Mahima Tiwari is a pelvic health physiotherapist who specialises in helping people achieve optimal sexual health. She has been a practising clinician for the past nine years.

Tiwari also worked with the United Nations for physical therapy rehabilitation in Nepal after the devastating earthquake in 2015. Currently, she runs a clinic called ‘EmpowerHeal Physical Therapy’ in Maryland, United States.

In this conversation with the Post’s Rishika Dhakal, Tiwari discusses the challenges of addressing sexual health and advocates for comprehensive, inclusive sex education.

In a society where open conversations about sex are often avoided, what are some ways to initiate meaningful dialogues within families, relationships or communities about sexual pleasure and health?

Typically, when we discuss sex within the Nepali curriculum, the focus tends to be on a very heteronormative view, covering topics like anatomy, reproduction, and menstruation. The first step towards fostering a more inclusive understanding of sexual health is to integrate comprehensive sex education into the curriculum for adolescents.

This curriculum should cover various aspects, including how sex can look different across sexual orientations, different forms of pleasure (both self and partner-based), issues like pain during sex, infections, erectile dysfunction, and age-related changes in the body's physiology.

In addition, medical professionals need to be trained to assess and treat sexual function and health.

In a patriarchal society, discussing sex and pleasure, particularly female pleasure, is a feminist act. When addressing women's rights and feminism, these conversations must also include discussions about sex and pleasure.

Finally, I encourage parents, teachers, elders, and friends to normalise these topics in everyday conversations. Restricting discussions about sex to the bedroom perpetuates taboos, especially when it’s a subject that impacts all aspects of personal health and relationships.

How does the portrayal of sex and relationships in media such as films, television and literature affect people’s understanding of sexual pleasure and expectations in real life?

The way sex and relationships are currently portrayed in the media is largely heteronormative and male-centric. It often presents sex as a one-dimensional act, frequently involving violence, and primarily focused on penetration (a male penetrating a female).

This portrayal ignores the crucial aspects of sexual experiences, such as the need for consent throughout each stage of intimacy, the importance of constant communication for arousal and stimulation, exploring kink, the significance of foreplay, self-pleasure, and non-penetrative forms of intimacy.

What common challenges about sex and pleasure do you encounter in your work?

In my work, I face challenges at every level of healthcare. One major issue is the lack of medical providers who are well-versed in pelvic health and sexual health, including topics like sex, pleasure, and intimacy. These subjects are not extensively covered in medical or physiotherapy education, leading to limited understanding and the potential for harmful narratives being spread by healthcare professionals.

When patients bring up concerns about their sexual lives, they are often dismissed with comments like, "You're making this up," "It's all in your head," or "Things will change after you have kids." They may also be told that "some pain is normal," "just drink more wine and relax," or "use more lubricants." These dismissive attitudes prevent patients from receiving the appropriate care they need.

Another challenge is that many patients don’t realise their conditions are treatable. There is a general lack of awareness that these issues can improve and that patients should expect better outcomes.

Even in countries like the US, sexual health services are often not covered by insurance. Because sexual health is not prioritised and there is limited knowledge about sex and pleasure, achieving sexual health is frequently not seen as a goal.

Awareness of physiotherapy is low, and even fewer people are willing to invest in their sexual health.

How do cultural barriers affect people’s understanding of their sexual health, and how can we break them?

In Nepal and globally, sex is often not discussed, leading to a lack of recognition and resources in the healthcare system to address sexual health issues. This silence contributes to the perception that sex is a frivolous topic.

Due to the stigma around discussing sex, many patients suffer in silence. I've encountered patients in the US who are opening up about their issues for the first time. By not addressing sexual health openly, we fail to prioritise it in healthcare.

Because of this silence, many believe they are alone in their struggles. For example, while 20 percent of women in the US experience sexual dysfunction, only 2-3 percent seek help.

Furthermore, without open discussions about sex and pleasure, people lack an understanding of normal sexual physiology. Many don’t know what their genitals should look like or what's normal, leading to confusion and suffering in silence due to the absence of proper sex education.

How does the widespread consumption of pornography impact our understanding of healthy sexual relationships?

The main source of information about sex for many people is pornography, which presents a harmful and unrealistic view of how sex works. It downplays the importance of communication, intimacy, and foreplay and often portrays sex as a violent act rather than a mutual and intimate experience where communication and connection are key.

With so many barriers to discussing sex, understanding sexual health is as crucial as any other aspect of health. Relying on porn for information leads to incomplete and misleading ideas about what a healthy sexual relationship and anatomy should be like.

How do you encourage people to embrace their sexuality and pleasure without shame in a conservative culture?

Sexual pleasure is a right for people of all genders. The way one achieves sexual pleasure can be so diverse that it does not have to be with a partner. It can be through self-exploration of your body; it can be through exploring different kinds of touch that you enjoy or using different kinds of sex toys.

It can also be by consuming knowledge through areas which give you a more real understanding of how sex, pleasure and intimacy work rather than just consuming pornographic content.

As a physiotherapist, I would encourage people to know that sexual health and the attainment of sexual pleasure is a right, and everybody is free to explore such pleasure in whatever way suits them.

Exploring and recognising what forms of touch and pleasure one enjoys is important, whether with or without a partner.

What message would you give to those afraid to seek help for sexual health due to societal pressures or myths?

People worldwide are struggling with painful sex, but it's important to remember that there is hope and healing. There are reasons behind this pain, and no one should have to suffer in silence.

Seeking out doctors knowledgeable in treating sexual dysfunctions could be a step toward recovery. I also recommend joining grassroots forums like Reddit, where you can connect with others facing similar issues. These platforms offer a space to discuss your problems, find support, and access helpful resources.

If you feel comfortable, start discussing these issues with your partner and friends. Treatment options are available, and open communication is key.

⁠What are some overlooked aspects of sexual health that you believe deserve more attention in public discourse, especially within the context of pleasure?

Clinical issues like difficulty with orgasm, reduced sex drive, and persistent genital arousal are often overlooked but can significantly impact well-being. Pain during penetrative sex, especially in the vulvar and vaginal areas, is common among breastfeeding and post-menopausal women and needs more attention. Clitoral pain and sensitivity, as well as recurrent infections after sex, are also critical yet frequently ignored concerns. These conditions can hinder sexual intimacy and enjoyment but are rarely addressed in broader sexual health discussions.