Episode 29: What is sexual health?

Dr. Sophia:
Welcome to the Dr. Sophia ObGyn podcast. I'm an obgyn practicing for over 15 years in my native New York City, and I love to help women learn about their bodies, empower them, and embrace themselves. On this podcast, we talk openly and with heart about all things affecting women from pregnancy, menopause, periods, sexual health, fertility, and so much more.Disclaimer: This is general medical information based on my professional opinion and experience. For specific medical advice, please refer to your physician.

Hello everyone, and welcome to the Dr. Sophia ObGyn podcast. Today I want us to talk about something that, for some, may feel a little bit more juicy, but to me is just a part of our wellbeing and health, sexual health. As always, I am joined by my friend and co-host Touseef Mirza, and we're just gonna go on a journey of a conversation that we started having earlier today, and we just looped you all in.

Touseef Mirza:
Exactly. So, hi everyone. As you might have noticed in the intro of the Dr. Sophia ObGyn podcast, she mentions a lot of different things that we cover in this podcast, including sexual health. And when you think about sexual health, obviously, the word sexual is in there, so it's associated with sex. But I was telling Sophia, I think it's not very commonly understood what actually encompasses sexual health, because there are so many different aspects that we can talk about when it comes to sex and in terms of health.

So let's start with the foundational element, which is, from your perspective, what would you say is sexual health?

Dr. Sophia:
So when I think about sexual health, I think about it in a number of different ways. Starting off with, if you're even someone who is sexually active, and if you are sexually active, what does that mean in terms of your desires sexually? And if you are healthy in that sexual activity, meaning prevention of STIs, sexually transmitted infections, or STDs, we kind of use those terms interchangeably. And also are your reproductive needs being met through that sexual activity, and are your emotional and spiritual needs kind of being met? Like, where are you in that journey around what sex is for you?

Touseef Mirza:
So it's a pretty broad aspect of sexual health. It's not just about the prevention of disease. If we think about it from a medical standpoint, for example.

Dr. Sophia:
It's definitely more than just the prevention of disease because there's so much more to the concept of sexual health. When I ask a patient, are you sexually active? They may say yes, they may say no, and there's so many more questions that can go on behind that. So that's why it's important actually, to even ask the question.

Touseef Mirza:
All right, so let's start there. When you ask that question, do you ask that to everybody or in what situation would you ask that question?

Dr. Sophia:
I ask every patient, are they sexually active? And then that then leads me to multiple different questions. Let's talk about someone who's in their twenties. I ask, are they sexually active? For a number of reasons, top of their minds typically, and mine, because I wanna make sure that I'm helping them with any decision making that they need to make around their sexual activity. Let's say regarding contraception or reproductive health. Do they want to get pregnant or are they trying to prevent pregnancy?

Touseef Mirza:
So you're coming at it from a proactive lens of asking these questions.

Dr. Sophia:
Definitely from a proactive lens, but also more basic than that. If you are sexually active, are you happy that you're sexually active?

Touseef Mirza:
That's a big question.

Dr. Sophia:
Are you sexually active because you want to be sexually active? Sometimes people become sexually active for multiple different reasons. And so I wanna make sure that in young women, especially in this day and age, they're not being forced. They have experienced pleasure in sex, that they are practicing safe sex, the prevention of disease, and that they are actually understanding the changes in their feelings and the things that are happening in their bodies, and that they feel comfortable with their own bodies in terms of the expression of sex. Even if that means what it is for themselves.

Touseef Mirza:
Which could be oral sex,

Dr. Sophia:
It could be it, it has nothing to do with gender types or gender roles. It could mean in all different types of sex, whether that is exactly oral sex, you know, vaginal sex, anal sex, you know, sex starts even just from touching at times. And so we have to remember that.

Touseef Mirza:
So it all depends on our own definition of what intimacy is for each one of us.

Dr. Sophia:
Right, exactly. Intimacy is a much broader term, if we think about it that way. But my goal is to help women through a process of feeling very comfortable with themselves and their sexual selves.

Touseef Mirza:
So when someone comes to see you and you ask the question, what's the question?

Dr. Sophia:
Are you currently sexually active?

Touseef Mirza:
Okay. So they might say yes or no. So if they say yes, then what is the next step in the different questions that you asked to understand their sexual health?

