A Sex-Positive Approach to Gynecology in Japan

Written by Elif Erdogan

Translated by Sachi Kikuchi

In Sakie Ladies Clinic in Nagoya, Doctor Sakie Niwa and Shiori Nagashima approach gynecology in a sex-positive way. Voice Up Japan met them to talk about inclusion in practices and to understand issues that surround gynecology, not only limited to health but also related to many other factors such as the low representation of female politicians in the Diet.

Sexual health can be a vulnerable topic to talk with a health professional. And, if the right environment is not sustained by the professional then the patient might avoid mentioning their true worries and eventually won’t be able to seek the treatment that they need. Therefore, some places started to introduce “sex-positivity” to challenge the “sex-negative” culture in their health care systems. A document that Doctor David Tovey and relationship consultant Tanja Jarvik published for the annual NPO education conference says that sex-positive healthcare acknowledges that sexuality is an important part of the general health and well-being; sexuality is various, and everyone has different practices and ways of experiencing sex; everybody has the right to access thorough health education and professionals who are not judgmental. In Nagoya Ikeshita-cho, Doctor Niwa from the Sakie Ladies Clinic is one of the gynecologists that is here to break the sex-negative culture.

Patients are coming from different prefectures just to visit Sakie Ladies Clinic

“Most of the patients who are coming from outside of Aichi are coming because of painful intercourses. Meaning, conditions that the individuals can’t have sex because of painful penetration or being afraid of having sex,” says Doctor Niwa. This emphasizes the issue in Japan that patients are still not feeling comfortable to talk about their medical issues to the nearest doctor they have. “I started this clinic to make sure that we can listen to the patient without rushing and listen to their worries clearly,” states Doctor Niwa. “It is still difficult for patients to consult about sex in Japanese society and many of the patients are coming to our clinic with worries.” were the words of Doctor Sakie. The fact that sex is still being stigmatized and still considered to be taboo in Japanese society makes it difficult for patients to put their worries into words and receive the health care they deserve. “When the patients are coming here for their visitations, we usually initiate to talk through their worries regarding sex. We try to make an environment that is easy for patients to talk to. On our clinic’s home page, we also have a page as “In Future Sex is Not Going to Be Painful” to give a positive attitude.” explains Doctor Niwa. These are some of the initiatives that Doctor Niwa takes in order to create a sex-positive environment in their gynecology clinic.

What is a Sex-Negative Culture? 

Under a sex-negative culture, it would be discouraged having sex in order to avoid painful intercourse or any unwanted condition that may occur from having sex. Sex-negativity and sex-positivity are terms that are coined by Wilhelm Reich around the 1920s but these terms are recently being taken seriously to really bring a critique to the society that we live in. Sex-negative culture basically refers to our society that attaches the stigma that sex is bad, dangerous, should be avoided. It also encourages sex only under heteronormative married couples, which excludes LGBTQIA+ individuals. However, Doctors like Dr. Niwa challenges this culture with sex-positivity, by encouraging destigmatization of sex and following inclusive policies towards queer individuals.

Figure 1 Doctor Sakie Niwa from Sakie Ladies Clinic in Nagoya. She opened Sakie Ladies Clinic in 2002. Along with running a clinic, she also goes to middle and high schools, and universities to teach sex education.

“Before I started practicing gynecology, which is 20 years ago, gynecology clinics would be built behind the roads and the entrance would be somewhere difficult to find. It sounds like love hotels now. It felt like if people understand that (it is a gynecology clinic) they would feel disgusted. Now they are located near stations or places that are easy to understand.” says Doctor Niwa. Not long ago, gynecology clinics in Japan were treated as something that should be “hidden”.  

LGBT, Sex Positivity and Gynecology

“We also try not to force gender norms and norms surrounding sex. To show that we have understood that there are various sexualities and genders we promote NPO Proud Life and we have an LGBT Consultation,” says Doctor Niwa. In the Sakie Ladies Clinic, Nagashima is responsible to take care of the consultations regarding LGBT related consultations. “I am a private secretary, and I am responsible for the LGBT consultation desk. Also, I am the staff of NPO Proud Life and a research student at Ritsumeikan University’s Graduate School of Core Ethics and Frontier Sciences researching sexuality,” says Nagashima. Since sexual minorities are having a much harder time expressing their sexuality in society out and free, they are more vulnerable in a sex- negative society when they want to reach out for health care. 

