Sexual Health for the Millennium
A Declaration and Technical Document
© Sexual Health for the Millennium. A Declaration and Technical Document. is a publication of
the World Association for Sexual Health produced with the financial support of the
Ford Foundation. Please quote this document as:
World Association for Sexual Health. (2008). Sexual Health for the Millennium. A
Declaration and Technical Document. Minneapolis, MN, USA: World Association for
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The Millennium Development Goals (MDGs) are designed to resolve some of
the most complicated and urgent social problems of our time and foster
human development in the new millennium. This declaration and technical
document assert that promoting sexual health must play a key role in achieving the
MDGs. The promotion of sexual health is central to the attainment of wellness and
well-being and the achievement of sustainable development and more specifically to
the implementation of the MDGs. Individuals and communities who experience
sexual well-being are better positioned to contribute to the eradication of individual
and societal poverty. By nurturing individual and social responsibility and equitable
social interactions, promotion of sexual health fosters quality of life and the realization
This document specifies and elaborates on eight distinct but inter-related aspects of
sexual health that play important roles in fostering human development. To
meaningfully and effectively contribute to the achievement of the MDGs, sexual health
promotion programs must address the totality of human sexuality. For example, to
effectively promote HIV sexual risk reduction, sexual health promotion programs
must reflect and incorporate the reality that sexual relationships include gender and
power dynamics and that the desire for intimacy and pleasure plays an instrumental
role in shaping sexual behavior. In addition, all governments, international agencies,
private sector, academic institutions and society at large, sexual health organizations
must develop an intersectoral approach which promotes sexual health as a distinct and
essential strategy in attaining the MDGs.
Sexual Health for the Millennium conceptualizes sexual health as multi-dimensional
and specifically identifies and examines eight specific goals that together encompass an
integrated and comprehensive approach to sexual health promotion. Finally, this
technical document describes specific necessary actions that are particular to each of
the eight goals of the declaration.
Sexual rights are an integral component of basic human rights and therefore are
inalienable and universal. Sexual health is an integral component of the right to the
enjoyment of the highest attainable standard of health. Sexual health cannot be
obtained or maintained without sexual rights for all.
1.1 To effectively advocate for and promote sexual health, it is important that sexual
rights are located within existing human rights contexts. Government and international
organizations and agencies should be encouraged to endorse the sexual rights agenda
through recognizing, promoting, respecting, ensuring, and protecting human rights and
fundamental freedoms essential to sexual health. This approach would serve to locate
sexual rights within existing treaties and conventions so that sexual rights are included
in the monitoring and enforcement mechanisms of these agreements.
1.2 The promotion of sexual rights requires participatory action and dialogic projects
that bring together different cultural, religious, and social perspectives to the issue of
1.3 A system for monitoring and evaluating advances in sexual rights should be
established. This system should include the study and evaluation of the implications of
changes in policy and law related to sexual rights for long-term outcomes in health and
quality of life.
Sexual health requires gender equality, equity and respect. Gender-related inequities
and imbalances of power deter constructive and harmonic human interactions and
therefore the attainment of sexual health.
2.1 The discourse of rights as it has been applied to the right of girls and women to
equality and sexuality education and services in international agreements and covenants
must explicitly include the fundamental right to autonomy and equality within sexual
2.2 Policy makers and public opinion leaders must speak openly of the fact that a
substantial and important component of gender inequality is directly related to power
imbalances in sexual relationships.
2.3 Fathers and mothers and families and communities play key roles in contributing to
the formation of the gender roles of children. They should be encouraged and assisted
in helping their children to develop gender equitable roles. Fathers, in particular, can be
instrumental in encouraging their sons to embody gender equitable conceptions of
2.4 To effectively reach their stated objectives sexuality education programs,
particularly those aimed at youth, must address the gender-based dynamics within
sexual relationships and assist students in developing and implementing gender
2.5 Media portrayals, whether it is through music or visual representation, frequently
model in subtle and blatant forms, sexual scripts for young people. The modeling of
gender equitable sexual scripts in popular media has the potential to make a powerful
contribution to societal-wide gender equality. The entertainment industry should,
therefore, be strongly encouraged by governments and the public at large to become a
force for positive change with regard to sexuality and gender.
2.6 Laws and policies should be implemented to ensure that women and men have
equal access to sexual health care services that are provided without stigma,
discrimination or bias. These services must be available to all women and men
regardless of their ability to pay for them.
Sexual health cannot be attained until people are free of stigma, discrimination, sexual
abuse, coercion and violence.
3.1 To be effective, laws, policies, and programs to reduce sexuality related violence
must address gender inequality with respect to human rights and economic position.
This includes legislation to prohibit all forms of sexual violence and harassment against
children, women, and sexual minorities.
3.2 Comprehensive public health programs to raise awareness of the need to address
sexual violence are required. Complementary programs aimed at the primary
prevention of sexual violence must also be instituted. Sexual violence prevention
programs should be delivered to all segments of society.
3.3 Effectively reducing the impact of sexual violence requires reform of the health
care domain. This includes eliminating all forms of discrimination related to gender or
sexual orientation within health care systems and ensuring that health care personnel
and the institutions in which they work are adequately prepared to receive and treat the
victims of sexual violence.
To achieve sexual health, all individuals, including youth, must have access to
comprehensive sexuality education and sexual health information and services
throughout the life cycle.
4.1 Mandate comprehensive rights-based, gender sensitive, and culturally appropriate
sexuality education as a required component of the school curricula at all levels and
provide the required resources.
4.2 Work with community agencies to reach out of school youth and other high risk
populations with comprehensive sexuality education.
4.3 Issue guidelines to ensure that sexuality education programs and services are
grounded in the principle of fully informed, autonomous decision-making.
4.4 Ensure that sexuality education programs are evidence-based and include the
characteristics that have been shown to contribute to effectiveness. This should be
done in a way that allows for creativity and community specific needs in the
development and evaluation of innovative programs.
Reproduction is one of the critical dimensions of human sexuality and may contribute
to strengthening relationships and personal fulfillment when desired and planned.
Sexual health encompasses reproductive health. Current reproductive health programs
must be broadened to address the various dimensions of sexuality and sexual health in
a comprehensive manner.
5.1 Government and transnational policy and policy statements regarding reproductive
health funding and mandating of services must include, in accordance with ICPD,
specific reference to sexual health.
5.2 Sexual and reproductive health programming should include a clear commitment
that such programming will fully reflect and incorporate the WHO working definitions
of sexual rights.
5.3 Sexual and reproductive health programming should recognize and reflect the
positive aspects of human sexuality and be aimed in a balanced way towards positive as
well as negative outcomes.
5.4 All reproductive health providers should receive, through pre-service and in-service
training the knowledge, comfort level, and skills to effectively address sexuality and
sexual health in their work.
Universal access to effective prevention, voluntary counseling and testing,
comprehensive care and treatment of HIV/AIDS and other STI are equally essential
to sexual health. Programs that assure universal access must be scaled up immediately.
6.1 Current funding and resources for STI/HIV prevention in the developing world
are currently significant but insufficient for achievement of the MDGs. Therefore,
funding for STI/HIV prevention must be increased.
6.2 Despite considerable distribution efforts, many people in the developing world do
not have consistent access to condoms. Therefore, condom distribution programs
must be increased from current levels.
6.3 Efforts must be increased to ensure that STI/HIV prevention programs are
developed and implemented according to up-to-date knowledge and research on
6.4 Funding and programming decisions for STI/HIV prevention must be based on
principles of human rights, not on the ideological viewpoints of funders or program
developers. This includes the right of individuals to make fully informed decisions
about their sexual health.
6.5 To be effective, STI/HIV prevention programming must address social inequalities
related to sexual orientation and gender. It is clear that halting and reversing the
STI/HIV epidemic in the developing world cannot occur without significantly
increasing the ability of women to equally participate in economic and political life and
to directly exercise control over their sexual and reproductive health.
Since sexual concerns, dysfunctions and disorders impact quality of life, it is critical to
recognize, prevent and treat sexual concerns, dysfunctions and disorders.
7.1 Given the importance of adequate sexual functioning for general sexual health,
overall health and well-being, and the health of interpersonal relationships, the
assessment and treatment for sexual concerns, problems, and dysfunction should be
specifically noted and included in national and international programs and agreements
to promote sexual health.
7.2 Sexual function and gender identity are increasingly recognized as key components
of overall health and problems with sexual dysfunction and gender dysphoria are
associated with other medical conditions and individual and relationship well-being.
Therefore, comprehensive sexual health assessment that includes evaluating basic
sexual function and gender identity should become a standard component of health
7.3 Many sexual concerns, disorders and dysfunctions are rooted in a lack of
information about sexuality. Information on sexual functioning should be included as
an integral component of the comprehensive sexuality education available to all people.
Schools, through their sexual health education curricula, and the health sector
(physicians, nurses, and other health workers) must play key roles in educating their
students and patients about sexual functioning.
7.4 Training programs for teachers, community workers, and health care workers must
include, as a standard component, training in sexual dysfunction, disorders and gender
problems. Such programs should include specific training on educating clients about
sexual function and gender identity development. Physician and nursing training
should go beyond providing education to include a specific focus on addressing and
treating sexual problems/dysfunctions.
7.5 Optimal treatment approaches for sexual concerns, dysfunction, disorders and
gender identity problems are in development, and more research is needed to develop
evidence-based guidelines for the majority of these conditions. Allocation of funds for
the conducting of this research is necessary and justified by the considerable impact
that these problems have in the individual, the couple, and the family and ultimately in
the social group at large.
Sexual health is more than the absence of disease. The right to sexual pleasure should
be universally recognized and promoted.
8.1 The international community is increasingly recognizing and endorsing the concept
of sexual rights. However, to-date, community, national and international consensus
has overwhelmingly focused on negative sexual rights (e.g., freedom from STI/HIV,
sexual violence and abuse), often to the exclusion of positive sexual rights (e.g., the
right to sexual pleasure and satisfaction). To better reflect human reality and meet the
needs of individuals and couples, international agreements and priority setting
documents should clearly articulate objectives in terms of both positive and negative
8.2 Sexual health promotion programs for all groups, including youth and people with
disabilities, should embody the reality that sexual pleasure and intimacy are strong
motivating factors for sexual behavior and that sexual pleasure contributes to
happiness and well-being.
8.3 Educators and health care providers have often been conditioned, through their
training, to conceptualize sexual health in terms of negative sexual rights. Pre-service
and in-service training for sexual health educators and health care providers should
place particular emphasis on the promotion of positive sexual rights for people of all
ages in order to counter the prevailing over-emphasis on negative sexual rights.
In order to achieve these goals and to carry out these necessary actions, it is
essential that international, regional, national and local plans of action for
sustainable development prioritize sexual health interventions, allocate sufficient
resources, address systemic, structural and community barriers and monitor
Sexual Health for the Millennium: Introduction
The World Association for Sexual Health (WAS) (formerly the World
Association for Sexology) was founded in 1978 by a multidisciplinary, worldwide
group of non-governmental organizations (NGOs) with the aim of
promoting sexual health and sexual rights throughout the world (See
Appendix I). For nearly 30 years, the WAS has accomplished its aims through the
advancement and exchange of scientifically-based multidisciplinary sexuality research,
sexuality education, and clinical sexology. More recently, the WAS constituency has
become much more involved in advocating for changes in public policy to recognize
sexual health as a key ingredient in overall health and well-being. Sexual Health for the
Millennium represents the collective voice of WAS in calling for the comprehensive
integration of effective, evidence based sexual health promotion programming as an
indispensable component of achieving the Millennium Development Goals (MDGs),
derived from the United Nations Millennium Declaration (United Nations, 2000).
By the year 2000, we were facing a unique juncture in history and had a rare
opportunity to develop global, national, and community strategies to promote sexual
health for the new century (Coleman, 2002). In large part, this opportunity arose from
the plethora of sexual health problems facing our world (most notably the HIV
pandemic), the recognition of sexual rights as human rights, and the recognition that
sexual health as a core component of overall health, as well as recent advances in the
science of sexual health promotion. Together, these developments created the
necessary conditions for the field of sexual health promotion to make an important
contribution to the health and well-being of individuals, families, communities, and
Previous globally focused initiatives have centered on the enunciation of sexual rights,
typically grounded in a broader concept of human rights. The 1999 WAS Declaration
of Sexual Rights (WAS, 1999) and the 2002 WHO Working Definitions of Sexual
Rights (WHO, 2004a; WHO, 2006) are key examples of the enunciation of sexual
rights for the global community (See Appendix II and III). The articulation and
understanding of the reality that the achievement of basic human rights is inevitably
tied to the achievement of a core set of sexual rights was a fundamental, initial step
forward in the global promotion of sexual health.
The second step in this process has been the recognition that broadly-based initiatives
to foster human development must invariably address sexuality and sexual health as
evidenced by, for example, the WHO (2004b) Reproductive Health Strategy. As these
steps forward in the understanding of the centrality of sexuality in human rights and
health were occurring, advances in the scientific study of human sexuality (sexology) from a range of fields including biology and medicine, behavioral and social
psychology, sociology and anthropology were making it possible for programs aimed at
preventing sexual health problems as well as sexual health enhancement to be
Recognition of the Importance of Addressing Sexuality and Sexual Health as Key Elements in Realizing the United Nations Millennium Development Goals
Parallel to the recognition of sexual rights as human rights has been the growing
recognition that the attainment and maintenance of sexual health for individuals,
couples, and families is a necessary prerequisite for the sustained social and economic
development of communities and nations. According to Girard (2005), at the
international level, the years that began with the 1994 International Conference on
Population and Development (ICPD) have been marked by significant progress in the
recognition by governments of sexual health as an essential dimension of overall health
and consequently, of human development. The ICPD Programme of Action (PoA)
adopted by 184 countries provided the first definition of sexual health negotiated and
agreed upon by national governments from around the globe. It situated sexual health
within a broader rubric of reproductive health care and recognized the important
multifaceted contribution that sexual health makes to human well-being.
...Reproductive health care is defined as the constellation of methods,
techniques, and services that contribute to reproductive health and wellbeing
by preventing and solving reproductive health problems. It also
includes sexual health, the purpose of which is the enhancement of life
and personal relations, and not merely counseling and care related to
reproductive and sexually transmitted diseases (UN, 1994, par. 7.2.).
Other international documents have recognized and emphasized the importance of
sexual health within the broader constellation of human well-being. For example, the
PAHO (2000) Promotion of Sexual Health: Recommendations for Action stressed
that if overall health is to be achieved, sexual health must be promoted and maintained.
Sexual health concerns and problems are important to address and find
solutions for not only because they undermine sexual health, and
therefore the general health of the individual, family, and society, but also
because their presence might signal other health problems. Moreover,
sexual health concerns and problems may generate, and/or perpetuate
other problems in the individual, family, community and population at
large (p. 15).
In September of 2000, the United Nations General Assembly adopted Resolution
55/2, the United Nations Millennium Declaration (UN, 2000). The Millennium
Declaration was rooted in fundamental values: freedom, equality, solidarity, tolerance,
respect for nature, and shared responsibility. The Millennium Development Goals
(MDGs) that were derived from the Millennium Declaration and adopted by world
leaders at the United Nations Millennium Summit in 2000 articulate objectives for
resolving some of the most complicated and urgent social problems of our time. They
are commonly accepted as a framework for measuring development progress and as a
tool to help governments and advocates mobilize resources and implement programs
that ensure sustainable and equitable development worldwide. At the United Nations
Millennium Summit, world leaders committed, through the MDGs, to measurable
goals for addressing a basic range of problems including poverty, hunger, disease,
illiteracy, environmental degradation and discrimination against women. To varying
degrees, these issues affect all the regions and peoples of the world. At their essence,
the MDGs are aimed at improving the human condition and promoting the most basic
of human rights.