Dr. Sophia:
Are you having regular sex? Are you happy with your current sexual relationship? Do you feel like it's pleasurable? Are you concerned about pregnancy? Would you like to be pregnant? Have you ever had an STD? Do you have any concerns about STDs today? Would you like to be tested?

Touseef Mirza:
So those are a lot of questions that can go in a lot of different directions.

Dr. Sophia:
Yeah, for sure. For sure. And I would say on average, most people say, no, I have, I'm fine. I feel great. And then if they are very confident in the way that they respond, I do still prompt them to further discuss and make sure that they've thought about some of these other aspects. But it doesn't have to be a big, long, drawn-out situation.

Touseef Mirza:
So if somebody says, like you say, most people say, Oh, I'm okay, I'm fine. Do you think that it's because a lot of them feel uncomfortable talking about that? Or do you really feel that they're doing okay?

Dr. Sophia:
Honestly, it depends on the patient. I mean, I think the way that someone responds, you know, you look at all different kinds of cues, not just their verbal response, but also their body language. And I also try to reassure patients that this is an important part of your life. And so if you are not able to address it with me, I hope you do have some close person that you are able to talk about your sex life with, and the concept of having good sexual health.

But I wanna try to get people away from either bad information or just feeling embarrassed, ashamed, and all the other different connotations that may be around sex. And especially when it comes to women, I think sex has become such an automatic, women are just supposed to kind of like,

Touseef Mirza:
They go along with it.

Dr. Sophia:
I think in this society, especially one that's very patriarchal, women get mixed signals about what sex is supposed to be for them. Oftentimes, sex may be something that they only think about for their partners

Touseef Mirza:
To give pleasure to their partners.

Dr. Sophia:
Exactly. That somehow validates them as women and as you know, sexual beings. And I want them to feel validated as sexual beings for themselves. And that starts with just the concept of understanding your body and the feelings that your body will go through, and the physical aspects that your body goes through, even during a sexual experience. And sometimes it's just answering questions.

Touseef Mirza:
Just to open it up.

Dr. Sophia:
It's just an opportunity to open up the conversation, because sometimes people have questions and they're either going to TikTok, or perhaps some of their friends, and then they're gonna get misinformation at times. So I like being able to be a trusted source for information. And sometimes even if we don't have to exchange information, but just comfort

And being listened to, or sometimes I don't have to say anything other than, you know, how are you feeling? Are you okay? Is this something you'd like to talk about? Do you have a question? And granted, some people don't wanna talk about it. Right. And that's okay too. But I like to remind patients that your sexual health is an important part of health too. And I'm here to address any concerns that they may have.

Touseef Mirza:
So for example, if they say they're having sex, and then, and then you ask them, is it pleasurable? Or are you satisfied with your sexual life? And they say, not really. I mean, does that happen often? Do people keep that?

Dr. Sophia:
It actually happens more often than you think. Okay. And it is something that people keep to themselves, oftentimes. Because they think that it's not something that they can actually address. And sometimes it's as simple as discussing or describing, well, what is the thing that may be causing it to be uncomfortable, or making it not pleasurable. Or for many women, they don't even know what orgasm actually is. And so just having that conversation alone, you know, sometimes it's like an aha moment. The number of times that I've had patients say to me, wow, no one's ever even asked me.

Whether or not they are having sex and if their sex is even pleasurable. And so there's a lot to unpack sometimes. And sometimes it's as simple as maybe they need a little lubricant. Sometimes it's as easy as discovering that they may have an actual reason why sex is painful. They may have a fibroid or, you know, some other thing that we can actually really intervene and change the scope of what's happening.

Touseef Mirza:
Or that they haven't completely explored their own body themselves to understand what makes them tick.

Dr. Sophia:
There's also that aspect, right, of the full, you know, real exploration and understanding of their body to understand what even brings them pleasure. And just having an open, honest conversation about that then gets them thinking, you know, for so many young women, they think that perhaps like them, their partner is supposed to touch a button and turn them on, and it doesn't work that way.

Touseef Mirza:
So, you know, as you're talking and you're saying, you know, you asked the question of, is this pleasurable? I think that some women might be taught to just do it for the sake of the act, and that is enough.