“Nowadays, it is more common to hear about LGBT related topics, but patients whose sexuality is other than gay, may not know the sexual problems they might have, and this makes it difficult for them to go to a gynecologist.” says Doctor Niwa. We should acknowledge the fact that the sex-negative culture may make it more difficult for LGBT people to go to gynecologists. “(In Nagoya) for transgender people, there are places that you can get hormone treatment and surgeries, but most of the health facilities want to be somewhat hidden. There aren’t many places that show rainbow flags or other signifiers that they have an understanding or open acceptance of LGBT.” says Nagashima. “Most of the hospitals are focused on hormone treatments or surgeries, that is why it is difficult for people to go through a transition to have a consultation,” states Nagashima. By that, although there are places that serve LGBT people, they want to stay hidden or they don’t put efforts for the consultation part.

Stigma against Gynecology in Japan

According to LunaLuna and Think Pearl’s collaborative opinion survey shows that only 40% of the respondents feel comfortable with their gynecologist and a survey that was done by #nandenaino project on “COVID-19 and morning-after pill” showed that 30% of the respondents were discouraged to go to a gynecologist to get morning-after pills.

Figure 2 LunaLuna and Think Pearl’s survey regarding gynecology in Japan. https://prtimes.jp/main/html/rd/p/000000499.000002943.html It shows that 39.9% of the respondents think that the medical institution they have been for examination felt “personal”. 34.6% answered no and 25.6% answered “not sure”
Figure 3 #nandenaino project’s “COVID-19 &the anxiety about unintended pregnancies/emergency contraceptives in Japan” survey. It shows the reasons why people decided not to get emergency contraception pills. 31.6% responded that because they have a resistance to go see a gynecologist. 55.3% responded because it is expensive and 36.8% responded as they worried that they might get infected by COVID19.

“It seems like there are still many people who cannot go to a gynecologist. From this, we can say that in Japanese society there is still oppression against sex, and it is not thought that women can have sexual desires,” explains Doctor Niwa answering why she thinks that people have a stigma against going to a gynecologist in Japan. “In Japan, there are many places that close a curtain from the waist down, but there are many countries that do not do that. They don’t close down the curtain because they view it as the same as the physician and they continue the visitation as they discuss. (In Japan), there is also the view that genitalia is not a part of the body. There is also a negative view of physical examination as if it is a scary or a painful thing.” states Doctor Niwa. Sex-negative culture prevails not only in thoughts but also in practices and this is an example of how one of the most common practice by gynecologists in Japan happens to be “sex-negative”. 

Figure 4 Image of a gynecology and obstetrics clinic’s chair and curtain for pelvic examination in Japan

“Yes, there is a stigma against gynecologists in Japan,” responds Doctor Niwa when she is asked if she thinks there is a stigma against gynecologists in Japan. “From long ago it is thought that gynecology and obstetrics are thought to be a place either to birth or if you have a sexual disease. Having STDs also meant that you have an active sex life and gynecology, and obstetrics were thought to be a place for that,” Doctor Niwa further explains why gynecologists are stigmatized.  

Why Are People Not Voicing Up?

“Japan’s approach to sex is a bit absurd. Although it is absurd, I don’t understand why people are not voicing up,” were the words of Doctor Niwa. “When you ask why there aren’t many people voicing up, it is because there are not many female politicians in Japan. The female politicians are either chosen by other male politicians or female politicians have to act like ‘male’ politicians to be accepted. It might be also because politicians don’t really think about the problems surrounding sex or they don’t really think of sex as a serious problem” explains Doctor Niwa. As Japan, including its politicians, becomes a more sexless society, it gets harder to address the issues surrounding sex.

If you would like to know more about Sakie Ladies Clinic please visit here.