UNITED NATIONS MILLENNIUM DEVELOPMENT GOALS
1. Eradicate Extreme Poverty and Hunger
2. Achieve Universal Primary Education
3. Promote Gender Equality and Empower Women
4. Reduce Child Mortality
5. Improve Maternal Health
6. Combat HIV/AIDS, Malaria and Other Diseases
7. Ensure Environmental Sustainability
8. Develop a Global Partnership for Development
The MDGs are necessarily broad in scope, placing eight basic objectives at the centre
of the global agenda. Meeting these broad global objectives must inevitably require
addressing those specific factors that make the attainment of the broader objectives
possible. For most of the MDGs, these specific factors directly or indirectly involve
sexuality and sexual and reproductive health. The WHO’s global Reproductive Health
Strategy adopted at 57th World Health Assembly in May 2004 explicitly recognized the
links between the MDGs and sexual and reproductive health. At a broad level, the
WHO (2004b) strategy recognizes not only that sexual and reproductive health is an
important determinant of the well-being of individuals, couples, and families, it is also
fundamental to the development of communities and nations. With respect to the
MDGs specifically, The WHO (2004b) notes that,
Of the eight Goals, three – improve maternal health, reduce child
mortality and combat HIV/AIDS, malaria and other diseases – are
directly related to reproductive and sexual health, while four others –
eradicate extreme poverty and hunger, achieve universal primary
education, promote gender equality and empower women, and ensure
environmental sustainability – have a close relationship with health,
including reproductive health (p. 7).
With respect to reproductive health, women without access to sexual and reproductive
health information and services will be less able to plan their families and will be at
increased risk for STI/HIV and other negative health consequences, all of which
directly facilitate poverty. The implications are clear. “Reproductive health is thus
crucial, not only to poverty reduction, but to sustainable human development”
(UNFPA, 2003, p. iv). More generally, the reciprocal relationship between establishing
sexual rights, the attainment and maintenance of sexual health, and the achievement of
the broader objectives of the MDGs is increasingly recognized.
If they are to achieve sexual and reproductive health, people must be
empowered to exercise control over their sexual and reproductive lives,
and must have access to related health services. While these rights, and
the ability to exercise them, constitute an important value in themselves,
they are also a condition for well-being and development. The neglect
and denial of sexual and reproductive health and rights are at the root of
many health-related problems around the world (WHO, 2004a, p. 2).
Awareness of the reciprocal relationship between sexual and reproductive health
problems and specific fundamental indicators of over-all well-being, such as poverty,
are increasingly recognized. Sexual and reproductive health problems are both a cause
and a consequence of poverty. This linkage is explicitly and succinctly pointed out by
Family Care International (2005) who point out that,
Poor sexual and reproductive health impacts the economic well-being of
individuals, families, and communities by decreasing individuals’
productivity and participation in the labour force. For example, early
childbearing perpetuates the cycle of poverty by disrupting girls’
schooling, limiting women’s and girls’ employment opportunities, and
reducing investments in the well-being of women and their children. At
the same time, the costs of treating sexual and reproductive injuries and
illnesses can drain meager incomes, exacerbating individual and
household poverty (p. 3).
Over the years it has been increasingly recognized that sexual and reproductive health
promotion efforts have a direct beneficial impact on these aspects of people’s lives.
What has been perhaps less clear to policy makers, but which is of crucial importance,
is the recognition that breaking the cycle of poverty requires the provision of effective
sexual health education and services delivered in an environment that encourages
individuals to act on their own behalf. For example, the report, Adding It Up: The
Benefits of Investing in Sexual and Reproductive Care (Singh, Darroch, Vlassoff &
Nadeau, 2003) extensively documents the extent to which investments in sexual and
reproductive health care services can make valuable contributions to wider
development goals. Indeed, with respect to the MDGs specifically, the report
concludes that “sexual and reproductive health is essential to achieving all of these
goals” (p. 30).
The recent WHO (2007, in press) Developing Sexual Health Programmes: A
Conceptual Framework and Basis for Action provides a comprehensive approach to
sexual health promotion recognizing that there are a wide variety of determinants of
sexual health including legal, political, religious, economic, and socio-cultural
influences. Effective societal wide sexual health promotion must not only involve the
health and education systems but must also be addressed through the implementation
of appropriate laws and policies. These efforts must include addressing the economic
inequalities that are associated with and underlie the occurrence of many sexual health
related problems. The WHO conceptual framework recognizes and incorporates the
crucial fact that to be successful, sexual health promotion programming must be
designed and implemented with the input, cooperation and acceptance of the
In both the developed and developing world we are faced with persistently high, and in
some cases, increasing rates of sexually transmitted infections including HIV,
unintended pregnancy, and unsafe abortions. These problems are particularly acute in
the developing world where they present fundamental obstacles to meaningful
progress in alleviating morbidity, mortality, and poverty. Gender-based discrimination
involving sexual norms and practices as well as coercive sex forced upon women and
children compound these problems. The onslaught of HIV/AIDS in Africa is
definitive example of how a multitude of specific sexual norms and practices, in the
absence of wide spread and sustained evidenced-based sexual health promotion
efforts, has facilitated an epidemic that has taken millions of lives as well as exacerbated
and directly contributed to extreme poverty.
Taken together, the range of sexual and reproductive health problems facing the global
community is extensive and their impact on the human condition is immense.
According to the WHO (2004b),
…aspects of reproductive and sexual ill-health (maternal and perinatal
morality and morbidity, cancers, sexually transmitted infections and
HIV/AIDS) account for nearly 20% of the global burden of ill-health for
women and some 14% for men. These statistics do not capture the full
burden of ill-health, however. Gender-based violence, and gynaecological
conditions such as severe menstrual problems, urinary and faecal
incontinence due to obstetric fistulae, uterine prolapse, pregnancy loss,
and sexual dysfunction – all of which have major social, emotional and
physical consequences – are currently severely underestimated in present
global burden of disease estimates. WHO estimates unsafe sex to be the
second most important global risk factor to health (p. 15).
Clearly, if global initiatives for sustained development are to be successful they must
specifically incorporate evidence-based sexual health promotion programs.
The developing world suffers a disproportionate burden from sexual and reproductive
health problems and this poses an important obstacle to the development of these
regions of the world. In addition, it should be noted that sexual and reproductive
health problems also place a significant burden on the health and well-being of
individuals and families in the developed world. For example, from the United States
we have The Surgeon General’s Call to Action to Promote Sexual Health and
Responsible Sexual Behavior (U.S. Surgeon General, 2001) which acknowledges the
extent to which many of these same problems result in considerable morbidity and
mortality in that country and are strongly associated with social and economic
disadvantage. A comparative study of adolescent sexual and reproductive health in five
developed countries clearly suggested that access to sexual and reproductive health
education and clinical services is often insufficient and a lack of access to education
and services is correlated with higher rates of teenage pregnancy and STI infection
(Darroch, Frost, Singh and the Study Team, 2002).
Sexual Health for the Millennium Reflects the State of the Art in the Science of Sexual Health Promotion
The WHO (2007, in press) provides a conceptual framework for developing and
implementing effective sexual health promotion programs that reflect a multi-sector
approach. The Sexual Health for the Millennium technical document provides a
complementary and in-depth research-based examination of key issues in sexual health
promotion that provides additional evidence-based support for the WHO conceptual
framework. A key component of the timeliness and relevance of Sexual Health for the
Millennium and technical document is that they come at a time when advances in the
extraordinarily diverse discipline of sexology make it increasingly evident that well
supported and well designed sexual health promotion programs can be successful in
reaching their objectives and, as a result, have a significant and wide-ranging positive
impact on the health and well-being of the people they reach. For example, advances in
behavioral science applied to STI/HIV and unintended pregnancy prevention as well
as sexual health education for youth have dramatically increased the potential
effectiveness of such programs. Epidemiological understanding of the biological and
social dynamics that drive the spread of STI/HIV within communities and across
borders has advanced significantly. Studies in the fields of sociology and anthropology
have given us a much greater understanding of sexual norms and practices within
diverse social and cultural contexts. Medical knowledge and clinical intervention related
to sexual function as well as reproduction and fertility control now have a growing
potential to improve quality of life.
The eight declaration statements of Sexual Health for the Millennium and technical
document represent and give substance to the next logical and progressive step in the
global promotion of sexual health (See Appendix IV and V for a description of the
process of developing the Declaration and the technical document and
acknowledgements of those who participated in this process). The declaration
statements identify eight key areas in the realm of sexual health where we must move
forward. Sexuality and sexual health are broad and diverse concepts that touch on
innumerable aspects of the human condition. Sexual Health for the Millennium not
only confirms the role that promoting sexual health must play in achieving the MDGs,
this document specifies and elaborates on eight distinct but inter-related aspects of
sexual health that play important roles in affecting human development. To
meaningfully and effectively contribute to the achievement of the MDGs, sexual health
promotion programs must address the totality of human sexuality. For example, to
effectively promote HIV sexual risk reduction, sexual health promotion programs
must reflect and incorporate the reality that sexual relationships include gender and
power dynamics and that the desire for intimacy and pleasure plays an instrumental
role in shaping sexual behavior. In sum, Sexual Health for the Millennium
conceptualizes sexual health as multi-dimensional and specifically identifies and
examines eight specific goals that together encompass an integrated and
comprehensive approach to sexual health promotion. Finally, this technical document
describes specific necessary actions that are specific to each of the eight goals of the
The promotion of sexual health is central to the attainment of wellness and well-being and the
achievement of sustainable development and more specifically to the implementation of the
Millennium Development Goals. Individuals and communities who experience well-being are
better positioned to contribute to the eradication of individual and societal poverty. By nurturing
individual and social responsibility and equitable social interactions, promotion of sexual health
fosters quality of life and the realization of peace. Therefore we urge all governments,
international agencies, private sector, academic institutions and society at large, and
particularly, all member organizations of the World Association for Sexual Health to:
1. Recognize, promote, ensure and protect sexual rights for all
Sexual rights are an integral component of basic human rights and therefore are inalienable and universal.
Sexual health is an integral component of the right to the enjoyment of the highest attainable standard of
health. Sexual health cannot be obtained or maintained without sexual rights for all.
2. Advance toward gender equality and equity
Sexual health requires gender equality, equity and respect. Gender-related inequities and imbalances of
power deter constructive and harmonic human interactions and therefore the attainment of sexual health.
3. Condemn, combat, and reduce all forms of sexuality related violence
Sexual health cannot be attained until people are free of stigma, discrimination, sexual abuse, coercion and
4. Provide universal access to comprehensive sexuality education and information
To achieve sexual health, all individuals, including youth, must have access to comprehensive sexuality
education and sexual health information and services throughout the life cycle.
5. Ensure that reproductive health programs recognize the centrality of sexual health
Reproduction is one of the critical dimensions of human sexuality and may contribute to strengthening
relationships and personal fulfillment when desired and planned. Sexual health encompasses reproductive
health. Current reproductive health programs must be broadened to address the various dimensions of
sexuality and sexual health in a comprehensive manner.
6. Halt and reverse the spread of HIV/AIDS and other sexually transmitted infections (STI)
Universal access to effective prevention, voluntary counseling and testing, comprehensive care and
treatment of HIV/AIDS and other STI are equally essential to sexual health. Programs that assure
universal access must be scaled up immediately.
7. Identify, address and treat sexual concerns, dysfunctions and disorders
Since sexual concerns, dysfunctions and disorders impact quality of life, it is critical to recognize, prevent
and treat sexual concerns, dysfunctions and disorders.
8. Achieve recognition of sexual pleasure as a component of holistic health and well-being
Sexual health is more than the absence of disease. The right to sexual pleasure should be universally
recognized and promoted.
It is essential that international, regional, national and local plans of action for sustainable development
prioritize sexual health interventions, allocate sufficient resources, address systemic, structural and
community barriers and monitor progress.
Approved by the WAS General Assembly, April 17th, 2007, Sydney Australia
We have arrived at a point in history where it is increasingly evident that advances in
sexual science have measurably improved the capability of well designed and supported
sexual health promotion programs to effectively address a number of problems that
inhibit or prevent individuals from living healthy and productive lives. As the WHO
(2004b) Reproductive Health Strategy suggests, “The number of evidence-based best
practices in reproductive and sexual health care has grown substantially, and the scope
of behavioral research and of internationally recognized standards, norms and
guidelines has broadened” (p. 9). In turn, Sexual Health for the Millennium declaration
and technical document illustrates and embodies the advances in the science of sexual
health promotion that have placed the field in an unprecedented position to contribute
to human development and make an indispensable contribution to the broad
objectives of the MDGs.
Coleman, E. (2002). Promoting sexual health and responsible sexual behavior: An introduction. The Journal of Sex
Research, 39, 3-6.
Darroch, J.E., Frost, J.J., Singh, S. and the Study Team. (2002). Teenage Sexual and Reproductive Health in
Developed Countries: Can More Progress be Made? New York, NY: The Alan Guttmacher Institute.
Family Care International. (2005). Millennium Development Goals & Sexual & Reproductive Health. New York, NY:
Family Care International. http://www.familycareintl.org
Girard, F. (2005). Sexual Health and Human Development in International, Inter-Governmental Agreements:
Background Paper. World Association for Sexual Health.
Pan American Health Organization. (2000). Promotion of Sexual Health: Recommendations for Action. Pan
American Health Organization. Retrieved March 28, 2006 from
Singh, S., Darroch, J.E., Vlassoff, M. & Nadeau, J. (2003). Adding It Up: The Benefits of Investing in Sexual and
Reproductive Health Care. New York, NY: The Alan Guttmacher Institute.
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Determinants. Population and Development Strategies Series, Number 10. New York, NY: United Nations
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Sexual Behavior. Rockville, MD: The Office of the Surgeon General.
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Switzerland: World Health Organization.
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WHO. (2004a). What constitutes sexual health? Progress in Reproductive Health Research, No. 67, 2-3.
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Development Goals and Targets. Geneva, Switzerland: World Health Organization.
Recognize, Promote, Ensure and Protect Sexual Rights for All
Sexual rights are an integral component of basic
human rights and therefore are inalienable and
universal. Sexual health is an integral component
of the right to the enjoyment of the highest standard
of health. Sexual health cannot be obtained or
maintained without sexual rights for all.*
The placement of sexual rights as the first item in the World Association for
Sexual Health’s (WAS) declaration Sexual Health for the Millennium is
consistent with the growing recognition of human rights as foundational
requirements for health (Farmer, 1999; Mann, Gruskin, Grodin & Annas, 1999).
Therefore, sexual health cannot be achieved or maintained without respect for human
rights (WHO, 2007, in press).
In its Gender and Reproductive Health Glossary, the secretariat of the World Health
Organization (WHO) proposes a working definition of sexual rights as “human rights
related to sexual health”. It thereby places sexual rights securely within the domain of
the array of human rights that are already recognized in international treaties and
conventions (WHO, 2002a). This working definition states:
* This chapter closely follows the background paper written by Eleanor Maticka-Tyndale and Lisa Smylie.
Additional input was informed by the WAS Expert Consultation in Oaxaca, Mexico and feedback from
reviewers (see Appendix IV and V).
Sexual rights embrace human rights that are already recognized in
national laws, international human rights documents and other consensus
statements. They include the right of all persons, free of coercion,
discrimination and violence, to:
* the highest attainable standard of sexual health, including access to
sexual and reproductive health care services;
* seek, receive, and impart information in relation to sexuality;
* sexuality education;
* respect for bodily integrity;
* choice of partner;
* decide to be sexually active or not;
* consensual sexual relations;
* consensual marriage;
* decide whether or not, and when to have children; and
* pursue a satisfying, safe, and pleasurable sexual life.
The working definition concludes that, “The responsible exercise of human rights
requires that all persons respect the rights of others” (WHO, 2002a).
Sexual rights as outlined above can be identified as an underlying core element within
all of the eight Millennium Development Goals (MDGs) (United Nations, 2005). The
availability of quality sexual and reproductive health services, information and
education in relation to sexuality; protection of bodily integrity; and the guarantee of
the right of people to freely choose sexual partners and spouses to make decisions
about child bearing, and to pursue satisfying, safe and pleasurable sexual lives are
grounded in and contribute to gender equality and the empowerment of women
(MDG 3); to access to primary education, particularly for girls (MDG 2); to reduction
of infant and child mortality, especially of female children (MDG 4); to improvements
in maternal health and mortality (MDG 5); to decreasing vulnerability to HIV/AIDS,
STIs and other health threats (MDG 6); and also to reduction of poverty (especially
among women) (MDG 1). Thus, it is evident that achieving sexual rights for all people
will not only contribute to sexual and reproductive health, well-being and quality of life
but will also advance the MDGs.