Dr. Sophia:
And that is enough. I have to also take into account all the very different, you know, cultural aspects in terms of, you know, where we are, not just as a society in general, but all the different cultural influences when we talk about women's sexual health. You know, again, when I think about it here for in the state of like men, we think about men and we think about, oh, they've gotta be having like a great time to the point where we have so many different available options for men when it comes to, let's say, erectile dysfunction. You know, and we just don't have that great of an armamentarium when it comes to women's sexual health and how to address different aspects.

Touseef Mirza:
Like lubricants, for example.

Dr. Sophia:
Whether it's lubricants, whether it's, you know, actual medications to help with either libido or actual sexual response, and things like that. I mean, I think people are starting to pay a lot more attention to women, but we are so far from where we could be. And it's a part of the reason why I like to open up the conversation, at least for the individual. For them to think about, yeah, that's true. Am I getting everything I can from my sexual experience? And remember, I see women through many different transitions in their life, right? So I see women, young women, I see women when they're pregnant and they ask the question, can they even have sex while they're pregnant?

So it's a question that I ask everybody. Sometimes the women are actually, let's take pregnant women, for example. They actually wanna have sex, and their partners are the ones who don't wanna have sex with them. You know, it's a funny place for some women because since they're pregnant, they're not worried about getting pregnant again. You know what I mean? Like, that is, that's done. That's done, that's off the table. Right. And so, because they don't have that worry, some women actually have more desire, increased desire, aside from the fact that there are all these like fluctuations in their hormones.

That may be causing them to have an increase in their desire. And they come and they say, well, my husband doesn't want to touch me because they're afraid they're gonna hurt something. Or I'm going to, you know, like, break something, break something. And yes, of course there are certain conditions that are considered high risk situations in terms of pregnancy, where perhaps sex is not advisable. But for the most part, women can have sex during pregnancy. And it really is up to them how they're feeling, how their body is responding.

But it's a conversation, and a lot of times we just don't have it. And so if we don't ask the question, then we would never know that that's perhaps a point of contention in that relationship. That is something that we can address by answering sometimes some very simple questions. And of course, I also see women during another point of transition, let's say perimenopause and menopause. And that's a big one, because there are changes that are happening, physical changes that are actually happening that will cause a woman to have so many different responses to their sexuality and their sexual health. One, maybe they do wanna get pregnant and they're having difficulty. Two, maybe they're experiencing for the first time something called vaginal dryness.

Maybe they're experiencing a decrease in libido, and they're in a new relationship where they have a partner. The amount of times that I will ask menopausal women, for example, you know, are you still sexually active? And they'll say, yes, they're sexually active, but, or they'll say their answer is, oh, I have a husband. And I say, well, I didn't ask if you had a husband, I asked you if you're sexually active. And moreover, is that activity what you want it to be? Sometimes I feel like it's a little dismissive, like, why are you even asking me? I don't wanna talk about this. But I also recognize it to mean I am doing my duty. And so for me, again, the goal here is to help them see that sex shouldn't be a dutiful concept. It should be pleasurable, and two people come together for shared intimacy.

Touseef Mirza:
So when they say that I'm married, how do you respond? Or are you able to connect with them for further, you know, understanding?

Dr. Sophia:
So I say to them, "Okay, that's great. I'm so glad you have a partner. Because also the other part of the question may be, I'm not sexually active and it's because I don't have a partner. But if they have a partner, I say, okay, that's wonderful. I'm so glad that you have a partner and you guys are able to share some intimacy. Is it what it used to be? Is it pleasurable? Do you experience any dryness? Is there anything I can address for you? Do you still have a desire?

Touseef Mirza:
So you're not just asking why you're actually providing all these potential reasons. So it's easier for them to respond right? People don't talk about sex, you know.

Dr. Sophia:
Don't even talk about it in their own relationships.

Touseef Mirza:
Exactly. Or with their girlfriends, like, yes. You know, like you and I talk about it, but some, like even other areas in the us.

Dr. Sophia:
Right. And I also try my best to be as culturally sensitive as possible. I also like to ask, do you wanna, is this something you'd like to have to address? Is there something I can help you with? But I have leading questions. Let me remind you that this is a healthy part of your life, and I want it to stay healthy. This is a part of your well-being. I remind them of those types of things, and I ask, you know, I don't want it to be something that's painful for you. Maybe there's a way that we can help. I don't want it to feel like it's a duty. Maybe there's a way we can bring back the joy.

