who will be able to do a comprehensive assessment. A pelvic floor physiotherapist will be able to teach you how to assist your pelvic floor muscles to respond appropriately by increasing or decreasing tension in addition to using other techniques.

It’s also important to note that treatment is usually multidisciplinary, involving pelvic floor physiotherapists, medical doctors, clinical psychologists, sexologists, or sex therapists depending on the individual’s condition.

In summary

It’s important to remember that doing Kegel exercises isn’t always a good idea, depending on what the problem is. If you, or someone you know, has any concerns about your pelvic floor, such incontinence or pain during sex, it’s best to first see a pelvic floor physiotherapist for a proper assessment.


Lorato T. Mosetlhi-Molelowatladi

Pelvic Floor Physiotherapist

SASHA Executive Committee & Membership Committee


Queering Sexual Health

Initially, when I was asked to write something about queer sexual health, I assumed it would be fairly simple. I identify as queer, I’ve used queer theory in my research, I work with sexual health, and I boldly tell people that I am especially interested in queer sexual health. Yet, weeks after the request I found myself at my desk staring at an empty word document, trying to wrestle a pen away from one of my cats. I felt at that point, despite the lack of opposable thumbs, they would be better placed to write this than me.

The main reason for this drawn-out process actually has something to do with one of things I love most about queerness – its resistance to definition. The word ‘queer’ is often used in numerous ways, with the meaning changing from context to context. Something that is both rich with possibility and potential but can also feel somewhat out of reach.

Consequently, in the spirit of queerness itself, I propose instead to engage in a reflective imagining about what queering sexual health does. As Julie Tilsen (2021, p.6) notes, using ‘queer’ as a verb is its “queerest elaboration”, and, let’s be honest, we all know that queers love to queer things. I would not be remotely surprised if we started seeing research queering toilet paper, isolation, and lockdown. That is, if they don’t already exist.

Exploring what work the word ‘queer’ is doing in sexual health

My central imagining is about exploring what the work the word ‘queer’ is doing in queer sexual health. What does queer mean is this context? And most importantly, what does it do? A simplistic way of understanding the role of the word queer could be to say that queer sexual health is about sexual health for queer people. And while that is certainly an admirable and useful goal, my feeling is that queer sexual health is less about sexual health for particular kinds of people, and more about a queer approach to sexual health.

In this sense, queering sexual health is more about what possibilities become available to you as a healthcare professional when you start to queer your understanding and practice of sexual health. As Tilsen (2021, p.6) argues, “when we queer something, we question and disrupt taken-for-granted practices and we can imagine new possibilities”.

In a sexual health context, this could mean many things, and the remainder of this post will be about articulating some of these possibilities. For instance, this could mean an insistence on the importance of pleasure. Making our work about facilitating pleasure and wellbeing. This is as opposed to a focus on dysfunction, damage or disease. In centering pleasure and wellbeing, we can begin to see sexual health framed as erotic possibility, cultivating shared kindness, openness and curiosity in ourselves and our clients.

Challenging preconceived rules and ideas

A queering is almost always about challenging preconceived rules and ideas. In sexual health, this may mean challenging our own and our clients’ assumptions about gender, sexuality, anatomy, identity, relationships, and the relationships between these. This means tossing out the rulebook that suggests particular kinds of sexual play have anything significant to say about your identities. Or that particular body parts mean anything about your gender identity.

Queering sexual health is a rejection of binaries. It’s about a resistance to simplified labels, and instead embracing the beautiful messy complex reality of people’s experiences. What is allowed to emerge in sexual health practice when we take seriously that experiences cannot be reduced to boxes? And when we give our clients permission to exist and explore outside of them?

This therefore means embracing uncertainty and exploration. It’s a rejection of the idea that the simplest answer is often the right one, or the idea that there is a right answer in the first place. In much the same way as pleasurable sex embraces the journey and the process rather than a particular outcome; queer sexual health is about fluidity and a commitment to remaining open to new possibilities and realities.

As Tilsen (2021, p.6) argues “Queering is an ever-emergent process of becoming, one that is flexible and fluid in response to context, and in resistance to norms.” What happens when we center becoming instead of being, what do we remain open to and curious about in our own and clients’ lives?

Prioritising the client’s knowledge and experiences

Queering sexual health is also about starting from where your client is at and prioritising their knowledge and experiences. From this viewpoint, consultations can be viewed as the meeting of two (or more) minds. Each mind with their own perspectives and expertise.