Despite the clear alignment of sexual rights with human rights, the broad international
support for numerous human rights treaties and consensus statements (Office of the
United Nations High Commissioner for Human Rights, 2004), and the health and
development gains of a rights-based approach (Farmer, 1999; Hendriks, 1995; Mann,
Gruskin, Grodin & Annas, 1999), attempts to reach international consensus on sexual
rights have faced obstacles (Correa & Parker, 2004; Girard, 2005; Petchesky, 2000) that
are, nevertheless, not insurmountable.
Religious and Other Cultural Barriers
As normative statements, international human rights agreements may represent a
challenge to the authority of the state, the cultural structures or religious organizations
(Cook, 1995). Sexual rights may be particularly contentious because they address
aspects of life that are considered to belong in the private and sacred domain and are
grounded in cultural and religious beliefs about the nature of human existence and its
relation to the fundamental power of life, as well as the nature and perpetuation of core
groups such as family and clan. These are set out in cultural and religious belief systems
and moral codes that are neither dependent on nor responsive to science or
democratic process (Plummer, 2003). Within these cosmovisions, health and
development are not prioritized above adherence to cultural or religious beliefs and
moral codes. In fact, ill health, suffering, and even death may be viewed as necessary
trials or passages, or even as inevitable consequences of transgressions of cultural and
religious norms. A sexual rights approach may be seen as violating the nature of
humanity as understood in religion and culture. This explains, for example, the
vehement opposition from Pakistan’s representatives (a stand that was endorsed by
other countries) to the inclusion of sexual orientation in a draft resolution to the
Commission on Human Rights in 2003, claiming it was an insult to the world’s 1.2
billion Muslims (as cited in Saiz, 2004, p. 57) and similar opposition of Roman Catholic
and Muslim clerics to inclusion of references to homosexuality in the 1994
International Conference on Population and Development Program of Action
(ICPDPoA) (United Nations, 1994), the Beijing Platform for Action (Beijing) (United
Nations, 1995) and the United Nations General Assembly Special Session on
HIV/AIDS (UNAIDS, 2002) platforms and resolutions (Bayes & Tohidi, 2001;
Girard, 2005; Parker, di Mauro, Filiano, Garcia, Munoz-Laboy & Sember, 2004).
Critical theorists have also challenged a rights and health-based approach to sexuality.
They underline the implications of framing sexual rights within a health paradigm as
compared to a paradigm of citizenship. Miller (2001) points out that “although locating
sexuality with health may liberate it from the strictures of religion, culture and morality,
it places sexuality under the normalizing control of health and medicine”. Historically
(and currently) health and medicine have imposed a tyranny of ‘nature’ and biological
determinism that does not acknowledge the socially constructed nature of sexuality or
the capacity of individuals and cultures to find pleasure and ‘naturalness’ in diverse
practices and experiences. Consider, for example, the pathologization of the otherwise
universal practice of masturbation or of all same sex adult consensual sexual contact
despite historical and contemporary examples of cultures where this is a normatively
bound practice. Consider also the relatively recent, and in some circles still contentious,
removal of homosexuality from the Diagnostic and Statistical Manual of Mental
Disorders (DSM) of the American Psychiatric Association (APA).
Those working in the globalization arena alert us to its more undesirable tactics and
consequences. Van Eerdewijk (2001) calls our attention to the ways in which western
ethnocentrism leads researchers to take their own circumstances as the “norm,” thus
applying their own values in interpreting their observations rather than searching out
the values of others. Boyle and Preves (2000) draw our attention to political tactics that
move a western agenda forward without concern for the preferences, attractions and
desires of local people, thereby denying their right to autonomy as a people. Plummer
(2003) challenges the relevance of universal and abstract rights devoid of local contexts,
histories and stories to creating an ethic for the global world of the 21st century.
Theorists of rights, sexuality and globalization point out that rights doctrines stemming
from a health rationale pay little attention to the work of social constructionists and the
evolving understandings of sexuality grounded in post-modern acknowledgements of
shifting and diverse subjectivities, knowledge and experience (Hawkes, 2004;
Richardson, 2000; Weeks, 1989;2000), or the power differentials between genders,
groups and nations in determining international agendas and norms. This has led some
feminist scholars such as Oriel (2005) to question whether the sexual rights agenda has
adequately taken account of women’s rights relative to those of men, particularly given
the still prevalent power differentials between men and women. Further, Miller (2001)
calls our attention to the need to reconcile fundamental incompatibilities between the
centering of human rights as compared to public health, particularly if we advance the
position that rights are essential to health.
These concerns related to new conceptualizations of sexuality within a health and
rights paradigm can perhaps be understood if we acknowledge the inherently dialectical
nature of change (Balakrishnan, 2001). Liberation from old forms of oppression brings
both new freedoms and new oppressions. Thus, the tyranny of the community is
replaced by the tyranny of the individual. Centering the rights of the individual may
threaten the well-being and very existence and identity of some individuals, groups or
communities. Consequently, opposition to rights may best be understood as a warning
that alerts us to the inevitability of competing or conflicting goals and the need to
proceed with due caution, being alert to new losses as well as gains and recognizing
that the best that may be achieved is a new balance.
Despite these debates, international organizations advocating for the rights of women
and children, and of gay, lesbian, bisexual and transgendered persons, such as Human
Rights Watch and Amnesty International, as well as Rapporteurs to various UN
Committees, have been in the forefront of documenting on-going violations of sexual
rights and their consequences for the health, well-being and the very life of men,
women and children. To enable all people to enjoy the highest attainable standard of
sexual health, various needs stemming from universally agreed upon ethical principles
must be met.
A) The Need for Autonomy in Sexual and Reproductive Health Decision-
Women’s autonomy in sexual decision-making and their right to sexual and
reproductive health care are denied in the legal prohibition of birth control and
abortion services that force them to access illegal and often unsafe abortions (WHO,
2004). But even the availability of contraception and safe abortion do not necessarily
guarantee women’s right to reproductive self determination. Organizations in Latin
America have documented the performance of surgical sterilization or insertion of
IUDs on indigenous and otherwise marginalized women without their consent in Peru
and Mexico (Castro & Ervitie, 2003). Among Mertus’(2001) review of numerous
reproductive and sexual rights problems in Central and Eastern Europe was the
involuntary sterilization of Romani women in Slovakia. In countries that prohibit
sexual activity outside of marriage, sexual and reproductive health services are
commonly denied to unmarried women (Amado, 2003; Shirpak, Mohammad, Maticka-
Tyndale, et al., 2006, in press).
B) The Need for Guarantees of the Freedom to Seek, Provide, and Receive
Sexual Health Information and Education
The sexual information and education needs of women and girls are poorly met in
many countries as illustrated, for example, in restriction of much school-based sex
education in the United States to abstinence-only programs (Arnold, Smith, Narrison
& Springer, 1999; Jones, 2002); inconsistent provision of sex education in Canada
(Barrett, King, Levy, Maticka-Tyndale, McKay & Fraser, 2004); absence of or scattered
access to sex education in much of Latin America, Africa, the Middle East and Asia.
When education for sexual health is available, it may be inappropriate to the needs of
many women and girls as evidenced in the ABC (Abstinence, Be Faithful, Condoms)
approaches to HIV prevention education that dominate in subSaharan Africa. These
assume personal autonomy and control over sexual decision-making and further disempower
and alienate the vast majority of girls and women who lack such autonomy
and control (Van Donk, 2006; Whelan, 1998).
Forms of sexual activity that are pathologized, criminalized, non-normative, or whose
existence is ignored or denied are either absent from or portrayed as such in sexual
education programs. Often those who practice them have no access to information,
education, or services except those that portray them as deviant, perverse, diseased or
ill. Thus, in countries where homosexuality is considered a disease, even health care
providers, researchers and educators are taught to approach it as illness or crime.
Similarly, where polygamy is criminalized, adults in consensual polygamous unions
(and their children) lack access to the rights, protections and services afforded to those
in legally recognized marital unions (Maticka-Tyndale, 2002, 2003). Where sadomasochistic
practices are criminalized, willing participants may be subject to arrest and
criminal prosecution with no consideration of the consensual nature of their practice
(e.g., Richardson, 2000, p. 112). In many countries people with disabilities are assumed
to have a lack of capacity for sexual decision-making and for sexual activity, and thus
have been denied rights to sexual self-determination and to sexual health services to
meet their needs (DiGiulio, 2003; Tilley, 2000; Zola, 1988). This is most evident with
respect to persons diagnosed with severe mental illnesses or who are mentally retarded
(Dybwad, 1976; Zola, 1988). The sexual capacity and interests of the elderly are
similarly denied with husbands and wives placed in separate chronic care facilities and
the elderly in these facilities not afforded the privacy and respect required to engage in
safe, pleasurable and satisfying sexual lives. The right of sex workers to engage in
consensual sexual activities is likewise denied through the criminalization of sex work.
The absence of information, education and sexual health services is considered to be a
contributing factor to poor sexual health including sexually transmitted infections,
unwanted pregnancy, sexual violence, sexual dysfunction, poor reproductive health
outcomes, and to ultimately jeopardize the right to pursue a satisfying, safe and
pleasurable sexual life (WHO, 2007, in press).
C) The Need to Protect People against Violence and Violation of Bodily
Verbal abuse, harassment, violence, violation of bodily integrity, and murder or capital
punishment are commonly used by the state and its agents, and implicitly condoned
when used by civil society, to punish men, women, boys and girls who violate cultural
norms of sexual conduct. The death penalty may be, and is, imposed for a conviction
of homosexuality in countries governed by shari’a (Islamic) law (Amado, 2004;
Ottoson, 2006). In Egypt, health professionals in Medical Forensics units violate the
bodily integrity of those arrested on suspicion of homosexual activity with forced and
repeated anal examinations in an attempt to determine their guilt (Long, 2004). India
provides a further example of the collusion of health professionals and police in what
Narrain (2004) describes as a Hindu nationalist backlash that has led to “rigorous and
harsh policing” with criminal proceedings or forced medical treatment for those
discovered in same sex activities. In Zimbabwe, Namibia, Zambia, Botswana and
Uganda government leaders have launched campaigns of hate against homosexual
people, inciting and condoning civil abuse of expected homosexuals and directing
police to aggressively pursue, arrest and prosecute them (Human Rights Watch and
IGLHRC, 2003). Homosexual men are harassed, intimidated, and assassinated with the
complacency of the society at large in Jamaica and other Caribbean countries. Reports
submitted to the United Nations Special Rapporteur on Torture and those prepared by
Amnesty International document police torture and rape of gay, lesbian and
transgendered persons while in police custody in India, Somalia, Turkey, Afghanistan,
Egypt, Mexico, and Venezuela as well as refusal of police to investigate rape and
murder of homosexual persons by civilians (Amnesty International, 2005; Long, 2001).
In the United Kingdom, Australia, the United States, and Canada a defense of
homosexual panic has been successfully used to obtain a lower sentence for
perpetrators of violence against gay or transgender men (Howe, 2000).
Violence in the form of rape, sexual torture, honor killings, beatings and disfigurement
are also used by agents of the state and members of civil society to control and punish
women and girls who have transgressed cultural norms of sexual conduct (Amado,
2004; Abu-Odeh, 2000; Fried & Landsberg-Lewis, 2000; Spatz, 1991; Zuhur, 2005).
Most recently, attention has been drawn to the rape, sexual torture, forced childbearing
and forced marriage of hundreds of thousands of women as part of armed conflicts in
the former Yugoslavia, Somalia, Burma, Kashmir, Sierra Leone, Rwanda, Angola and
various Latin American countries (Heyser, 2006; Hughes, Mladjenovic & Mrsevic,
1999; Human Rights Watch, 2003; Human Rights Watch/Africa, Human Rights
Watch Women Rights Project, & La Fédération Internationale des Droits de
l’Homme, 1996; La Luz, 2000; Mladjenovic & Hughes, 1999). Rape and sexual
violence against women and girls have also been documented in U.S. prisons (Human
Rights Watch, 1996), refugee settlements, and as part of human trafficking (Blum &
Kelly, 2000; Mertus, 2001; Olujic, 1995). Such violence has been linked to unwanted
pregnancy, STI and HIV acquisition, poor maternal and infant health, sexual
dysfunction, and inability to make sexual choices and negotiate sexual encounters in a
way that minimizes a woman’s health risks (Garcia-Moreno & Watts, 2000; WHO,
Female genital mutilation (FGM) continues to be practiced on girls and women despite
the documented threats to health (WHO, 1998) and heightened risks to both women
and their infants during childbirth (Banks, Meirik, Farley, Akande et al., 2006). Male
infant circumcision, although very different in purpose and nature from FGM, is
considered by some groups as an abuse against male infants since, according to their
argument; it is an irreversible cutting of genitalia without the consent of the individual
(i.e. the infant). This practice is still routinely performed among Muslim and Jewish
populations as an essential religious ritual and for the majority of male infants born in
the United States, South Korea and the Philippines against the claims of American,
Canadian, British, Australian and European physicians’ and pediatricians’ associations
that there is insufficient evidence of health benefits to recommend the routine practice
of circumcision among children (American Academy of Pediatrics Task Force on
Circumcision, 1999; American Medical Association, 1999; Australian College of
Paediatrics (1996); Fetus and Newborn Committee, 1996). Recent studies, it should be
noted, demonstrate a protective effect of adult male circumcision on HIV transmission
when combined with other prevention tools. Adult male circumcision for HIV
prevention, if it is to be ethical, must be safe, culturally appropriate, voluntary, and
informed (WHO & UNAIDS, 2007).
D) The Need to Ensure Self-Determination and Autonomy in Sexual Decision-
At the most fundamental level, sexual rights embody the right to participate in sexual
acts with whom one chooses, if one so chooses, and to pursue one’s own route to
sexual pleasure and fulfillment. That is, to self-determination and autonomy free from
coercion, force, punishment, or discrimination. At the local level where people live
their lives, self-determination and autonomy are both guaranteed and limited by law
and social custom. Laws governing age of consent or majority determine, for example,
when youth have access to legal guarantees of autonomy as well as when they are held
fully accountable and governed by legal limitations to autonomy. Thus, below the age
of majority, youth are not granted the right to consent to sexual practices, partnerships,
or to access certain services. It is a paradox that marriage, even if not consensual,
grants in some places the majority of age to individuals, including the right to engage in
consensual sexual activity. In addition to laws governing age of consent, laws in many
countries also set limits on the free choice of sexual partners and sexual acts. Often
restricted are sexual activities or marriage between people of the same sex, between
those who are not married, between partners with certain lineage relationships to each
other, as well as sexual activity for immediate material gain and when there are more
than two partners involved. These restrictions apply even when there is consent among
Sexual activity between persons of the same sex is most often regulated through
sodomy laws in which anal intercourse (and sometimes other practices such as oral sex)
is criminalized. Such laws exist in over 80 countries (Amado, 2004; Khaxas, 2001;
Ottoson, 2006; Saiz, 2004; Samelius & Wagberg, 2005). Marriage for same sex couples
is likewise restricted in most countries, denying them the well-established health and
social benefits that accrue from marriage (Herdt & Kirtzner, 2006). Niveau et al. (1995)
further document denial of the right to marriage on the part of transsexuals in
countries where, for example, there is no mechanism for changing civil status despite
complete surgical and hormonal transformation of biological sex characteristics (e.g.
It is not uncommon for heterosexual women to be denied the right to choose their
sexual partners, to choose whether and with whom they will marry, to decide whether
or not to engage in sexual activity, to be free from sexual activity to which they do not
consent, and to expect that their bodily integrity will be respected. For example, in
Turkey, where an unmarried woman cannot decide to engage in sexual activity,
virginity testing is conducted by state physicians at the request of parents or other
community authorities and against the will of women and girls themselves (Girard,
2001; Lai & Ralph, 1995; Tambiah, 1995). Female genital mutilation is used in
countries in the Middle East, Northern and subSaharan Africa, and Asia to control the
sexual activity and enhance the acceptability and attractiveness of girls and women
(Amado, 2004; Bop, 2005; Igras, Muteshi, Wolde Mariam & Ali, 2004; Jaldesa, Askew,
Njue, & Wanjuru, 2005; Lewis 1995; Shaaban & Harbison, 2005; WHO, 1999).