Touseef Mirza:
So see, I think there's like a couple of things there. Like, there's one which is pleasure, and there's another one which is pain, right? Yes. So let's start first, if you have pain, of course, you're not gonna enjoy yourself.

Dr. Sophia:
Yeah, absolutely. That's number one. That's number one. But so many women have unfortunately painful sex because they are in positions where they feel like they have to be quote unquote dutiful. And they also may not understand what's happening in their bodies, perimenopause and menopause. And that's only one aspect, right? We're not even, I'm not even diving into potential just relationship issues in general, right? If you're not in the mood for sex, it's very hard for your body to respond to sex. If a woman says, I ask, are you having relationship issues? Do you find that you're having trust issues and things like that? Maybe you guys wanna see a couple's therapist. Like, and if you sometimes don't even bring those things up, that's not even a thought in their minds that, Hey, I can address this issue. I am not trying to solve everybody's problems. But at least help them with it.

Touseef Mirza:
And give them potential solutions that there are solutions that you don't have to just suffer.

Dr. Sophia:
Right. We certainly don't have to suffer. And certainly I think everybody would like to have a better sex life. So if we're not talking about it, then we're never gonna get there. And if you're having a great sex life, then I am the first person to pat you on the back and say, this is fantastic. We can still have a conversation. And even with those couples or people who are having great sexual relationships to maintain it, to make sure that we're doing all the preventative things, making sure that they have their sexually transmitted infection exams or lab work done once a year. The bottom line is that there's so many different aspects to this. And the reality is, if we don't ask, then we will never get the opportunity to help. And that's only if you need help.

At the end of the day, it is a way to relieve stress. It is a way to feel connected with another human being. And all of those things help in longevity. You know, it just helps you to literally be healthier. And so to encourage that is something that's just important to me. Reproductive health, understanding sex is the role in terms of whether you want to be pregnant or don't want to be pregnant. And how we manage that for so many women, they end up feeling trapped by only one way of having, you know, contraception. They're like, oh, I, there's only the pill. Just even just opening up that conversation can stem from, Hey, are you sexually active?

Touseef Mirza:
You're kind of like opening Pandora's box in different ways of poking it. And then all these different types of information can come through, and then you can address it.

Dr. Sophia:
Yes. And the bottom line is making sure that women understand that this is a part of their health that should be addressed. This is not taboo. It's not something to be ashamed to talk about. We should feel excited and happy to talk about where we are, whether that's we're thinking about having sex for the first time, we're having great sex, we're having sex, or it's not that great. I want to, I don't want to, and all the things in between.

Touseef Mirza:
It would be wonderful to be excited and happy to talk about it. Unfortunately, it is taboo. Yes. For so many reasons, in terms of what we see in society. And so I think even to start from a perspective of leaning into the uncomfortable, but looking at it as part of your health, like if you go see the optometrist because of your eyes, you go see the dentist because of your teeth, you go see the OB GYN because of your

Dr. Sophia:
Reproductive organs, and that includes your sexual organs.

Touseef Mirza:
Exactly. And unfortunately it's taboo. But that being said, we need to just look at it as another aspect of our health.

Dr. Sophia:
It's a serious aspect of our health. We need to de-stigmatize it. We need to, like you said, have fun with it a little bit. I think even as a society, we were a little bit more playful or joyful surrounding the concept of intimacy and the understanding that intimate relationships that are good relationships add to longevity and the concept of health. So, for me, I go back to that as a baseline.

Touseef Mirza:
So we talked a lot about, like, when you are having sex, so let's say that you ask a person how is their sex life? And they say, well, I don't have any, are there any other prompts or any other questions that you ask? If somebody's providing you with that info,

Dr. Sophia:
If they're not having sex, that's totally fine. But I just ask, is it because you don't have a partner? Are you not having sex because you don't want to? Are you not having sex because it's painful? Are you not having sex for religious reasons? Are you not having sex? You know, like there's so many different reasons why someone does not have sex, and that's okay. You're not having sex because you're afraid you'll get pregnant. I get that a lot. And then I say, okay, well then let's talk about ways that if you want to have sex and you don't wanna get pregnant, well let's talk about how you can accomplish both those things. And I mean, oftentimes it really can be as simple as, well, I don't, I just don't have a partner right now. And then I say, okay, well, are you at least able to pleasure yourself?