Consequently, we can resist conventional notions of medicalised professionalism by being able to identify and disrupt the power dynamics which are so present in healthcare settings today. This is about rethinking informed consent as an ongoing process, always giving your clients all the of the options available and letting them make the decisions that are best for them, perhaps guided by, but not determined by our own ideas and beliefs.

In order to facilitate this kind of reflective process, healthcare workers need to be mindful of our own beliefs, values and assumptions, and the ways in which these may create blind spots and/or undermine our clients’ agency. Being aware of the complexity of our clients’ identities and experiences is also about a commitment to intersectional practice.

Intersectionality and diversity

Intersectionality has recently become something of a buzzword which treats inclusivity and diversity as little more than a box-ticking exercise. Queering sexual health is about remaining aware of all our own intersecting identities, experiences and social realities, and the recognition that each client comes with their own. Some of these identities and experiences are less visible than others. We need to ensure we are able to listen out for these as and when they are articulated (or not), and the ways in which they may enter the consultation room and our lives. This requires an ongoing commitment to authenticity which can hopefully facilitate the same for our clients.

Tilsen (2021, p.6) says that a queering is about breaking rules “in order to liberate people who have been held hostage by what the rules require or prevent”. Sexual health tends to operate from the viewpoint of cisgender, heterosexual, vanilla, monogamous, able-bodied white humans, and their relationships. Rules about what kinds of sex and relationships are legitimate and normative are widespread, whether they are explicitly stated or not. As a result, breaking the rules is about identifying and labelling the discrimination and marginalisation experienced by those outside of Rubin’s (2011) Charmed Circle, and instead turning the circle inside out.

In healthcare settings like South Africa where white, middle class, able-bodied, cisgender men continue to be a large focus of research and intervention, we can queer our sexual health practice by centering the experiences of those who are currently on the margins.

What does sexual health look like when we start with the experiences of sex workers? Ace, intersex, trans and gender fluid humans? Non-monogamies and kinksters? What erotic possibilities are opened up by moving away from heteronormativity and monogamism?

Expanding our toolbox

Queering sexual health is about recognising that the toolbox we’ve been given is limited, comes with sets of rules and expectations and frames client experiences in ways that can have negative consequences for their emotional and sexual wellbeing. For instance, defining sex as a penetrative act that involves only a penis and a vagina has consequences for the ways in which we are able to engage with clients around their sexuality. It creates a hierarchy around what kinds of sexual practices are considered legitimate and normalised, makes assumptions about body parts and pleasure, and limits the ways in which we can talk about consent, play and safety.

A queering of sexual health is about offering new and alternative frameworks that challenge essentialism, reject binaries and facilitate fluidity. Let’s begin from the perspective of those on the margins, make a commitment to inclusivity and authenticity and dismantle power dynamics. Let’s center pleasure and wellbeing and suspend our assumptions and judgements long enough to work collaboratively towards facilitating sexual health, whatever that looks like from person to person.

In line with my feeling about the importance of locating yourself socially and being authentic, it would be remiss of me not to own that this is a vision of what queering sexual health could/does look like from my perspective: a queer, white, middle class, mental health professional in South Africa. I can also acknowledge from personal experience that it may feel anxiety-provoking and difficult to toss the rulebook out the window (although not your ethics please). It can leave you feeling stuck or wondering “Well, where do we go from here?” While that uncertainty isn’t always easy, it is also rife with potential.

Where do we go from here? Where can we go now that we could not previously? I invite you to dive headfirst into this beautiful complexity with your clients – who knows where the adventure will take you.


  • Rubin, G. S. (2011). Deviations: A Gayle Rubin Reader. Duke University Press: Durham & London.
  • Tilsen, J. (2021). Queering Your Therapy Practice: Queer Theory, Narrative Therapy, and Imagining New Identities. Routledge: London & New York.


Chant Malan
Counselling Psychologist
SASHA Executive Committee & Media Committee

Gender based violence in the consultation room

Gender Based Violence in the Consultation Room

Gender Based Violence (GBV) is a commonly heard phrase in the South African context, and something that is widely experienced either directly or indirectly. It has become more and more crucial to not only provide support to those affected but also to the healthcare professionals who might provide services to them.