Women’s organizations in Peru and other Latin American countries have documented
challenges to women’s right to autonomy in sexual decision-making on the part of
personnel in public health facilities, particularly when women are poor or members of
minority ethnic communities (Comité de America Latina y el Caribe para la Defensa de
los Derechos de la Mujer and Center for Reproductive Law and Policy, 1999). In an
attempt to control the spread of HIV, in 2001 the government of Swaziland ordered a
five-year ban on sexual relations for unmarried women, including abstinence from
even shaking hands with males (Girard, 2001).
Child marriage and early childbearing – below the age at which independent consent is
considered possible in international treaties – has been documented in Asia, Africa and
the Middle East (Bruce & Clark, 2004; Germain, 2005; ICRW, 2004; Lai & Ralph,
1995; Save the Children, 2004). In countries where the decision of whether, when and
whom to marry rests with the father or male relatives, the consent of girls and women
is not necessarily sought, constituting forced marriage (Amado, 2004). Once married,
women in many countries, particularly in the Middle East, Northern Africa and Latin
America, but also in Ireland, cannot leave the marriage, since they are denied access to,
or severely limited in their ability to access, divorce (Amado, 2004; Fried & Landsberg-
Lewis, 2000; Shephard, 2000).
Finally, while the exchange of sex for immediate material gain (commonly referred to
as prostitution, or more usually as sex work), even when there is consent between
parties, falls outside the criminal codes in some of its forms in only 12 countries
(Australia, Brazil, Canada, Costa Rica, Denmark, Germany, Netherlands, New
Zealand, Spain, Sweden, Switzerland, and the states of Nevada and Rhode Island in the
United States), UN agencies report the trafficking of hundreds of thousands of women
and girls, against their will, from Africa, Asia, and Eastern Europe for purposes of
sexual labor (UNDP, 2000; UNFPA 1999, 2000; UNICEF, 2001; United Nations
1994, 1999, 2000).
E) The Need to Recognize, Promote, Ensure and Protect Sexual Rights for All
to Achieve the Millennium Development Goals
There is an extensive literature on the close connections among the MDGs. Gender
inequities and women’s lack of power exacerbate and are at the root of much of the
world’s poverty and of maternal and child health. Poverty is also a prime determinant
of maternal and child health and the three collectively influence access to and
completion of primary education (especially for girls). Poverty, health, education and
being female create and exacerbate conditions of vulnerability to HIV, AIDS, malaria
and other diseases. Collectively, poverty, health, education, and especially HIV/AIDS
and malaria, through their effects on individuals, families and communities place
greater stresses on the physical environment. Experience has clearly demonstrated that
these can only be effectively addressed through a coalition among nations, the eighth
The remaining chapters in this document address, individually, how the promotion of
sexual health in reproductive health programs, the provision of access to universal
sexuality education, the promotion of gender equity in sexuality, the eradication of
sexual abuse and violence, the recognition of sexual pleasure as a component of wellbeing,
the eradication of STI`s including HIV/AIDS, and combating sexual disease
and dysfunction contribute to achieving the MDGs. Official acknowledgement of
sexual rights would set legal and policy guarantees for these recognitions, eradications,
access, provisions and promotions which could then be used to develop appropriate
programming, service delivery, and legal action. Consequently it is through these
mechanisms that sexual rights contribute to the MDGs. Since the debates on sexual
rights at ICPD and Beijing, there has been increasing evidence of legal and policy
changes that embody the sexual rights listed in WHO’s working definition.
F) The Need for Protective Laws and Policies
Violence against women has been addressed in legal reform in 24 countries in the past
decade (WHO, 2002b). In Morocco, a new family law passed in 2004 gives women
equality in the family (Amado, 2004), and Iran is considering modification to its family
law that will place the same requirements on husbands to fulfill the sexual needs of
their wives that have been the long-term legal obligation of wives with respect to their
husbands (Iran news paper July, 27th 2005). These contribute to gender equity, the
experience of a sexually pleasurable and fulfilling life, and to respect for women’s right
to self-determination in the choice of marital and sexual partners, without fear of
Women’s right to reproductive self-determination is supported by change in abortion
laws. Since 1995, fifteen countries have passed laws liberalizing access to safe abortion.
Included among these are Benin, Burkina Faso, Chad, Guinea, Mali and Nepal which
formerly had some of the most restrictive laws. Five countries, however, (El Salvador,
Ireland, Hungary, Poland, Russian Federation, and the United States) have made access
to abortion more legally restrictive (Center for Reproductive Rights, 2005).
Respect for women’s bodily integrity, and protection of the sexual and reproductive
health and the health and life of infants born to them (Shaaban & Harbison, 2005) is
evidenced in the passage of laws criminalizing female genital cutting in 9 industrialized
and 11 African countries since 1995 (CRIP, 2006; Rahman & Toubiah, 2000).
However, as evidenced in examples from several countries, and also experienced in the
work of one of the authors (Maticka-Tyndale) in Kenya, such laws have often driven
the practice underground (e.g., BBC, 2004a; WHO, 1999) increasing the health risks
(BBC, 2004b). As mentioned above, concern for the bodily integrity of boys is
evidenced in the policies set by various national medical associations (American
Academy of Pediatrics Task Force on Circumcision, 1999; American Medical
Association, 1999; Australian College of Paediatrics (1996); Fetus and Newborn
Committee, 1996) that discourage routine circumcision of male infants on the grounds
of “insufficient evidence of its beneficial health effects”.
G) The Need for Positive Rights and Enabling Conditions
Positive rights and enabling conditions are those that speak to the ability of persons to
act as they choose and to make their own decisions. There has been a gradual move
toward recognition of the right of same sex couples to marry, adopt and raise children,
and to benefit from the social and legal status of spouse in a growing number of
countries. As of June, 2006, Belgium, Canada, Netherlands, Spain, and the state of
Massachusetts in the United States provided for marriage regardless of the sex of
members of the couple (IGLHRC, 2006). In 1994, South Africa became the first
country to incorporate nondiscrimination based on sexual orientation in its
Information, education and sexual and reproductive health services are advocated as
sexual rights themselves and also comprise a component of the enabling conditions
that make it possible for people to act on other sexual rights. The WHO Conceptual
Framework (WHO, 2007, in press) outlines shifts that have occurred in the delivery of
sexual and reproductive health services from needs-based to rights-based approaches.
Services have been expanded to address the sexual and reproductive health needs of
couples as well as women, and of those outside the reproductive years. There are also
gradual shifts from addressing merely sexual disease and ill-health to promoting sexual
well-being and pleasure, although these are taking longer to be realized (WHO, 2007,
in press). Several programs have begun to incorporate programming for men,
particularly in relation to gender equity or violence (e.g., Guedes, Stevens, Helzner &
An increasing number of countries are moving forward to provide effective HIV
prevention programming to youth through schools (see Kirby, Laris, & Rolleri, 2006
for a review) and communities (see Maticka-Tyndale & Brouillard-Coyle, 2006, in
press, for a review). The Government of Kenya’s mandate in 2001 of one AIDS lesson
a week in all primary and secondary school grades supported the rights of children and
youth to information and sex education related to HIV and AIDS. The government’s
adoption, in 2005, of an in-service and pre-service training program for all primary
school teachers on HIV/AIDS prevention education further supported that right
(Maticka-Tyndale, Wildish, & Gichuru, 2004; Wildish & Gichuru, 2006, in press).
Several organizations in Latin America are working from a sexual rights orientation
(e.g., Profamilia, Horizons, Instituto Promundo, the Jamaica Family Planning
Association, and the International Planned Parenthood Federation). They have
launched interventions designed to establish more gender equitable norms in
communities, specifically addressing situations of violence against women in Brazil,
Jamaica , Colombia, and Venezuela (Guedes, Stevens, Helzner, & Medina, 2002;
IPPFWH 2001a, 2001b; Pulerwitz, Barker, Segundo & Nascimento, 2006). Religious
leaders have been mobilized in Uganda (Kagimu, Marum, Webwire-Mangen,
Nakyanjo, Walakira, & Hogle,1998), Malawi (Willms, Arratia, Makondesa, 2004), and
Thailand (Maund, 2006; Sangha Metta, 2006) to empower youth and adults alike and to
deliver information and education for HIV prevention and care that often involves
reinterpreting religious doctrine to provide otherwise contentious information
(Wolderhanna, Kingheim, Murphy, et al., 2005). In Canada, coalitions of organizations
representing sex workers and university-based researchers have used rights-based
approaches to research and advocate for legal and policy changes to support the
programmatic work of sex worker organizations that target the health, safety and wellbeing
of sex workers (e.g., STAR, 2005).
Finally, Cabal, Roa and Sepulveda-Oliva (2003) remind us that courts, using
international treaties, provide a venue for bringing about change, especially when there
is a disconnect between international, constitutional and legislative norms and the
realities of people’s lives (Cabal, Roa and Sepulveda-Oliva, 2003). Organizations in
Latin America have pioneered use of courts and international litigation as strategies to
improve national legislation and policies to the benefit of women and girls (see Cabal,
Roa and Sepulveda-Oliva, 2003: p. 51-2 for more details).
These illustrations of legislation, policy and programs that promote sexual rights have
been developed in the absence of any international treaties or formal recognitions of
sexual rights per se. Instead, they have used international human rights conventions or
local agreements to advance these initiatives. The existence of a sexual rights dialogue
has been sufficient to advance these actions.
While evidence of the need for and possibilities resulting from a formal
acknowledgement of sexual rights appears compelling, the complexity and challenge of
achieving such an acknowledgement must be recognized. It is of paramount
importance to raise two such challenges:
* The challenge of expanding the domain of a rights-based approach;
* The challenge of developing and establishing a method for reaching
international acknowledgement of sexual rights.
The Challenge of Expanding the Domain of a Rights-based Approach
While sexual rights are not explicitly referenced in any UN treaties or conventions,
defense of sexual rights is well grounded in the provisions of virtually all existing
human rights treaties and conventions and has figured prominently in the debates,
resolutions, and reports to UN commissions set up to monitor progress toward
realization of treaty provisions. Two examples are the General Comment issued by the
commission on the International Convention on Economic, Social and Cultural Rights
calling for nondiscrimination based on sexual orientation (CESCR, 2000) and the
recent report of Paul Hunt, Special Rapporteur to the United Nations arguing for the
recognition of sexual rights (Hunt, 2006). The persistence of violations to human rights
related to sexuality, despite wide endorsement of such treaties and conventions and the
actions taken by watchdog committees, alerts us to the limitations of such treaties and
conventions in advancing a rights agenda. We are reminded by legal scholars and rights
advocates such as Wilets (1997) of three key limitations of such treaties and
agreements. First, although most are widely endorsed (Office of the United Nations
High Commissioner for Human Rights, 2004), they are non-binding in nature and
defer to national laws and customs when issues are in contention. Thus, for example,
in states whose medical professionals view homosexuality as a disease whose public
expression fosters its spread (as is the case in most Islamic countries), what have been
presented in this paper as violations of rights are seen instead as consistent with the
right to treatment of people suffering from a disease and the right of the public to
protection from the spread of a preventable disease.
Second, treaties and agreements address the responsibilities of states and agents of
States, but have little or no influence over civil society. This is illustrated in the
examples of Egypt, Kenya and other countries where, despite bans on female genital
cutting, it is still practiced. It is also seen in Canada (and other countries) where, despite
laws prohibiting hate crimes as well as physical assault, gay men are still the victims of
assaults and murder perpetrated by private citizens or vigilante groups (Janoff, 2005).
Third, the legal frameworks accessed through rights agreements are better able to
forbid or prevent physical harm than to promote positive rights (e.g., the right to
pursue a satisfying, safe and pleasurable sexual life) or to ensure that enabling
conditions necessary for the realization of rights are in place. This is particularly salient
when we consider that the exercise of many rights is premised on the idea of consent
(consensual relationships, sexual acts, marriage). Research in diverse settings has raised
the question of whether consent is possible without enabling conditions. Economic
and social conditions may, for example, place severe limitations on possible
alternatives. Thus, young girls consent to sexual relations or marriage when they have
no other way to meet economic needs or to hold a socially endorsed status in their
community (Maticka-Tyndale, Gallant, Brouillard-Coyle, et al., 2005; Sanyukta, Greene
& Malhotra, 2003). Similarly, widows may consent to sexual intercourse with a male
relative or community member in order to maintain their economic and social position
in the community (Luginaah, Elkins, Maticka-Tyndale, Landry & Muthui, 2005). The
role of economics is also evident in Romania and other countries in Central and
Eastern Europe where legal and often free abortions are used for birth control rather
than high cost, difficult to access contraceptives (Mertus, 2001; Yamin, 2004) raising
the question of whether women have freely chosen methods to control their fertility or
have been coerced by economic circumstances.
These limitations illustrate the divide between international treaties and agreements, or
even national laws, and the local realities of people’s lives where a multiplicity of
interdependent conditions influence the actions they take. The consequences of a
disconnect between raising awareness of rights and having enabling conditions in place
for the actualization of such rights is poignantly illustrated in events reported in Ilam
province, Iran. Raising women’s “awareness and demands” through education in Ilam
province is credited with contributing to a substantial rise in suicide rates among
women in the province in 2004. Heyran Pour-Najaf, an advisor to the Ilam governor,
reasoned that women had immolated themselves to protest “appalling family
conditions” when they were unable to attain the “rights” of which they had learned
(Ilam Suicide High Rate, February 28, 2005). Finally, the at times conflicting goals of
human rights and public health are illustrated in global differentials in HIV prevalence
and in policies that are credited with either maintaining low or in decreasing incidence.
Great care must be taken in interpreting information pointing at the association
between positive health outcomes and legislation restrictive of sexual rights. For
example, globally, HIV incidence has been lowest in countries with particularly
restrictive laws related to sexual autonomy (e.g., Middle East, Senegal) or that have
implemented public health measures that restrict human or sexual rights such as in
Cuba’s early policy of quarantine of HIV-positive people. Similarly, Thailand’s decrease
in HIV incidence is credited, in large part, to its policy of mandatory condom use in
brothels; a policy which violates the right to self-determination and which, on these
grounds, was opposed by several wealthy countries and international groups. While
gains can be documented with vertical programs and prescriptive and restrictive
approaches, especially at the initial stages of a health program or initiative, backlashes
may occur as a result of behavioral disinhibition caused by oppressive conditions and
attainment of physical health without complete wellness and well-being.
The Challenge of Developing and Establishing a Method for Achieving
Sexual rights cut to the core of deeply held beliefs about the nature of being human,
individual and group identities, and the moral order. As such, they stir heated debate
and resistance that has prevented any movement toward consensus or
acknowledgement. Bauman (1993), in Post-Modern Ethics, provides a convincing
argument for the need for a novel approach to addressing global ethical dilemmas,
such as that posed by sexual rights. Plummer (2003) and Correa and Parker (2004)
describe such an approach, consisting of open, reciprocal, communicative dialogue for
establishing international codes and consensus. The approach is consistent with what
Miller (2001) identifies as a key principle underlying human rights work, i.e. the
participation of individuals and groups in defining and resolving the issues that affect
Such participatory action approaches are increasingly used in local work with
populations that have otherwise been excluded from setting agendas, priorities and
designing programs (Horizons, 2002; Maticka-Tyndale & Brouillard-Coyle, 2006, in
press). It is also seen in the dialogic projects of the National Issues Forum, the Public
Conversations Project, and the Public Dialogue Consortium (Pearce and Littlejohn,
1997) and in the process used by the former Surgeon General of the United States to
establish a consensus statement about sexual health (Satcher, 2006). Participatory
action is particularly salient in the case of sexual rights where differences exist not only
across cultural and religious groups, but also within them. The differences within
groups are seen in the example of Islam where despite the opposition of conservative
Islamic groups to wording in recent rights-based agreements and programs of action
(Parker et al., 2004; Petchesky, 2000), several Muslim scholars have presented the
argument that Islam is consistent with and supportive of a rights-based approach (e.g.,
An-Naim, 2004; Chase & Alaug, 2004; Senturk, 2005). Similar differences in
interpretation of religious doctrine are evident within all faith-communities (see, for
example, documents on the website of the Religious Institute on Sexual Morality,
Justice and Healing: www.religiousinstitute.org, or Catholics for Free Choice:
www.cath4choice.org). This suggests that there is a place for dialogue within faith
Participatory action approaches could be applied internationally to move the global
community further in the direction of consensus on contentious sexual rights issues.