And are you at least comfortable with your own body? And I talk openly with women about the concept of understanding their bodies, their body, having a sense of pleasure, and the concept of masturbation. And I get that, again, being culturally sensitive and the taboos around that. But like we said earlier, if you're not able to understand what kind of makes you tick, what are your own pleasure sensors, then it's hard for you to direct someone else. And it's hard for you to get to the point where you find, you know, for those women who maybe have never had an orgasm, then I say, okay, well have you ever had one on your own? Meaning, have you ever gotten to the point where you are able to please yourself to the point of orgasm? So that way you can now perhaps direct and help have a more robust conversation with your partner.

Touseef Mirza:
And also it's fun.

Dr. Sophia:
And then there's that part.

Touseef Mirza:
I keep saying the fun and playful part.

Dr. Sophia:
So many women, unfortunately are just so, they don't even know what they necessarily even look like. So baby steps, sometimes I have to take. With my patients. And we start even just by, do you know all the different parts of your vulva? Do you know what feels like, this kind of pressure? That kind of pressure? Have you ever just maybe put the shower head there? I mean, there are so many different things. And yes, definitely more than I can probably do in a 15 or 20-minute exam.

Touseef Mirza:
I think one thing that's gonna just be thought about this on Netflix, I think there's two different, like series, the principles of pleasure. And then there's another one, Gwyneth Paltrow's Goop lab that looks into sexual pleasure. And I think if some people are shy, that's a good way to start looking. Like, you know, maybe you don't want, you know, you don't wanna maybe go all completely on the other end and look at pornography or anything like that. But if you wanna just start to have, I think we just don't even have the verbiage to talk about this, you know, to really understand how to even talk about it in a way that it doesn't feel embarrassing to me. So if you see other people talking about it, it becomes a little bit easier to understand, oh, okay, so this is how it is and this is so I'm not alone feeling this way. You know, to be exposed to that a little bit.

Dr. Sophia:
I fully agree with you. And it doesn't mean that you have to go to things like pornography. There are other ways to get this kind of information. There's an app, I believe I wanna say it's called Oh My God. And in that application, it really dives into the body and the pleasure sites of the body and the concept of masturbation and the concept of pleasure during sex without it being pornographic at all. And it's really just an educational tool. And so I think taking away the concept of shame and embarrassment and opening up the conversation to, oh, this is something that I can feel and be comfortable feeling, and I'm coming at it from a place of curiosity, you know?

Dr. Sophia:
About yourself, and what feels good to you will help your partner know how to make you feel good. And then vice versa, opening up. If you are able to open up that conversation with yourself, then you can further open up that conversation with your partner

Touseef Mirza:
Or not. You just do it because you are having a good old time with yourself.

Dr. Sophia:
It's more than just having a good old time. It's a matter of intimacy. Yeah.

Touseef Mirza:
Knowing your body.

Dr. Sophia:
And it's a matter of knowing your body. So for me, I like being able to open up the conversation and no matter which direction it goes, I am happy to facilitate a more open conversation than I think we're having in general. I'm not sure how many of my colleagues or other medical professionals really have an opportunity to open up that Pandora's box, so to speak.

Touseef Mirza:
So if a person that's listening has an obgyn, but they don't talk about these things and they're not being inquisitive about these areas, how could someone like to bring that to the conversation?

Dr. Sophia:
I think this is where being as the we become more comfortable with ourselves, the more empowered we may feel to ask these questions at a visit. And for example, for so many women I know right now who are going through, let's say the perimenopause and menopause, it's hard to have a conversation about my libido is on the floor. It's hard to have that conversation that I feel like my vagina is a little bit dry, or I don't get, as, you know, quite unquote wet when I'm with my partner. And it's starting to make me feel uncomfortable. It's starting to make me feel self-conscious. The amount of times that I've had women literally walk into my office and say to me, Dr. Lubin, do I have a broken vagina?

Touseef Mirza:
'Cause they think something's wrong with them.

Dr. Sophia:
'Cause they really think something is really wrong.

Touseef Mirza:
That's so sad.