Healthcare professionals, like myself, encounter people from all kinds of different backgrounds, and tools in order to ascertain risk or what kind of intervention is needed is always pivotal in the care of clients and patients.

How this can be achieved?

Often where one might first start with is creating a safe, non-judgemental space for the individual to share. This can be achieved through curiosity and not judgement, an empathic approach, and a sensitivity to the emotion that may be elicited for the patient. As often there is a feeling of mistrust and threat for some who are experience GBV, this environment needs to acknowledge this and provide something different.

Often, getting patients to open up and acknowledge that they need help is an important first step. This can also be overwhelming for the patient, and some delicacy will need to be exercised here. There is usually a set of cultural norms that frame conversations and stigma around GBV which a healthcare professional should always be mindful of. We enter particular spaces within larger communities, and such norms or ideas can permeate into our work.

Self-care for healthcare professionals

As such work in communities can be quite challenging, self-reflection and self-care for healthcare workers is crucial. Working in particular contexts where GBV might be prevalent can be taxing on professionals which means strong but compassionate boundaries needs to be practiced, as well as supportive spaces for healthcare workers. Self-reflection is a vital part of understanding one’s own biases, challenges, obstacles to providing services, and other aspects of providing support to patients. Once one has an awareness of this, can effective work take place.

Working with communities and context

Working with stigma can prove challenging, as patients are often so resistant to help seeking behaviour because of it. Therefore, some may feel avoidant or confrontational regarding questioning around GBV. This is where rapport will come in, and can really aid in the patient feeling safe enough to disclose and accept support. Or what it can at least do, is provide a potential space for them to return to should they feel ready to seek out the intervention needed. Creating such safe spaces is so crucial not just for GBV but in so many different contexts where marginalized populations can find refuge.

What is also an important part of intervention is working with possible perpetrators of GBV who might also interact with healthcare professionals. Although this may present difficulties, it may present potential for intervention and improved outcomes for those affected. Possessing an inclusive framework will be important in working with communities.

The lens of inclusivity

A professional’s own beliefs should be examined in relation to gender, sexuality, sexual orientation, and culture. As all of this is encompassed on conversations around GBV. An important note here, is that not all GBV exists within a heteronormative lens, i.e. is a cis-gendered woman being abused by a cis-gendered man. There is so much of nuance and grey area that can exist here that one must be sensitive towards. One way to help with this is to always have an open mind and never make assumptions based upon gender or assumed sexuality.

Sexuality also provides an avenue of exploration to gauge the threat of GBV, as often GBV can manifest in human sexuality, sexual relationships, power within relationships, access or lack thereof to contraceptives, and so many other ways. Power becomes a central component in GBV, and this means that it can present in many ways, sometimes quite subtly. Therefore, GBV may not look like explicit bruising or the marks of physical violence but through coercion, manipulation, misinformation, control, gatekeeping, and in many other ways. Again, always view this through an inclusive lens, and meeting the patient where they are at and their experiences.

GBV is a complex issue, and one should not gloss over or simplify it. We need to seek to understand, be compassionate, and exhibit sensitivity. GBV drastically impacts health on various levels, and this also therefore informs our interventions as healthcare professionals. If we are to make recommendations, the restrictions that GBV can place on that could prove an obstacle in how the patient takes it up. If marginalised patients are not able to access services, or follow through on their healthcare this significantly affects outcomes.

What can a healthcare professional do?

Once it has been established or suspected that a patient or client is involved in GBV it is best to approach them to ascertain as much information as possible. Try to always do this in a calm, compassionate and open manner, as this may be a sensitive matter for the individual and needs to be handled with much care. Once co-operation is achieved, it is best to know who one can refer to in such a situation. Always keep in mind the safety of the person in question, if they are even able to seek out the support needed and if the resources are available for them to do so. If there are minors involved, it will be an important question to consider and therefore shape the nature of the intervention and which parties will need to be privy to it.

To help establish a safe space, the client or patient can try to identify somewhere they can be safe. This can be a relative’s home, the residence of a friend, or anywhere that is considered out of danger. Then it is important to report the matter to the South African Police Service (SAPS) for urgent assistance, to open a case and possibly assist with a protection order. Social workers, counsellors and psychologists are also important resources to assist with trauma debriefing, mental health resources, counselling and many other forms of intervention.