This would, however, require commitment of all parties to work towards consensus
and to engage in critical examination and open communication about their own
positions, to accept critical examination of their position from the outside, and to
respectfully hear and duly consider the positions of others.
Sexual rights, as with all human rights, are looked to for their liberatory potential. The
great hope presented by sexual rights together with the concerns raised by nation-states
and theorists alike suggest that work must move forward with humility, i.e. recognizing
the profound liberatory as well as the oppressive powers of rights as they change long
established and respected social relationships that have been central to the security, as
well as the oppression, of individuals and communities alike. This requires work on
Government, non-government and multilateral organizations must continue delivering
and expanding rights-based sexual health approaches. At the same time, more work is
needed in developing a broader, more empowering conception of sexual rights that is
capable of cutting across localized divisions and struggles to serve as a foundation for a
transformed public health praxis (Parker et al., 2004).
This work must involve multiple partners from different cultural and religious
backgrounds as well as from diverse disciplines and sectors. As this work moves
forward, it is essential to be alert to both its liberatory and oppressive potentials.
As Collier (2000) suggests in his examination of changes in family law and Plummer
(2003) in his discussion of developing an ethics of intimate citizenship, we need to ask
whether we are losing an ethic of obligation and care in our focus on rights of the
Sexuality, after all, exists and is experienced not only within the individual, but in
relationships: relationships with partners, with children, with parents and with fellow
community members. It will be in striking a balance between rights and obligations,
between caring for self and caring for others that we will strike the balance and develop
sexual rights that benefit health, well-being and quality of life of entire communities
and move nations forward toward achieving the Millennium Development Goals.
Three recommendations to move sexual rights forward emerge from the discussion
presented in this section:
1.1 To effectively advocate for and promote sexual health, it is important
that sexual rights are located within existing human rights contexts.
Government and international organizations and agencies should be
encouraged to endorse the sexual rights agenda through recognizing,
promoting, respecting, ensuring, and protecting human rights and
fundamental freedoms essential to sexual health. This approach would
serve to locate sexual rights within existing treaties and conventions so
that sexual rights are included in the monitoring and enforcement
mechanisms of these agreements.
1.2 The promotion of sexual rights requires participatory action and
dialogic projects that bring together different cultural, religious, and social
perspectives to the issue of sexual health. World Association for Sexual
Health (WAS) and World Health Organization (WHO) and other
relevant organizations are well placed to foster such dialogue.
1.3 A system for monitoring and evaluating advances in sexual rights
should be established. This system should include the study and
evaluation of the implications of changes in policy and law related to
sexual rights for long-term outcomes in health and quality of life.
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Advance Toward Gender Equality and Equity
Sexual health requires gender equality, equity and
respect. Gender-related inequities and disparities of
power deter constructive and harmonic human
interactions and therefore the attainment of sexual
Millennium Development Goal 3 calls for the promotion of gender equality
and women’s empowerment. At the time of the Millennium Declaration
the primary target advocated for measuring progress for MDG 3 was
gender disparities in access to education. The U.N. (2005) Millennium Task Force on
Education and Gender Equality expanded the range of progress indicators to include
health and nutrition, access to opportunities in the work force, and participation in
Furthermore, the Task Force has clearly acknowledged that “Achieving Goal 3
requires guaranteeing women’s and girls sexual and reproductive health and rights”
(U.N., 2005, p. 53). It has been clearly and unambiguously demonstrated in this
technical document and elsewhere that the provision and universal access by girls and
women to schooling and sexuality education and clinical services is a necessary prerequisite
to achieving the MDGs. However, the dispensation of these services, as
crucial as they are, is not sufficient to empower women to exercise the right to gender
equality. Genuine equality for girls and women in achieving the right to sexual health
will require not just access to education and services; it will require increasing levels of
autonomy of sexual expression and equality of power within sexual relationships.
*This chapter was informed by the WAS Expert Consultation in Oaxaca, Mexico, a thorough review of the
literature, and the background paper written by Elizabeth Castillo Vargas and Adriane Little Tuttle (see
Appendix IV and V).
Achievement of the human right to sexual health demands the autonomy for girls and
women to enter into sexual relationships on their own accord and on an equal footing
with their partners.
MDG 3 utilizes the term “gender equality”. Nonetheless, the term equity has been
frequently used. In some cases equity and equality are used interchangeably. Equality
has been defined as equal treatment of women and men in laws and policies, and equal
access to resources and services within families, communities and society at large
(WHO 2001). However, to fully and adequately address the need for girls and women
to achieve sexual and reproductive health rights also requires that we recognize that
men and women have different experiences and needs with respect to sexuality and
sexual health. To achieve sexual health, therefore, all people, but particularly girls and
women, require gender equality, equity and respect.
Gender equity is the process of being fair to women and men. To ensure
fairness, strategies and measures must often be available to compensate
for women’s historical and social disadvantages that prevent women and
men from otherwise operating on a level playing field. Equity leads to
equality. Gender equality requires equal enjoyment by women and men
of socially-valued goods, opportunities, resources and rewards. Where
gender inequality exists, it is generally women who are excluded or
disadvantaged in relation to decision-making and access to economic and
social resources. Therefore a critical aspect of promoting gender equality
is the empowerment of women, with a focus on identifying and
redressing power imbalances and giving women more autonomy to
manage their own lives. Gender equality does not mean that men and
women become the same; only that access to opportunities and life
changes is neither dependent on, nor constrained by, their sex. Achieving
gender equality requires women’s empowerment to ensure that decisionmaking
at private and public levels, and access to resources are no longer
weighted in men’s favour, so that both women and men can fully
participate as equal partners in productive and reproductive life (UNFPA
Therefore both gender equality and equity both must form the basis of sexual and
reproductive health programming that will meaningfully address sexuality related
power imbalances and enable girls and women to achieve full sexual and reproductive
According to the WHO (2003),
The MDGs explicitly acknowledge that gender – what a given society
believes about the appropriate roles and activities of men and women,
and the behaviors that result from these beliefs – can have a major
impact on development, helping to promote it in some cases while
seriously retarding it in others (p. 1).
The need to promote the empowerment of women in the realm of reproductive health
was recognized by the International Conference on Population and Development
(ICPD) (UN, 1995). Furthermore, gender-based violence and sexual coercion, sex
trafficking, female genital mutilation, and forced early marriage have been identified as
some of the manifestations of gender inequality that must be addressed in order to
achieve the MDGs (UN, 2006).
Many of the most basic gender inequalities that pervade nearly all cultures are deeply
rooted in prevailing, entrenched attitudes and norms towards sexual behavior. It has
been made clear in the literature on sexual health and global development that
increased access for women and girls to sexual and reproductive health is an essential
enabling factor in reaching the goal of gender equality (e.g., U.N., 2005; 2006).
Access to services, however, is insufficient. It is necessary to also recognize that the
inequitable gender norms and practices enacted in sexual relationships cannot be
isolated from gender equality in wider social, economic, and political relations. In
other chapters of this declaration and technical document, female genital mutilation,
sexual violence against girls and women, the sexual trafficking of girls and women (see
Chapter 3), as well as the disproportionate burdens of HIV/AIDS and STIs that are
bourn by women (see Chapter 6) has been amply demonstrated. These expressions of
gender inequality related to sexuality cannot be resolved without purposefully
addressing the entrenchment within most cultures of gendered norms which control
sexuality and sexual behavior.
Several theoretical frameworks emphasize the relationships between gender inequalities
and sexuality (Butler, 1990; Weeks, 2003). Scripting theory (Gagnon, 1990) provides a
useful framework for studying and analyzing the cultural construction of gender roles
and has been used effectively to examine gender inequality in sexual relations (See
O’Sullivan, Harrison, Morrell et al, 2006). Modification of inequitable gendered sexual
scripts may begin with an affirmation of girls and women’s basic human rights to
sexual health and gender equality.
Gender power imbalances can relate to sexual partnerships (number, timing, choice
and social status of partners); sexual acts (their nature, frequency,
voluntary/involuntary); the sexual meanings given to specific behaviors (male/female
gender roles related to sexuality, ideal images of manhood and femininity, beliefs about
virginity, etc); sexual drive and enjoyment (how they contribute to sexual identity,
gender differences in perceptions of sexual pleasure) (Dixon-Mueller, 1993;
Spicehandler, 1997). These imbalances of power are played out in a culturally dominant
script for sexual interaction between men and women and in most contexts the script
places the control of sexual activity in the hands of men. As Dixon-Mueller (1993) puts
it, “Interpersonal sexual scripts are played out in the context of hierarchal social
structures in which some people have the power to determine the sexual and
reproductive lives of others” (p. 279).
Psychological and social elements of reproductive behavior are shaped to some extent
by physiology and psychological determinants. Nevertheless, all gender related
behavior, including most prominently, sexual activity, is shaped by cultural traditions
and expectations. It is these forces that largely write the script for sexual behavior. In
brief, the sexual script is the experiential and behavioral guide that each of us learns
from our culture about how to be sexual (Gagnon, 1990). In most societies, gender
and sexual conduct are closely linked and the scripts for how men and women are
expected to behave sexually are clearly delineated. As Gagnon suggests,
Scripts for sexual encounters from the opening phase to the couple
separating are now acknowledged to be entirely gendered, with men
conventionally expected to conduct themselves assertively, to make the
first move and to lead in the subsequent steps, and to be knowledgeable
in the ways of sexual practice….Women are expected to be more passive,
more compliant at the beginnings of sexual interactions, and pleased and
responsive as such interactions progress (p. 15).
O’Sullivan et al., (2006) caution that while some generalizations are possible concerning
the applicability of this script, “….it is important to note that such generalizations need
to be understood as being contingent on specific gender paradigms and sociocultural
contexts” (p. 100). Given the vast diversity in social and cultural norms across the
globe, the basic script for heterosexual sexual activity is remarkably consistent across
cultures with respect to the gendered power imbalance it enacts. In playing out this
dominant sexual script boys/men and girls/women are often conforming to typically
rigid conceptualizations of masculinity and femininity from which it is often very
difficult for individuals to make even subtle personal revisions without risking derision,
humiliation, stigmatization, or worse. Wiederman (2005) describes the confining nature
of these scripts. For boys and men, the script dictates that they should be goal directed,
in control, and assertive in the pursuit of sexual activity and self-pleasure. Girls and
women play their complementary role in the script by showing restraint, emphasizing
emotional-relational concerns over physical pleasure, but finally ceding control and
giving in to male desires.
That females’ standards typically represent a barrier each male must
overcome fits well with the competitive and achievement-oriented
aspects of masculine gender roles. Masculinity calls for being proactive
and able to outdo one’s opponent, and unfortunately this is a stance
many young men take in relation to early sexual relationships. In many
cases, male-female differences in sexual roles set up a dynamic of polar
extremes; the more he pushes for sex, the more defensive she has to be,
and vice-versa. For many couples, it can seem as though he is obsessed
with sex and that she is completely indifferent or disinterested
(Wiederman, 2005, p. 498).
Not only do these prevailing ideas constrict people’s ability to form mutually beneficial
relationships, they also place women and girls in a disadvantaged position with regard
to sexual and reproductive health. Dixon-Mueller (1993) gives some apt examples:
….cultural definitions of masculinity and femininity influence people’s
perceptions of the use or nonuse of a contraceptive method – or of such
particular methods as condoms or sterilization – as unmanly or
unfeminine, quite apart from whether the methods are considered safe or
effective. How do people’s perceptions of what is masculine or feminine
or of the nature of their sexual relationships, or of the meaning of
particular sexual acts influence their decisions about contraception or
pregnancy termination? In turn, how does contraceptive use or the
experience of abortion – that is the separation of the act of intercourse
from its reproductive consequences – affect people’s perceptions of their
own or their partner’s masculinity or femininity, of the quality of their
relationships, of the meaning of their sexual acts? (279).
Amaro (1995) points to the various ways in which culturally determined gender roles
influence and define the interpersonal relationships in which sexual behaviors occur
and the gender inequitable nature of these relationships often places girls and women
at much greater risk for negative sexual health outcomes, particularly HIV infection. As
an example, Amaro cites Pleck, Sonestein and Ku’s (1993) analysis of large-scale survey
data of Black, Latino, and White teenage boys in the United States which found that
those who scored higher in traditional masculine ideology were less likely to have sex in
the context of an intimate relationship, more likely to view male-female relationships as
adversarial, less likely to use condoms, and less likely to believe that it is a male’s
responsibility to prevent pregnancy.
Studies that have explored and shown the relationships between gender role
stereotypes related to sexuality and relationship power and their implications for sexual
health have been conducted in many parts of the world including the United States
(Pulerwitz, Amaro, De Jong et al., 2002), Ghana (Ampofo, 2001), South Africa (Varga,
2003), Mexico (Marston, 2004), Nicaragua (Sternberg, 2000), and Thailand
(Tangmunkongvorakul, Kane, & Wellings, 2005). For example, Pulerwitz et al. found
that young women in the United States who perceived that they had low levels of
power in their relationships were much less likely to use condoms than women who
experienced high levels of relationship power. In their study of young people’s access
to health care in Thailand, Tangmunkongvorakul, Kane and Wellings found that young
women’s access and standard of care related to sexual health was compromised by
gender double standards favoring males and that this led the subjects to seek unsafe,
In describing gendered expectations for behavior related to sexuality, Ilkaracan and
Jolly (2007) illustrate additional examples of the oppressive nature of prevailing gender
scripts for both males and females.
…social influences around sexuality affect us all. Gender is one of those
influences, i.e., expectations about how women and men, boys and girls,
will behave differently from each other (as well as expectations that
everyone will be either male or female, and not transgender). Those who
conform to these expectations, such as girls who undergo female genital
mutilation or have an early marriage, may suffer to fit their sexualities into
limited and unequal channels. Boys may pay a price too. For example, in
places as diverse as Turkey, Pakistan and Brazil, many boys are taken to
brothels by their fathers, brothers or friends at an early age without
feeling willing or ready for such an experience, and sometimes finding it
traumatizing (p. 4).
Langen’s (2005) research in Botswana and South Africa provides a vivid example of
how gender power imbalance in sexual interactions curtails women’s ability to protect
themselves from HIV infection. Langen concluded from her studies that the public
health community must come to see sexual health as “the business of men” not just
women because simple educational messages such as instructing people to “use a
condom” are much less effective if they do not address these gender power
imbalances. Without the involvement of men and boys in sexual and reproductive
health programming, it will not be possible to genuinely empower women and girls.
Men and boys must be educated so that they are fully informed of the consequences of
their sexual behaviors and encouraged to take responsibility for their own sexual health
and take equal responsibility for the sexual health of their partners.
It is increasingly recognized that the basic principles of human rights extend to sexual
rights (WAS, 1999, WHO, 2004). The issue of gender inequality related to sexuality
therefore falls precisely within the realm of human rights (Ilkkaracan & Jolly, 2007).
These authors point out that resistance and retrenchment in the area of human rights
has frequently been based on the argument that cultural traditions, often specific to
gender and sexuality, can be held up to legitimately limit basic human rights. They also
note that appeals to cultural tradition that have been used to justify discrimination
against gays and lesbians have also functioned to curtail the sexual autonomy of
However, the notion that cultural tradition ought to limit human rights is waning in
many parts of the world and has been challenged by scholars (Mullally, 2006). While
respect for cultural tradition remains a justifiable aspiration, progressively larger
proportions of the global community are moving towards a recognition of women’s
right to reproductive and sexual health as evidenced by the ICPD endorsed definition
of reproductive health (U.N., 1994) as well as a recognition of the importance of
gender equality to global development as evidenced by MDG 3.