Dr. Sophia:
If a woman has that level of self-awareness and then the feeling that she can advocate for herself, I have a doctor's appointment today. I know I'm going in for my pap. Or when you go in, I know I'm here for my pap, but can I ask you a few questions? These are some of the things that I'm experiencing with my partner, or these are some of the ways that I'm feeling right now. You think that's something related to menopause, perimenopause, or a woman who's just had a baby who's also maybe breastfeeding and having decreased desire, or her baby's now like three or four months and her husband's looking at her like, hello, who wants to still feel that sense of intimacy with her partner, but her body is not responding. And so these are all very legitimate. And again, that's the other thing. I don't think we validate the way women feel

Touseef Mirza:
That's so important.

Dr. Sophia:
And really legitimize the thing that they're going through. I really think that that's super important, that yes, you are really going through something. This part of you really does need to be addressed. So if I can do anything in this particular podcast episode, it's to remind women that this is a legitimate part of your health, your sexual health is a legitimate concern and an aspect that you should feel fully comfortable in,

Touseef Mirza:
And that you have the right to get the information and the care. So if there's somebody that goes and sees their obgyn and, and, you know, opens up from that perspective. Because I'll be honest, well, now you're my obgyn, so, you know, now it's fabulous, but before, it's almost like when I used to go see an obgyn it was almost technical. Like, you know, the person would come and then, okay, is everything all right? Okay, great. We'll do the pap smear and blah, blah, blah, blah.

Dr. Sophia:
And then you're out the door and-

Touseef Mirza:
Then I'm out. So, in my mind, I never even thought that that would've been a conversation, really.

Dr. Sophia:
To have.

Touseef Mirza:
To have, just even to check in. I mean, regardless of whether, you know, something's wrong. That was never part of the way I thought that a relationship would be with an obgyn. So this is why when you said sexual health, I said, okay, what does that mean? Because based on my experience, it means something different than what you are offering in terms of how you approach your patient.

Dr. Sophia:
Again, like I said, it's just more than just whether or not you get an STD check today. Right. It's way more than that. And I think this is definitely where our healthcare system may be kind of failing us in a way, because we just don't have an opportunity to build that kind of doctor patient relationship where we do have an opportunity to kind of have more conversation in a setting where we feel more comfortable because we've gotten to know each other. If I have a patient that I'm seeing year after year, then maybe it's a question or a conversation that we don't have so robustly the first time we meet, but certainly by, probably by year two, three, you know. Or one or two babies in, we are able to really talk, kind of almost like girlfriends. You know, I wanna be able to really be helpful.

Touseef Mirza:
The other part, as we were talking about all this, is some of the aspects that we talked about almost feel to me that they were more intended for a sex therapist versus talking to an obgyn. So I think also, like in my mind, separate those two, you know, no, this is not, this is not in this environment. This is not for her, this is for the other person.

Dr. Sophia:
And I am not taking a single thing away from a sex therapist. I just think that how do you even know how to get there? You know, if you don't even understand if there is a sexual problem that may require a sexual therapist, you know, you just, if we don't even have a conversation, how do we even know how to get there? And by far, I think sex therapy is very underutilized here in this country and, and probably around the world, quite frankly.

And they're hard to find, and they're, they may be expensive because they're not likely covered by your insurance, and, and it's something you have to pay out of pocket. I definitely think there's a huge, huge role for sex therapy and sex therapists, but sometimes it's just not accessible. And even if it is accessible, you don't know you need it. And maybe starting the conversation with something as simple as, are you able to enjoy sex as you're having it now? Maybe the question that turns on the light bulb, huh? This is something I need to address.

Touseef Mirza:
So I think for me, the main thing out of this is just being okay to lean into the uncomfortable.

Dr. Sophia:
And discomfort. Yeah, sure. Yeah.

Touseef Mirza:
Just think of it as another part of your body.

Dr. Sophia:
It's another part of your body that we should, and another part, another aspect of being healthy. We should explore and make sure we remain healthy. I think the first step is, again, as always here on the Dr. Sophia Obgyn podcast, is to embrace your body. Embrace your body, know your body, know your body's needs, know how you feel, explore love on your body, love on your body, love on yourself. Embrace your body, embrace yourself, because that is going to help you to lead a healthier life. I hope you've enjoyed this particular episode of the Dr. Sophia ObGyn podcast. Thank you so much for listening. Bye-bye.

This is General medical information based on my professional opinion and experience. For specific medical advice, please refer to your physician. Until next time, embrace your body. Embrace yourself.