There are also remarkable, reputable organisations who work with those affected by GBV that can be contacted such as People Opposing Women Abuse (POWA), Agisanang Domestic Abuse Prevention and Training (ADAPT), Family and Marriage Society of SA (FAMSA), Nisaa Institute for Women’s Development and Sonke Gender Justice. All of these NGO’s represent great opportunities for referrals for those affected by GBV.

A way forward

Healthcare professionals hold key roles in intervening in the healthcare, support and aid for those affected by and who may perpetrate GBV. This aims towards enhancing healthcare outcomes and make strides in the crisis of GBV in South Africa. Taking all the above into consideration, a working framework to approach supporting patients involved in GBV emerges. This conversation needs to occur in the consultation room and beyond. Relationships between healthcare professionals and those they serve can prove significant gateways to intervention in GBV, and its importance need not be underestimated. Education, compassion, sensitivity, empathy and communication are vital in thinking on a way forward. What is evident is that there needs to be an appreciation and valuing of healthcare professionals, and how they contribute towards a system that can help rather than hinder progress.


Vickashnee Nair

Counselling Psychologist

SASHA Executive Committee & Membership Committee

Tel: 011 706 2269



Facebook: Vickashnee Nair – Counselling Psychologist

The Role of Physiotherapy in Sexual Health

I’ve been in several situations where I’ve seen people’s eyes grow wider and wider as I explain to them what pelvic floor physiotherapy entails. I don’t think it’s because they were scared of the treatment itself, but rather because it was totally new to them. They didn’t know what to expect, or that it even existed at all. 

In my experience, going to see a pelvic floor physiotherapist feels more or less the same as when you need to visit a gynaecologist. I cannot speak for men, but I think they get a similar feeling when they need to see a urologist. Having anyone near your genitals can make you feel vulnerable!

What does a pelvic floor physiotherapist do?

We treat conditions such as urinary and faecal incontinence, sexual dysfunction, pelvic and perineal pain, constipation, and over- or under-active pelvic floor muscles in men, women and children.

Common problems we treat include conditions such as pelvic organ prolapse (the descent of the pelvic organs through the vaginal walls) and erectile dysfunction, especially post-prostatectomy (removal of the prostate).

The pelvic floor muscles play a huge roll in most of these conditions, but it’s not the only thing we focus on during assessment and treatment. With all conditions, we follow a bio-psycho-social approach to treatment, which is patient-centered.

What does the pelvic floor physiotherapist look for?

We assess (and treat where indicated) different components that may contribute to a certain condition or dysfunction.

This may involve physical components, such as posture, breathing, general fitness, functioning of the peripheral, central and autonomic nervous systems, and contraction and relaxation of the pelvic floor muscles, diaphragm, abdominal muscles, or other muscles we might think are involved.

This usually includes assessments of the joints, specifically in the pelvic, lumbar and hip region. It is also important for us to note how these muscles, nerves and joints work together and coordinate their movements, as it may cause imbalances and problems in other areas – contributing to the dysfunction.

What does the pelvic floor physiotherapy treatment entail?

We have several ways of investigating and treating the pelvic floor muscles, sometimes using devices that can assist us, as these muscles are located quite deep and are not always visible or palpable from the outside of the body.

Examples of these devices include electromyography, ultrasound, and neuromuscular electrical stimulation. We may also use these in our treatment plan, together with appropriate exercises which usually forms a large part of the treatment plan. The type of exercises done will mainly depend on the aim of the treatment, be it to relax or strengthen the applicable muscles.

We always work as part of a team

As physical therapists we obviously focus a lot on the physical aspects of the treatment, but we also need to address any environmental, social or health factors that may be contributing significantly to the condition.

If we are concerned about medical or psycho-social factors, or have severe cases, we refer appropriately.

The multi-disciplinary team is crucial in the management of pelvic floor dysfunctions, as they can often be quite complex due to different contributing factors. We work closely together with social workers, psychologists, dietitians, general medical practitioners, gynaecologists, urologists, sexologists, gastroenterologists, orthopaedic surgeons, physicians and nurses.

As a team we can provide our patients with the best possible treatment plan and get the best results.

Pelvic floor dysfunction is not something you should be ashamed of

Going to your first pelvic floor physiotherapy session can make you feel anxious and vulnerable, but believe me – by the end of the session, you will feel so much better about it.

Pelvic floor dysfunction is not something to be ashamed of. Help is available for you. By talking about it, you can get the help you need, and stop suffering in silence.