In other words, the conditions for meaningful progress in moving towards gender
equality in sexuality are increasingly falling into place.
Positive change is possible. An innovative program conducted in Rio de Janeiro, Brazil
focused on addressing gender norms among young men as a strategy to reduce HIV
risk (Pulerwitz, Baker, Segundo, & Nascimento, 2006). The program combined
interactive group education sessions for young men led by adult male facilitators with a
community-wide social marketing campaign to promote condom use that emphasized
gender-equitable messages. Among the findings of the program’s evaluation study was
that support for inequitable gender norms among young men at baseline was
significantly associated with HIV risk behavior, the program was able to effectively
promote gender equitable norms, and therefore lower HIV/STI risk.
A similar program conducted with men aged 18-29 in Mumbai, India was successful in
encouraging young men to critically discuss gender dynamics and health risks as well as
in advancing gender equitable norms related to sexuality (Verma, Pulerwitz, Mahendra,
et al., 2006). In their study of the gender dynamics in the primary sexual relationships
of rural South African women and men aged 18-24, O’Sullivan et al., (2006) found that
the traditional sexual script of male assertiveness and control and female passivity
predominated but that some young men and women had begun to internalize more
equitable gender norms for sexual relationships. The authors note that there is a lack of
new models of sexual relationship behavior and that the voices of men and women
expressing egalitarian norms could be utilized as peer leadership in sexual health
For girls and women accessing health care, particularly when it is reproductive health
care, the issues of sexual partnerships, sexual acts, sexual meanings, and sexual
drives/enjoyment should be addressed with individuals as part of the services offered.
In some cultures, males may hold their physicians in very high regard and, thus, these
professionals may be ideally placed to speak with men and boys about gender equitable
norms for sexual behavior. For boys and men who may seek out health care less often
or not at all, school-based education, media campaigns, and community opinion
leaders influential with males (e.g., sports stars) can be utilized to endorse
social/cultural norms that promote gender equality in the sexual realm.
The process of achieving gender equality has been gradual, with progress being uneven
across the many different cultures of the world.
There can be no doubt, however, that among the greatest changes in the social fabric
of the world community during the twentieth century was a significant trend to
question rigid patriarchal social structures and to move towards more gender equitable
In many ways, the strides that many cultures have taken in pursuit of gender equality
have been part of a larger process of extending fundamental and basic human rights to
oppressed and marginalized communities that have suffered discrimination based upon
race, ethnicity, religion, class, gender, sexual orientation, disability, and age. Clearly, the
process of attaining basic human rights by all peoples of the world is in its infancy.
And, in many cultures the same may be said with respect to the human right of equality
for girls and women. In articulating key priorities for global development, the United
Nations has definitively recognized the centrality of gender equality, making it one of
the eight MDGs. Furthermore, it must be recognized that many of the MDGs (i.e.,
reduce child mortality, improve maternal health, combat HIV/AIDS) are tied in
various ways to the attainment of girls and women’s right to sexual and reproductive
These rights, however, cannot be fully realized without basic equality of power within
Clinical programs related to sexual health can and should address these inequalities.
However, such programs, in-of-themselves, cannot bring about the profound social
change required to transform the communal and individual level scripts that shapes all
aspects of our sexual behavior.
Leadership in advocating for social change with respect to sexuality and gender equality
must permeate all levels of society. Political, religious and cultural opinion leaders
should advocate for gender equality in all realms of life including interpersonal
relationships and sexuality.
Fathers and mothers must teach their sons and daughters that equality means that girls
and women should have equal power in determining and negotiating sexual behavior
with their partners and that this equality of power extends to all types of sexual
relationships including marital relationships.
Sexuality education programs taught to youth in schools and other settings must be
gender sensitive as well as encouraging participants to think about sexuality and
relationships from the standpoint of principles of human rights, including gender
Popular entertainment media (music, movies/television, video, internet) is often
infused with sexual imagery and the makers of popular media should be encouraged to
create representations that model gender equality, not reinforce traditional sexual
scripts that perpetuate inequality. In sum, all levels of society must work collectively in
order to realize meaningful change in the realm of sexuality and gender equality. Failure
to address gender imbalances in sexual relationships will cripple broader efforts to
promote sexual health and to achieve MDG 3 in particular but also the Millennium
Development Goals in general.
2.1 The discourse of rights as it has been applied to the right of girls and
women to quality and sexuality education and services in international
agreements and covenants must explicitly include the fundamental right
to autonomy and equality within sexual relationships.
2.2 Policy makers and public opinion leaders must speak openly of the
fact that a substantial and important component of gender inequality is
directly related to power imbalances in sexual relationships.
2.3 Fathers and mothers and families and communities play key roles in
contributing to the formation of the gender roles of children. They
should be encouraged and assisted in helping their children to develop
gender equitable roles. Fathers, in particular, can be instrumental in
encouraging their sons to embody gender equitable conceptions of
2.4 To effectively reach their stated objectives, sexuality education
programs, particularly those aimed at youth, must address the genderbased
dynamics within sexual relationships and assist students in
developing and implementing gender equitable behavior.
2.5 Media portrayals, whether it is through music or visual representation,
frequently model in subtle and blatant forms, sexual scripts for young
people. The modeling of gender equitable sexual scripts in popular media
has the potential to make a powerful contribution to societal-wide gender
equality. The entertainment industry should, therefore, be strongly
encouraged by governments and the public at large to become a force for
positive change with regard to sexuality and gender.
2.6 Legal and policy change to ensure that women and men have equal
access to sexual health care services, regardless of income differentials,
without stigma, discrimination or bias by providers and the health
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Condemn, Combat, and Reduce all Forms of Sexuality Related Violence
Sexual health cannot be attained until people are
free of stigma, discrimination, sexual abuse,
coercion and violence.*
According to the World Health Organization (WHO, 2003) “sexual violence is
ubiquitous; it occurs in every culture, in all levels of society and in every
country of the world” (p. 1). The victims of sexual violence are young, old,
male and female, although women and girls are disproportionately the victims of all
types of sexual violence. The individual and societal consequences of sexual violence
are vast. A significant reduction, if not eradication of sexual violence will directly
impact upon achieving gender equality, improving infant and maternal health, as well
as interrupt in a number of ways, the epidemiological spread HIV/AIDS. As such, the
fight against sexual violence is an important component of attaining the Millennium
Development Goals (MDGs). This chapter will outline the role of reducing sexual
violence in achieving the MDGs, define sexual violence, summarize the prevalence and
consequences of various forms of sexual violence, and discuss and list strategies and
recommendations to reduce sexual violence.
*This chapter was informed by the WAS Expert Consultation in Oaxaca, Mexico, a thorough review of the
literature, and the background paper written by Ine Vanwesenbeeck (see Appendix IV and V).
In a recent report, the WHO (2005a) noted that the connection between preventing
violence against women and the MDGs is a reciprocal one. That is, “working towards
the MDGs will reduce violence against women; and preventing violence against
women will contribute to achieving the MDGs” (p.1). The same WHO report also
recognized sexual violence and intimate partner violence (intimate partner violence
often includes coerced sexual acts) as fundamental manifestations of the global
problem of violence against women. It must be stated and recognized by governments
and other public institutions in clear and certain terms that the achievement of MDG 3
(Empower Women and Promote Equality Between Women and Men) and MDG 6
(Reverse the Spread of Disease, Especially HIV/AIDS and Malaria) cannot be
achieved without a reduction and eventual elimination of sexual violence. In addition,
the rape of girls and women results in unintended pregnancy which, as detailed in other
sections of this document, has important implications for the achievement of a
number of the MDGs.
Sexual violence negatively impacts upon girls and women’s lives in multiple ways, but
first and foremost sexual violence prevents girls and women from exercising the most
basic and essential human rights. Sexual violence against girls and women not only
reflects the profound gender inequality that exists globally, sexual violence also acts as a
means of enforcing and perpetuating gender inequality. The centrality of gender
equality for sustainable human development has also been firmly established and
recognized by much of the international community including various United Nations
conferences and declarations such as the 1993 UN Declaration on the Elimination of
Violence Against Women. The UN Millennium Declaration makes the connection
through MDG 3. Although gender-based violence must ultimately be addressed as a
fundamental issue of human rights, it is relevant in the context of promoting
sustainable development to note its economic implications. According to a World
Bank report (Bott, Morrison & Ellsberg, 2005) “Gender-based violence poses
significant costs for the economies of developing countries, including lower worker
productivity and incomes, lower rates of accumulation of human and social capital, and
the generation of other forms of violence both now and in the future” (p. 12). Given
the centrality of sexual violence as a component of gender-based violence, the issues
raised by the WAS declaration on the critical need to eliminate sexual violence and
abuse must be addressed and utilized by the international community as a critical and
necessary component of the Millennium Development Goals process.
The World Health Organization (2002) defines sexual violence as:
any sexual act, attempt to obtain a sexual act, unwanted sexual comments
or advances, or acts to traffic, or otherwise directed, against a person’s
sexuality using coercion, by any person regardless of their relation to the
victim, in any setting, included but not limited to home and work (p.149).
Sexual coercion, which itself can be seen as a form of violence, can involve physical
force, psychological intimidation, blackmail or other threats or may occur when the
victim is unable to give consent, for instance when drugged, asleep or mentally
incapable of understanding the situation. Other descriptors closely related to sexual
violence, sometimes used synonymously, are: gender-based violence, violence against
women, and domestic violence. Violence that is perpetrated against a person because
of his or her sexuality and/or because of his or her actual or presumed sexual behavior
can also be considered a form of violence. Thus, physical violence and intimidation
directed at gay, lesbian, bisexual, and transgendered persons also constitutes a form of
The WHO (2002) specifies 11 different types of sexually violent acts:
* rape within marriage or dating relationships; rape by strangers;
* systematic rape during armed conflict;
* unwanted sexual advances or sexual harassment, including demanding
sex in return for favours;
* sexual abuse of mentally or physically disabled people; sexual abuse of
* forced marriage or cohabitation, including the marriage of children;
* denial of the right to use contraception or to adopt measures to protect
against sexually transmitted diseases;
* forced abortion;
* violent acts against the sexual integrity of women, including female
genital mutilation and obligatory inspections for virginity;
* forced prostitution and trafficking of people for the purpose of sexual
exploitation (p. 149-150)
Sexual violence is nearly always gender-based and disproportionately directed at girls
and women. For example, the UN Declaration on the Elimination of Violence against
Women includes a definition of violence against women that clearly captures the extent
to which sexual violence is involved in the harm of women. The Declaration defined
violence against women as:
physical, sexual and psychological violence occurring in the family and in
the general community, including battering, sexual abuse of children,
dowry-related violence, rape, female genital mutilation and other
traditional practices harmful to women, non-spousal violence and
violence related to exploitation, sexual harassment and intimidation at
work, in educational institutions and elsewhere, trafficking in women,
forced prostitution, and violence perpetrated or condoned by the state
The prevalence of various forms of sexual violence is, in many regions of the world,
difficult to determine. Most instances of sexual violence are not reported to the police
and are not well recorded by survey research. In other words, the scope of sexual
violence is not well documented and is vastly underreported. Most of what we know
about prevalence and incidence of sexual violence stems from police statistics, clinical
settings and population-based survey research. But there is a wide range of figures
reported, depending on the country, setting and/or sample studied, the definitions of
sexual violence used and data collection methods and procedures. There is enormous
cultural variation in the degree to which individuals are willing and have the capacity to
report sexual violence and there is equal variation in the extent to which police
departments and governments record the relevant figures.
Paradoxically, higher figures may be reported in countries where sexual violence has
been the subject of public debate, where attitudes towards sexuality and sexual violence
have become more open, and where awareness of sexual violence among the
population has risen. In these countries, acts of sexual violence are more likely to be
reported. The prevalence of sexual violence may well be higher in those countries
where sexuality and sexual violence are not talked about openly, where being a victim
of sexual violence is a source of shame and ostracism, and where some forms of sexual
violence are normatively accepted if not condoned. The WHO (2002) World Report
on Violence and Health notes that, globally, the number of instances of sexual violence
reported to police represents only a tip of the iceberg of the actual prevalence and that
survey research captures only an additional small percentage of actual cases. Thus, the
statistics presented below should be viewed with caution and in many cases
significantly under-estimate the magnitude of the problem.
Child Sexual Abuse and Forced Sexual Initiation
In addition to the limitations discussed above, the prevalence of child sexual abuse
(CSA) may be particularly susceptible to under reporting. For example, young children
may not recognize the inappropriateness of the act, particularly if the perpetrator is
known to them, and disabled children may not have the capacity to report it (Sapp &
Vandeven, 2005). Nevertheless, the available data are suggestive of the scope of the
problem. According to Sapp and Vandeven (2005) a review of the available research
suggests that, world-wide, the prevalence of CSA ranges from 11-32% for females and
4-14% for males and that in the United States studies have found that 22.3% of
females and 8.5% of males reported experiencing sexual abuse. A review of the data
from sub-Saharan Africa indicated incidence rates of CSA of 7-36% for females and 3-
29% for males (Lalor, 2004). In a multi-country study of the Caribbean, close to half of
sexually active females reported that their first sexual intercourse was forced (Halcon,
Beuhring & Blum, 2000 cited in WHO, 2002).
According to Tavara’s (2006) review of studies from both the developing and
developed world examining the prevalence of sexual violence, 10-33% of women of
reproductive age have been forced to have sex at least once in their life. In a series of
country studies conducted by the UN (cited in WHO, 2002), the percentage of women
that reported they had been sexually assaulted in the previous five years ranged from
0.8-4.5% in Africa, 1.4-5.8% in Latin America, 0.3-2.7% in Asia, and 2.0-6.0% in
Eastern Europe. There is relatively little data concerning the prevalence of sexual
violence against men. According to the WHO (2002) studies from the developed
world indicate that 5-10% of men report a history of CSA and a few population-based
studies of the percentage of males reporting that they have ever been the victim of
sexual assault found prevalence rates of 3.6% in Namibia, 13.4% in Tanzania to 20%
Sexual Violence as a Weapon of War
Systematic rape as an instrument of war has left millions of girls and women dead,
traumatized, forcibly impregnated, or infected with HIV or other STIs. There is little
accurate data available concerning the number of girls and women who have been
raped as a part of war (Watts & Zimmerman, 2002; Gottschall, 2004). Rape as an
instrument of war has existed throughout human history. Using a wide range of
sources, Gottschall compiled a partial list of countries where during the 20th century
mass rapes were reported to have been conducted by military or paramilitary forces.
This list includes Afghanistan, Algeria, Argentina, Bangladesh, Belgium, Brazil, Burma,
Bosnia, Cambodia, China, Congo, Croatia, Cyprus, East Timor, El Salvador, Germany,
Guatemala, Haiti, India, Indonesia, Italy, Japan, Korea, Kosovo, Kuwait, Liberia,
Mozambique, Nicaragua, Pakistan, Peru, Philippines, Russia, Rwanda, Serbia, Sierra
Leone, Somalia, Turkey, Uganda, Vietnam, Zaire, and Zimbabwe.
Intimate Partner Sexual Violence
Intimate partner violence perpetrated by husbands, wives, boyfriends, girlfriends, and
ex-partners is extremely common and a large percentage of these assaults are in the
form of sexual violence. The WHO (2002) review of population-based studies from
around the globe on the percentage of adult women reporting attempted or completed
forced sex by an intimate partner at some point in their lives found rates ranging from
6.2% in Yokohama, Japan to 42.0% in Durango, Mexico, 46.7% in Cusco, Peru, 29.9%
in Bangkok, Thailand, and 25.0% in Midlands Province, Zimbabwe. A more recent
WHO (2005a) multi-site study involving 10 countries found the percentage of women
reporting that they had been sexually assaulted by a partner to range from 6% in Japan
and Serbia and Montenegro to 59% in Ethiopia with most sites falling between 10%
and 50%. A survey of men in Cape Town, South Africa found that 15.3% reported
that they had committed sexual violence against an intimate partner in the previous
decade (Abrams, Jewkes, Hoffman & Laubsher, 2004).
Trafficking and Forced Prostitution
Reports published by the United States Department of State (cited in UNFPA, 2005)
indicate that between 600,000 and 800,000 people are trafficked each year, the majority
for the purposes of sexual exploitation and approximately 2,000,000 children, mostly
girls are believed to be sex slaves in the commercial sex industry. These figures do not
include women and girls who are bought and sold for sexual exploitation within
countries. According to the International Organization for Migration (cited in Watts &
Zimmerman, 2002) the number of women trafficked each year, mostly for the
purposes of forced prostitution, from different regions of the world is enormous with
250,000 coming from Asia, 100,000 from the former Soviet Union, 175,000 from
eastern and central Europe, 100,000 from the Caribbean and Latin America, and
50,000 from Africa. The WHO (2002) notes that significant numbers of trafficked
women and girls are sent to North America and Europe.
Female Genital Mutilation
According to the WHO (2000) between 100 million and 140 million girls have been
the victims of female genital mutilation (FGM) (i.e., the partial or total removal of the
external genitalia for cultural, religious, or other non-therapeutic reasons) and up to 2
million girls are subjected to the procedure each year. The practice occurs in 28 African
countries and is found in parts of the Middle East and Asia.
The negative impact of sexual violence on the individual victim and on society is wideranging
and far-reaching. The devastating impact on the victim causes physical and
psychological trauma that unfolds in a myriad of ways. Because sexual violence takes
many forms and therefore affects victims in a range of ways it is difficult to briefly
catalogue and summarize its impact on the individual and society. Discussed below are
only some of the many consequences of sexual violence.
In discussing the impact of sexual violence on the individual it should be recognized
from the onset that the victim may well be killed in course of or in the aftermath of a
sexual assault. A violent sexual assault may itself cause death or the victim may be
Depending on the degree of physical force used, physical trauma, both genital and
extragenital, may or may not be evident (Tavara, 2006). The most common types of
gential injuries include tears, bruising, abrasions, redness and swelling of the posterior
fourchette, labia minora, hymen, and/or fossa navicularis (WHO, 2003). Non-genital
physical injuries often include bruises and contusions, lacerations, ligature marks to
ankles, wrists, and neck, pattern injuries (i.e., hand prints, finger marks, belt marks, bite
marks) and anal or rectal trauma (WHO, 2003).
The short term physical consequences of FGM include severe pain, shock,
haemorrhage, urine retention, and ulceration of the genital region while longer term
consequences include cysts and abscesses, keloid scar formation, damage to the urethra
resulting in urinary incontinence, dyspareunia and other sexual dysfunctions, and
difficulties with childbirth (WHO, 2000).
Mental Health and Psychosocial Consequences
The psychological consequences of sexual violence vary considerably from person to
person. However, there can be little question that psychological impact of sexual
violence on the victim is often severe and debilitating. These short and long-term
(lasting for many years) outcomes include rape trauma syndrome, post-traumatic stress
disorder, depression, anxiety, social phobias, increased substance use, suicidal
behaviour, eating disorders, and sleep disturbances (WHO, 2003).
A number of studies have found an association between sexual assault and the
development of sexual dysfunctions among victims which may persist for years. In
particular, a review of the literature suggests that many women experience a significant
reduction in sexual pleasure and satisfaction and that over the long-term many women
experience sexual dysfunctions related to desire and arousal (Van Berlo & Ensink,
Sexual Violence and HIV/AIDS
Although in the Western world HIV/AIDS is sometimes thought of as a disease
primarily affecting men who have sex with men, it is important to recognize that
globally about half of those living with HIV/AIDS are female. In parts of the
developing world, such as sub-Saharan Africa, a majority of persons with HIV/AIDS
are female (WHO, 2005b). It is clear that many cases of HIV/AIDS are tied in one
way or another to sexual violence against women. The perpetrators of sexual violence
rarely use condoms, and because the often physically coercive nature of sexual violence
results in genital trauma, victims are at extremely high risk of sexually transmitted
infections including HIV infection (Tavara, 2006; WHO, 2003). Studies from Africa
clearly demonstrate the link between sexual coercion and increased risk for HIV
infection for women (Population Council, 2004). For example, one study from South
Africa (Dunkle et al, 2004, cited in WHO, 2005b) found that women who had a
violent or controlling partners had an HIV infection rate 50% higher than other
women and that abusive men were more likely than non-abusive men to be HIV+.
It is important to understand that sexual violence increases women’s HIV risk in
multiple ways. As the WHO (2001) report on sexual violence and HIV notes, “This
violence can contribute to women’s increased risk of HIV infection both directly
through forced sex and indirectly by constraining women’s ability to negotiate the
circumstances in which sex takes place and the use of condoms” (p. 7). A fear of
violence can easily prevent a woman from suggesting or insisting on condom use
(Maman, Campbell, Sweat, & Gielen, 2000). In addition, the risk for STI and HIV is
particularly high for women who have been trafficked for purposes of sexual
exploitation (WHO, 2002).
Sexual Violence and Unintended Pregnancy
Rape frequently results in unintended pregnancy (Stewart & Trussel, 2000). For
example, a study from the United States found that 5% of rape victims become
pregnant as a result of the assault (Holmes, Resnick, Kilpatrick, & Best, 1996) while a
study from Ethiopia found that 17% of adolescent women who were raped became
pregnant (Mulugeta, Kassaya, & Berhane, 1998 cited in Tavara, 2006). In many parts of
the world, girls and women who find themselves pregnant as a result of rape are forced
to either have the child or put their lives at risk with “back-street abortions” (WHO,
2002, p, 162). Needless to say, a girl or woman who has given birth to a child as a result
of rape has been unable to elect the time when her children are born.
A thorough discussion of the multiple causes of sexual violence is beyond the scope of
this brief report. Nevertheless, nearly all of these causes are rooted in an inescapable
and fundamental factor that must be grasped and confronted if meaningful progress
toward eliminating sexual violence is to occur. First and foremost we must clearly
understand and accept that most forms of sexual violence are related to, and occur in
the context of gender inequality and that sexual violence against women is more likely
under relatively strong patriarchal regimes. Cross-cultural research provides evidence
that the greater the asymmetry in power between the sexes is to the disadvantage of
women in a given culture, the more likely control of female sexuality as well as sexual
violence against women occurs (Wood & Eagly, 2002).
It is in this context of gender inequality and control that sexual violence must be
understood. As summarized by the WHO (2003),
Sexual violence is an aggressive act. The underlying factors in many
sexually violent acts are power and control, not as is widely perceived, a
craving for sex. Rarely is it a crime of passion. It is rather a violent,
aggressive and hostile act used as a means to degrade, dominate,
humiliate, terrorize and control women. The hostility, aggression and/or
sadism displayed by the perpetrator are intended to threaten the victim’s
sense of self (p. 9).
Throughout the world, sexual violence is pervasive and deeply rooted. An effective
approach to reducing sexual violence must therefore be broadly-based, addressing the
issue at the international, national, community, and individual levels of society.
International/National Action and Advocacy
The international community must play a pivotal role reducing sexual violence.
International recognition of the scope of the problem and the damaging effects of
sexual violence on the individual and on society is an initial first step but such
recognition must be followed up by action. International treaties, such as the UN
(1979) Convention on the Elimination of All Forms of Discrimination Against
Women set standards for national legislation and provide a lever to campaign for legal
reforms. In particular the shift from a needs-based approach to a rights-based
approach to sexual health has been important in relation to sexual violence. The
human rights framework has, among other things, helped to officially recognize the
experience of violence as a violation of human rights, it has helped challenge the false
public/private dichotomy of international law, has provided a feminist vocabulary for
international political documents, and has played a role in forming coalitions: “The
status of women of all regions and the diverse violations to their human rights, which
were previously hidden and silenced, have all surfaced, linking local movements to a
global women's movement that continues to grow”(Obando, 2004, online). For further
progress to be made, future international treaties and declarations focusing on human
rights and/or economic/social development must explicitly recognize, name, and
address sexual violence as a significant impediment to human well-being and progress.
National governments, because they possess substantive political and legal power, will
play the most important role in eradicating sexual violence. Governments must adopt
policies that explicitly recognize the problem of sexual violence. They must introduce
and enact effective legislation that makes all forms of sexual violence illegal (e.g., FGM,
marital rape) and includes the prosecution and punishment of perpetrators of sexual
violence. National governments must also launch public awareness campaigns to
discourage sexual violence and promote gender equality. Such campaigns must also
encourage the victims of sexual violence to access health care. Such campaigns must
also seek to educate and motivate boys and men to resist sexual violence both in their
own lives and in the lives of other men.
In some cases, national governments have taken steps to reduce sexual violence (Kelly,
2005: WHO, 2002). For example, some governments have implemented relatively
simple measures to encourage the reporting of sexual violence and improve sensitivity
among police and judiciary. Some have created dedicated domestic violence units and
sexual crime units, employed female examiners/investigators to perform forensic
examinations with female victims, used female court officials, and created women-only
police stations and courts for rape offences. The WHO (2002) notes that legal reforms
in many places have included broadening the definition of rape, reforming rules on
sentencing and on admissibility of evidence, and removing requirements for victims
accounts to be corroborated.
Health and Education Sector Actions
Health care facilities such as hospitals and clinics must be properly equipped to receive,
assess, counsel, and treat the victims of sexual violence. Adequate medical/health
services specific to the needs of sexual violence victims are often lacking. Facilities are
often not victim friendly and health care providers often lack training in sexual violence
and forensic evidence collection. Wide spread dissemination and implementation of
the WHO (2003) Guidelines for Medico-Legal Care for Victims of Sexual Violence
would represent a leap forward in the care of victims of sexual violence.
As noted above, FGM is a form of sexual violence that damages the health and wellbeing
of millions of girls and women. Although it is linked to sometimes deeply held
cultural and religious traditions, there is hope that professional and community groups
working together can make meaningful progress in discouraging the practice of FGM.
The WHO (2002) describes a campaign in Egypt in which government, health
organizations, and religious leaders have united in their opposition to FGM. Similar
efforts are required in African countries where FGM is still common. To be successful,
it will be important that local programs addressing FGM are tailored to the specific
cultural and/or religious factors influencing the practice of FGM. The participation of
community opinion leaders is vital if such programs are to succeed.
Sexuality education programs for youth, where they exist, very often focus narrowly on
HIV/STI and basic reproduction but do not directly address either gender equality or
sexual violence. Some progress in being made in providing high quality sexual health
education to increasing numbers of youth around the world (See Chapter 4). Such
programs provide an ideal opportunity to educate youth, during a time in life where
basic attitudes and values concerning sexuality are formed, on issues relevant to sexual
There are a wide range of community-based actions involving public health agencies,
community groups, media, as well as many others that can play an active role in
reducing sexual violence. They are to numerous to adequately address here (see WHO,
2002, 2003) but a few examples that target men are mentioned below.
The media can be used effectively to raise awareness and to campaign against sexual
violence. The WHO (2002) cites several examples from South Africa and Zimbabwe
where billboards, radio, and television have been used to communicate anti-sexual
violence messages. In addition, influential public figures, such as sports stars, need to
be increasing utilized to voice opposition to sexual violence and communicate healthy
messages concerning sexuality and gender equality to young men. Sports organizations
such as the Fédération Internationale de Football Association (FIFA) are ideally placed
to reach hundreds of millions of boys and men around the world with educational
messages to combat sexual violence. Involving media and sports organizations in
efforts to reduce sexual violence holds considerable promise as they have significant
potential to fundamentally transform values and customs that support the culture of
3.1 To be effective, laws, policies, and programs to reduce sexuality
related violence must address gender inequality with respect to human
rights and economic position. This includes legislation to prohibit all
forms of sexual violence and harassment against children, women, and
3.2 Comprehensive public health programs to raise awareness of the
need to address sexual violence are required. Complementary programs
aimed at the primary prevention of sexual violence must also be
instituted. Sexual violence prevention programs should be delivered to all
segments of society.
3.3 Effectively reducing the impact of sexual violence requires reform of
the health care domain. This includes eliminating all forms of
discrimination related to gender or sexual orientation within health care
systems and ensuring that health care personnel and the institutions in
which they work are adequately prepared to receive and treat the victims
of sexual violence
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Low Income Countries: A Global Review and Analysis. World Bank Policy Research Working Paper 3618.
Washington, DC: The World Bank.
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characteristics from a national sample of women. American Journal of Obstetrics and Gynecology, 175, 320-
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organized by the UN Division for the Advancement of Women, May 17-20 2005, Vienna, Austria.
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World Health Organization.
Provide Universal Access to
Comprehensive Sexuality Education and Information
To achieve sexual health, all individuals, including
youth, must have access to comprehensive sexuality
education and sexual health information and
ser vices throughout the life cycle.*
As noted at various points in this document, improving, maintaining and
promoting sexual health will play a significant and indispensable role in
achieving many of the Millennium Development Goals (MDGs). The eight
goals outlined in Sexual Health for the Millennium declaration statement are highly
inter-related. Universal access to comprehensive sexuality education is closely related,
and indispensable to the other sexual health objectives stated in the declaration all of
which have educational components. Individual and community awareness as well as
knowledge and acceptance of sexual health issues are pre-requisites for positive change.
Universal access to comprehensive and consistent sexuality education is an essential
component in the development of any successful strategy to promote sexual health in
the new millennium.
*This chapter was informed by the WAS Expert Consultation in Oaxaca, Mexico, a thorough review of the
literature, and the background paper written by Doortje Braeken and Melissa Cardinal (see Appendix IV and
As affirmed in the declaration statement, comprehensive sexuality education is a
process which ought to occur over the life-span. Our need for sexuality education does
not begin or cease with puberty. The life course developmental periods of childhood,
adolescence, young adulthood, middle age, and later life are all characterized by
different but equally important sexuality related developmental tasks and sexuality
education needs (Delamater & Friedrich, 2002). Youth however, warrant special
emphasis in our call for universal access to comprehensive sexuality education,
particularly with respect to the proposition that wide-spread implementation of
sexuality education programming will make a meaningful contribution to the MDGs. It
is also important because the provision of high quality sexuality education to children
and youth offers a foundation for knowledge, attitudes and skills that are essential to
the attainment of optimal sexual health, which can evolve with their changing needs
through out the life span.
Due to nearly universal access to schooling for youth in the developed world, schools
are often viewed as the ideal forum for implementing sexuality education. In the
developing world, on the other hand, access to schooling has traditionally been
severely limited with unequal opportunity according to gender, income and geographic
location. School-based sexuality education, therefore, held little promise of reaching a
plurality of youth in many communities. However, this is changing. As documented by
Loyd (2006), in her background paper for the U.N. Millennium Project, more and
more young people in developing countries, especially females, are attending school up
to and through the pubertal years. As Loyd illustrates, school attendance in-it-self can
have beneficial implications for sexual and reproductive health. Just as importantly, the
rapid growth of school attendance, although access is still far from universal, presents a
tremendous opportunity to scale up comprehensive sexuality education. It is crucial
that as school systems are created and expanded, renewed and reformed,
comprehensive sexuality education takes place as throughout the curriculum and is a
core component of it. Justification for inclusion will rest, in part, upon demonstrating
the links between sexuality education and sexual and reproductive health and
community development as envisaged by the MDGs.
With respect to general education, the primary purpose of educating children is to
prepare them for life. Hence, we teach them to read, write, problem solve, think
creatively etc. These are the skills they will use throughout their life times. With respect
to sexuality education more specifically, the information, attitudes and skills people
acquire as children and youth will influence their choices and impact on their general
sexual health as adults. Childhood, puberty and adolescence are critical periods for the
development of sexuality. Basic knowledge, formative attitudes, and healthy practices
that are learned before or as sexual activity begins are much more likely to be carried
forward consistently and into adulthood. For example, there is evidence to suggest that
young people who use condoms the first time they have intercourse are significantly
more likely to use condoms when they are older compared to those who have first
intercourse without condoms (Klavs, Rodrigues, Wellings, et al., 2005; Shafii, Stovel,
Davis et al., 2004). Thus, it is vital that youth be reached with comprehensive sexuality
education before becoming sexually active because for many youth around the world,
first sexual intercourse, if it is voluntary or not, can and does occur anytime after the
onset of puberty. It is also important that school-based comprehensive sexuality
education is linked to informal and complementary education that occurs in the
community and in the home.