Dr Corlia Brandt (SASHA Executive Committee)
Pelvic Floor Physiotherapist, Senior Lecturer, Researcher.
South African International Urogynaecology Association Physiotherapy Representative.
Chairperson of Pelvic and Women`s Health Physiotherapy (South African Society of Physiotherapy).



what does a sexologist do

Becoming A Sexologist

Sexology, despite having been around for nearly sixty years, is still a relatively misunderstood area of health care. According to the World Association of Sexual Health (WAS), “sexologists work in a wide variety of disciplines” and they have specialist post-graduate training, but could have a background in psychology, medicine, public health, research or nursing.” In South Africa, the term sexologist is used according to this definition.   

How to become a Sexologist

A sexologist must have an initial qualification that will lead to registration with reputable and accrediting healthcare bodies, such as the health professions council of South Africa (HPCSA).

In South Africa, a healthcare provider who has obtained specialist postgraduate qualifications in human sexuality can call themselves a sexologist, which entails training in the broad spectrum of human sexuality and includes the multiple factors that influence our behaviour and feelings about our sexuality.

A sexologist should also have undertaken sexual attitude reassessment seminars (SARs) as a fundamental part of their training.

They could have an initial qualification in psychology, medicine, nursing, public health or research, but they can only use the title of clinical sexologist if they have completed a postgraduate qualification, obtained the relevant accreditations to practice as a registered healthcare provider with a legitimate body and are practicing clinically.

Unfortunately, there is currently no postgraduate qualification available in human sexuality or sexology in South Africa that would enable a qualified and registered practitioner to become a sexologist. Therefore, a practitioner has to qualify internationally in order to become a sexologist at this time.

What does a Sexologist do?

A sexologist works to understand what people do sexually and how they feel about what they do. For example, a clinical sexologist may offer sex therapy (a form of talking therapy) to help people understand and accept themselves as sexual beings, overcome sexual challenges they might be facing and meet their sexual goals.

Sexology should never (and will never) involve patients interacting sexually with or in front of their sexologist.

It can be offered to individuals, to partners or in a group setting, and could take place weekly (for example for therapy) or less frequently depending on the patient’s needs (such as monthly for medical purposes).

When a patient consults with a sexologist, the sexologist should always maintain a ‘sex-positive’ and non-judgmental approach to their patient and their concerns. Like with any healthcare provider, the success of the patient’s treatment rests heavily on the dynamic between them and the practitioner. They should feel that they can trust their sexologist and open up to them about their concerns, without the fear of criticism, prejudice or rejection. A strong rapport between the patient and the practitioner has been found to be one of the single most important predictors of successful treatment.

A sexologist should uphold a broad perspective on sexuality by taking biological, psychological, sociological, anthropological and cultural factors into consideration when addressing a patient’s concerns. Education is a large part of process, and a sexologist should use an educational approach as part of treatment to help their patients meet their goals; without holding any preconceptions of what a patient’s sexual experience and sexuality ‘should’ look like. Sexual growth is facilitated by helping them to identify their sexual goals and by offering education, resources, tools and techniques to help them meet those goals and ultimately manage their own sexual development.

The PLISSIT model (Anon, 1976) is the foundation for sex therapy, but the treatment of sexual concerns by other healthcare providers also utilises this model. The PLISSIT model is based on the following premise: giving patients explicit and implicit permission to ask and explore their sexuality, offering the patients limited information regarding their specific concerns (often in the form of educational resources), making specific suggestions to the patient based on their needs and concerns, and either referring for or offering the patient intensive therapy when their concerns have psychology origins.

When should a Sexologist refer a patient?

If sexual difficulties appear to be rooted in deeper issues that require intensive therapy, a clinical sexologist with a background in psychology will be able to undertake this work with a patient. If they feel that a patient requires further treatment from another practitioner who is part of the multidisciplinary team, they will provide a referral to an appropriate specialist, and it is advised that this be someone whom the referring clinician has a working relationship with and who’s expertise are known.

In the treatment of sexual issues, it is common practice for a sexologist to work closely with a multidisciplinary team of healthcare providers. These might include, but are not limited to:

  • A medical doctor practicing in sexual health
  • A psychologist
  • A pelvic floor physiotherapist
  • A urologist
  • A gynaecologist
  • An endocrinologist
  • A psychiatrist


Catriona Boffard (SASHA Member)

Clinical Sexologist, Psychotherapist, Sex Researcher & Educator and Speaker

BA (Hons) (WITS, SA)
MA Psychology (WITS, SA)
Masters of HIV, STIs & Sexual Health (MHSSH) – (USyd, AUS)
European Certified Psychosexologist – European Society of Sexual Medicine/ European Federation of Sexology.
Postgraduate Diploma in Cognitive-Behavioural Therapy – (RHUL, UK)





How Do I Know If I Need A Sex Therapist? What Can I Expect During Sex Therapy?

My experience is that most of us don’t realise that our sexual health can have a significant impact on our overall health and wellbeing. Sex is an integral part of health and wellness which is why the WHO defines Sexual Health as a HUMAN RIGHT!

Sexual Health refers to everything about you and your sexuality. The lens of Sexual Health encompasses your mental, physical and social wellbeing as it relates to your sexuality. Sexual Health is premised on your right to sexual pleasure and your right to safe sexual expression and experiences.

Because most people never even think about whether they need a Sex Therapist or not, they live with a host of issues that can affect them negatively on all these levels – when indeed there are people like us Sex Therapists who can help with such a wide range of these issues!   

So what is Sex Therapy all about?

Well there is the stuff about your sexual identity, like:

  • Your sexual orientation – who do you find yourself sexually attracted to?
  • Your romantic orientation – who do you find yourself developing romantic feelings for? (The answers to these 2 questions don’t have to be the same and don’t have to remain static over time!)
  • Your gender – now this goes way beyond whether you are a man or a woman but extends to how you like to present yourself to the world, and also how you feel about yourself in terms if your gender – and this too does not have to remain fixed or static over time

Then there’s stuff about the act of sex:

  • What kind of sex do you like? And by ‘what kind’ I mean – when, how, with whom, with what, how often, if at all?
  • What turns you on?
  • What grosses you out?
  • Does sex hurt sometimes?
  • Is there anything you wish you could try, but feel totally weirded out by the idea?
  • Have you ever been aroused by something that took you completely by surprise because it’s just “not normal”?
  • Are you happy with your current level of sexual satisfaction?

Then there’s your sexual relationship with others:

  • What do your sexual relationship structures look like, and what do you wish they could be?
  • How important is monogamy to you in a sexual relationship? And to your partner/s?
  • How do you talk to your kids about sex?
  • How are you feeling about the sex with your current partner/s?
  • What kinds of things did you learn and experience about sex growing up? How do you think this may be influencing your expectations and experiences of sex and sexual relationships now?

These are just a few of the things that a Sex Therapist can help you explore, this list is by no means exhaustive.

As Sex Therapists we can help you whether you are experiencing extreme distress and dysfunction relating to the kinds of topics listed above, or if you are just wanting to find out if there’s more to the sex that you are currently experiencing.

Most people have questions about sex that they find difficult to explore within their social circles, so they google it and often don’t find answers, or just live with the uncertainty, disappointment, or distress that the issue causes.

What can I expect from Sex Therapy?

Sex Therapists are typically trained in Psychology or Social Work, and have obtained further training and or experience working in the field of Sexual Health. Much like general counselling, Sex Therapy does NOT involve any touching, bodily exposure or manipulation of any kind! It’s all “talk therapy” based on general counselling techniques, where we would explore topics that relate to your sexual health.

We may give you homework that can involve you and/or your partner exploring various physical techniques and exercises, which we would then talk about at the follow up sessions.

*You should NEVER allow a Sex Therapist to engage with you in any physical way, unless they are a qualified medical practitioner, and qualified to do what they are offering! It is also very important that you check the credentials and registrations of the professional that you seek help from before you see them.

Besides social or psychological problems relating to your sexual health, there can often be problems of a physical nature as well.

Sex Therapists are qualified to assess whether this might be the case, but we can’t diagnose or offer medical treatment. We thus work closely with medical health professionals who have training in sexual health, and will refer you to them if deemed necessary. We may also do this just to rule out any organic cause for dysfunction. Most often we work hand in hand with the medical practitioner to help you achieve resolution.

So how do you know when you need a Sex Therapist?

Everybody needs to talk about sex. You may not need to talk to a professional, but talking to one, can help you talk about sex to the people in your life who influence your sexual health.

There is a strong link between sex and psychology because sex is often about relating to others and requires a level of vulnerability that many other social interactions do not.

I have had many clients who have found that just having a space to talk about sex freely and without judgement, knowing that all is kept 100% confidential, has given them freedom and insights that have helped them experience sex in a much more positive way than they had prior to therapy.

So the simple answer would be, if you are unhappy, unsure or experiencing distress about any area on your sexuality, an assessment by a Sex Therapist can give you clarity about your issue and also afford you the opportunity to claim your right to live a more sexually healthy and fulfilling life.


Chantal Fowler (SASHA Executive Committee)
Clinical Psychologist
Psycho-Sexologist – European Society of Sexual Medicine (ESSM)
PHD candidate – UCT school of Public Health and Family Medicine



Mobile: 076 586 9857

A Sexologist Vs Sex Therapist

The question is frequently asked – What is a Sexologist? What qualifications do you need to be a Sexologist? There is further confusion between what differentiates a Sexologist to that of a Sex Therapist. The following synopsis aims to clarify these differences.   


Sexology is the general term for the scientific study of human sexuality and sexual behaviour. The people who study this field, are generally referred to as Sexologists.

Some people think Sexologists and sex therapists are one and the same. There is a difference with reference to Sexologists who choose to pursue a career as a sex therapist by working directly with patients in a clinical setting, whilst others may explore careers such as researching sexual behaviour, or sexual health.

Additionally, these persons may choose to become a sex educator helping in expanding sexual knowledge in the general public domain, or a medical doctor specialising in sexual health and treating diseases associated with sexual behaviour, like sexually transmitted infections and other physical symptoms.

Lastly another group of individuals working in Sexology are able to act as public policy activists regarding sexually related issues, such as legalising prostitution, LGBTQI&A rights and building on the general rights of marginalised individuals allowing everyone to have fulfilling sexual relationships.

How do you become a Sexologist?

A small number of Universities in the world offer degrees in sexology, or human sexuality at undergraduate and post graduate levels. It is common that people who do choose to pursue the academic process to become Sexologists, have
educational backgrounds in disciplines such as sociology, psychology, biology, medicine, public health (nursing) or anthropology.

Sexologists generally have a master’s or doctoral degree, although some individuals have another type of advanced professional degree. Although a board certification is not required to call yourself a Sexologist, many students in this field seek credentials from professional organisations such as the American Board for Sexology, or the International Society for Sexual Medicine.

To be certified, you typically need to show a relevant advanced academic degree, relevant work experience in the field and completion of a certain number of training hours. These requirements however may vary based on the certification.

Sex Therapist

Sexologists who are also sex therapists work with clients, either individually or as a couple, to improve and address problems and aspects contributing to distress in their sexual functioning. This might include sexual education for couples who may experience problems such as mismatched libidos, difficulties reaching fulfilling orgasms, sexless relationships, sexual trauma
and other issues specific to personal problems regarding sexual identity and problematic sexual behaviour like pornography addiction.

Sex therapists should have specific qualifications such as an advanced degree in either psychology, psychotherapy or counseling, and specific courses in sex therapy training and clinical experience. Unfortunately, these terms are not currently regulated, so anyone is able to call themselves a Sexologist or a sex therapist. It is good practice when you are looking for
someone to help you in this area, to check their qualifications first.

Do not expect any physical contact during a sex therapy session with a Sexologist!

People sometimes think that a sexologist would do ‘hands-on’ work. This would be regarded as unethical conduct within the profession and is defined as such by the professional boards situated under the Health Professional Council of South Africa (HPCSA). An HPCSA registered practitioner can be charged by the HPCSA, in the event of unprofessional behaviour. Therefore it is rather a matter of “All talk, No action”.

This would clearly differ from being a sex surrogate, which is a different profession all together by involving actual sexual contact with clients.
Thus, if you are in need of, or you are interested in consulting with a certified Sexologist or professional sex therapist, the SASHA website would be able to direct you to a list of professionally qualified Sexologists and sex therapists in South Africa.


Dr Eugene Viljoen (Past President of SASHA)

Clinical Psychologist
B.Sc. Hons. (Physiol. & Bioch.)
B.Sc. Hons. (Psych.); M.Sc. (Clin. Psych.)
Dipl Aviation Psych & Physiol. (USA) Ph.D
ISSM/EFS Certified Clinical Sexologist (European Federation for Sexology)

Phone: 012 346 4760