To say that the global community is far from unified with respect to sexual values,
beliefs customs, and patterns of behavior is to state the obvious. This diversity
warrants sustained recognition and consideration in the formulation of strategy and
policy directed towards developing and implementing comprehensive sexuality
education programs that contribute on a global scale to the attainment of the MDGs.
Matters related to sex and reproduction are sensitive – enmeshed in
issues of culture and ideology of social institutions and personal identities.
In many countries, various cultural groups have different understandings
and positions on SRH (and on associated service provision). Public
discussion and attention may be limited so political divisions can be
avoided or because there is stigma attached. SHR has only become a fit
topic for international discussion and consensus within the last 10-15
years (UN Millennium Project, 2006, p. 4).
This observation gives us just a taste of the unique culturally specific contexts in which
sexuality education programs for youth occur – or don’t occur – across the globe. The
substance and character of these programs, or the lack of them, are often a very clear
and precise reflection of the cultural beliefs towards sexuality that exist in the
community. Clearly, religious, political, and social-moral stances on sexuality divide the
global community and this is a fundamental obstacle to a unified, shared approach to
the development and implementation of the comprehensive sexuality education that
would contribute to impact on not only the HIV/AIDS epidemic but on a host of
other issues such as gender equality and family planning. A very basic international
unity of approach and recognition of the need for comprehensive sexuality education
is required to underpin international agreements pertaining to sexual and reproductive
health and rights, to secure funding for programs, to share expertise, and to ensure
community engagement, active participation and ownership of programming. Given
the vast cultural diversity of beliefs related to sexuality, where do we begin in
developing a global strategy for comprehensive sexuality education?
Germain and Woods (2005) in writing about the need for an integrated approach to
HIV prevention note that “Global politics do not make HIV prevention strategies easy
or straightforward to operationalize” (p. 59). They propose, following the lead of the
2005 UNAIDS Prevention Strategy, that prevention programs be grounded in the
components of human rights, comprehensiveness, and an evidence base. A platform
incorporating these three components for proposing universal access to high quality,
comprehensive sexuality education follows.
Human and Sexual Rights
Existing commitments by governments to human rights and non-governmental
agencies to sexual rights as human rights provides us with a substantive and workable
beginning point to advocate for universal access to comprehensive sexuality education
within a broader framework of sexual health promotion. As noted elsewhere in this
document, the WHO (2002; 2006) Working Definition of Sexual Rights states that
sexual rights based upon already recognized national laws and international human
rights documents includes the right of all persons, free of coercion, discrimination and
violence to, among other things, obtain information about sexuality and receive
The call for universal access to comprehensive sexuality education is inseparable from,
and a key component of the demand to respect and promote human and sexual rights.
It is the recognition of basic human and sexual rights that must provide the
philosophical foundation for a global perspective on comprehensive sexuality
education. As discussed in more detail below, care must be taken to not inject external
presumptions concerning either the meaning and purpose of human sexuality or the
precise definition of comprehensive sexuality education that go beyond the basic rights
that have been the basis for international agreement. These conceptions must be
internally derived within the specific ethno-cultural communities in which sexuality
education is to be provided.
In describing comprehensive sexuality education, SIECUS (2001) specifies a number
of key concepts such as human development, relationships, personal skills, sexual
behavior, sexual health and society and culture. Very often the term comprehensive
sexuality education suggests that programs aimed at sexual risk reduction address both
delay of first intercourse or abstinence and condom/contraceptive use as viable
preventive measures. In this sense, the term comprehensive sexuality education is
simply used as a way of distinguishing such programs from so-called “abstinence-only”
programs which only promote refraining from sexual activity and do not address other
options, such as condom use, for people who are or who will become sexually active.
However, comprehensive sexuality education is a much broader term which implies a
rights-based approach that takes into account gender and is culture sensitive.
Together, the rights articulated in the WHO (2002; 2006) Working Definition of
Sexual Rights emphasize access to sexuality information and autonomous decisionmaking.
As stated above, and for the purpose of this section, the concept of
comprehensive sexuality education is one which includes and respects basic human
rights, provides broad based and accurate information and enables motivational and
skill building opportunities which enable individuals to make autonomous, informed
decisions about their sexual and reproductive health. In many western countries and
some developing nations these ideas and what they imply for the specifics of sexuality
education programs are well articulated and suitable for those cultures (see, for
example, SIECUS, 1991; Health Canada, 2003; Ministerio de Educacion, Chile, 2002).
The Pan American Health Organization (PAHO, 2000) has made the provision of
comprehensive sexuality education to the population at large one of its stated goals in
promoting sexual health. The PAHO recommendations include a specific nine-point
outline of the meaning and purpose of comprehensive sexuality education that are
consistent with a human and sexual rights perspective and can be effectively applied to
that region. In many other countries and regions, culturally specific and appropriate
conceptions of comprehensive sexuality education have yet to be specified as the
foundation for programming that reach large numbers of youth. Initiatives to do so
will be essential in establishing universal access to comprehensive sexuality education.
In some countries, but most particularly in the United States, ample funding and
advocacy for abstinence-only sexuality education programs is widespread. If we agree
that the ethical foundation of comprehensive sexuality education is rooted in basic
human rights and sexual rights that confer to each individual the indisputable right to
autonomous and informed decision making, it is evident that abstinence-only
programs fall out side this basic ethical perspective.
Programs that, by design, withhold the information necessary for individuals to make
voluntary, informed decisions are unethical and from the perspective of sexuality
education presented here, a violation of human rights.
Abstinence-only programs have been repeatedly shown to be ineffective in promoting
and sustaining behavioral change. In addition a large majority of abstinence-only sex
education programs have been shown to be ineffective in preventing sexual activity or
in reducing HIV/STI or unintended pregnancy. While a few abstinence-only programs
have been shown to modify attitudes towards abstinence and sexual behavior over
short periods of time (up to six months), no evaluated abstinence-only program has
resulted in delayed intercourse among abstinence program participants over longer
periods of time compared to control groups or groups receiving broad-based sexual
health education (Bennett & Assefi, 2005).
Despite U.S. federal government backing, including hundreds of millions of dollars in
funding, a recent review of program evaluations designed to measure the impact of
abstinence-only interventions implemented in the United States shows that they are
not only ineffective but potentially detrimental to public heath.
Abstinence-only programs show little evidence of sustained (long-term)
impact on attitudes and intentions. Worse, they show some negative
impacts on youth’s willingness to use contraception, including condoms,
to prevent negative sexual health outcomes related to sexual intercourse.
Importantly, only in one state did any program demonstrate short-term
success in delaying the initiation of sex; none of these programs
demonstrates evidence of long-term success in delaying sexual initiation
among youth exposed to the programs or any evidence of success in
reducing other sexual risk-taking behaviors Abstinence-only programs
show little evidence of sustained (long-term) impact on among
participants (Hauser, 2004, p. 4).
Given the evidence noted above, funding and implementing abstinence-only programs
should be considered as a poor use of valuable human and financial resources which
could be deployed to the planning, implementation and evaluation of coordinated,
cost-effective, evidence based programming. The abstinence-only approach restricts
the provision of information to one specific strategy for HIV/STI and unintended
pregnancy prevention, purposefully excluding information that can be utilized by those
who are or inevitably will become sexually active. Thus, the abstinence-only approach
is exclusionary, reflecting a narrow and specific point of view. The comprehensive
approach, on the other hand, is conceptually inclusive rather than exclusive, presenting
information on multiple strategies (including abstaining from sexual activity, delaying
first intercourse, reducing the number of sexual partners, as well as practicing safer sex)
for HIV/STI and pregnancy prevention.
In contrast to abstinence-only programs, comprehensive sexuality education programs
ensure that decisions about whether to have sex or not, decisions about if and when to
have children, and decisions about how to protect oneself and one’s partner from
HIV/STI are informed decisions based on choices that all people, including youth,
have a right to make based on their own self-defined values as well as the values of
their families and communities.
As opposed to the ineffectiveness of abstinence-only programs in reaching their
behavioral objectives, there is evidence to suggest that more comprehensive sexuality
education programs are able to help youth who have not been sexually active, to delay
first intercourse (e.g., Jemmott, Jemmott & Fong, 1998). That comprehensive sexuality
education is likely to be more effective than abstinence-only programming in enabling
youth to delay first intercourse may well be due to the fact that well developed
comprehensive sexuality education programs engage youth in the process of informed
decision making, enabling them to actively make choices to protect and enhance their
sexual health. Abstinence-only programs discourage youth from weighing alternatives
and making choices based on their own realities, needs, traditions, and values.
Evidence-Based Sexuality Education
The objectives of HIV/STI prevention and unplanned pregnancy prevention are
included in all conceptualizations of comprehensive sexuality education programs for
youth across the globe. Certainly, it is in meeting these objectives that universal access
to comprehensive sexuality education contributes most significantly to attaining the
There is growing and unequivocal evidence derived from peer-reviewed published
studies evaluating the behavioral impact of well designed sexual health interventions
that leads to the definitive conclusion that such programs are capable of significantly
reducing sexual risk behavior among youth (For reviews of this literature see Alford,
2003; Bennett & Assefi, 2005, Jemmott & Jemmott, 2000; Kirby, 2000; 2001; 2005).
With respect to HIV/AIDS prevention specifically, there is also clear definitive
evidence that educational interventions have the potential to significantly reduce high
risk sexual behaviour among individuals, including youth.
Albarracin, Gillete, Earl et al. (2005) conducted a comprehensive review and metaanalysis
of 354 HIV prevention interventions implemented from 1985 to 2003 in 33
different countries. Collectively, the interventions were shown to have increased
knowledge of HIV, as well as increase positive attitudes toward condom use, change
norms and intentions, improve behavioral skills, and increase actual condom use. The
Albarracin et al., analysis also revealed effective prevention education strategies for
different groups including youth.
More generally, there is an extensive body of HIV/STI prevention evaluation research
indicating positive behavioral outcomes for interventions targeting adolescents, street
youth, STI clinic patients, women, heterosexually active men, men who have sex with
men, and communities (CDC, 2001; McKay, 2000).
The vast majority of the HIV/STI and pregnancy prevention evaluation literature
concerning youth examines interventions implemented in the developed world (i.e.,
United States and Europe).
However, evidence of the effectiveness of prevention interventions from the
developing world is growing. In a recent review of controlled studies in both the
developed and developing world that employed experimental or quasi-experimental
designs to evaluate the impact of sexual health and HIV education programs on the
sexual behavior of youth, Kirby, Laris, & Rolleri (2005) identified programs from
Brazil, Thailand, Kenya, Nigeria, Belize, Mexico, Chile, Tanzania, and Nambia that
either helped individuals delay first intercourse, reduce their number of sexual partners,
or increase condom use. Wang, Hertog, Meir, et al. (2005) reported on a
comprehensive sexuality education program in China that resulted in increased
condom and contraceptive use.
The literature providing evidence of the effectiveness of comprehensive sexuality
education is compelling but it should not be construed as suggesting that all existing or
prospective programs will be effective in reaching their objectives. One of the crucial
lessons that we must learn from past experience is that there is no generic form of allpurpose
sexuality education that can be effectively applied to all audiences or contexts.
We must learn from both our successes and failures in order to create the most
effective programs possible. Fortunately, we have already learned a great deal about the
necessary ingredients of effective sexuality education. For example, a review and
analysis of the existing literature (e.g., Albarracin et al., 2005; Fisher & Fisher, 1998;
Kirby, 2005) suggests that programs are most likely to reach their behavioral objectives
if they contain the following ten key components:
1. Include a realistic and sufficient allocation of instructional time
and financial resources.
2. Provide educators with the necessary training and administrative
support to deliver the program effectively.
3. Employ sound teaching methods including the utilization of
theoretical models to develop and implement programming (e.g.,
IMB Model, Social Cognitive Theory, Transtheoretical Model,
Theory of Reasoned Action).
4. Use elicitation research to ascertain student characteristics,
needs, and optimal learning styles. This includes tailoring
instruction to student’s ethnocultural background, sexual
orientation, and developmental stage.
5. Specifically target negative sexual health outcomes such as
HIV/STI infection and unintended pregnancy.
6. Deliver and consistently reinforce prevention messages related to
sexual limit setting (e.g., delaying first intercourse, abstinence),
consistent condom use and other forms of contraception.
7. Include program activities that address the individual’s social and
environmental context including social pressures to engage in
unhealthy sexual behaviors.
8. Incorporate the necessary information, motivation, and skills to
effectively enact and maintain healthy sexual behaviors.
9. Provide clear examples of and opportunities to practice (e.g.,
role plays) sexual limit setting, condom negotiation, and other
communication skills. In effective programs, individuals are active
participants, not passive recipients.
10. Employ appropriate evaluation tools to assess program strengths
and weaknesses in order to enhance subsequent programming.
4.1 Mandate comprehensive rights-based, gender sensitive, and culturally
appropriate sexuality education as a required component of the school
curricula at all levels and provide the required resources.
4.2 Work with community agencies to reach out of school youth and
other high risk populations with comprehensive sexuality education.
4.3 Issue guidelines to ensure that sexuality education programs and
services are grounded in the principle of fully informed, autonomous
4.4 Ensure that sexuality education programs are evidence-based and
include the characteristics that have been shown to contribute to
effectiveness. This should be done in a way that allows for creativity and
community specific needs in the development and evaluation of
Alford, S. (2003). Science and Success: Sex Education and Other Programs That Work to Prevent Teen Pregnancy,
HIV and Other Sexually Transmitted Infections. Washington, DC: Advocates for Youth.
Albarracin, D., Gillette, J.C., Earl, A. et al. (2005). A test of major assumptions about behavior change: a
comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of
the epidemic. Psychological Bulletin, 131, 856-897.
Bennett, S. & Assefi, N., (2005). School-based pregnancy prevention programs: a systematic review of randomized
controlled trials. Journal of Adolescent Health, 36, 72-81.
CDC (2001). Compendium of HIV Prevention Interventions with Evidence of Effectiveness. HIV/AIDS Prevention
Research Synthesis Project. Atlanta, Georgia: Division of HIV/AIDS Prevention, Centers for Disease
Control and Prevention.
Delamater, J. Friedrich, W. (2002). Journal of Sex Research, 39, 10-14.
Germain, A. & Woods, Z. (2005). Women’s sexual and reproductive health and rights: a key to ending HIV/AIDS.
Development, 48, 56-60.
Fisher, W. & Fisher, J. (1998). Understanding and promoting sexual and reproductive health behavior: theory and
method. Annual Review of Sex Research, 9, 39-76.
Hauser, D. (2004). Five Years of Abstinence-Only-Until Marriage Education: Assessing the Impact. Washington,
D.C.: Advocates for Youth.
Health Canada. (2003). Canadian Guidelines for Sexual Health Education. Ottawa, ON: Health Canada.
Jemmott, J. & Jemmott, L. (2000). HIV behavioral interventions for adolescents in community settings. In J.L.
Petersen & R.J. DiClemente (Eds.) Handbook of HIV Prevention (pp. 103-124). New York: Plenum
Jemmott, J., Jemmott, L. & Fong, G. (1998). Abstinence and safer sex HIV risk reduction interventions for African
American adolescents: a randomized controlled trial. Journal of the American Medical Association, 279, 1529-
Kirby, D. (2005). Impact of Sex and HIV Education Programs on Sexual Behaviors of Youth in Developing and
Developed Countries. Research Triangle Park, NC: Family Health International.
Kirby, D. (2001). Emerging Answers: Research Findings on Programs to Reduce Teen Pregancy. Washington, DC:
National Campaign to Prevent Teen Pregnancy.
Kirby, D. (2000). School-based interventions to prevent unprotected sex and HIV among adolescents. In J.L. Petersen
& R.J. DiClemente (Eds.). Handbook of HIV Prevention (pp. 83-101). New York, NY: Plenum Publishers.
Klavs, I., Rodrigues, L., Wellings, K., et al. (2005). Increased condom use at sexual debut in the general population of
Slovenia and association with subsequent condom use. AIDS, 19, 1215-1223.
Loyd, C. (2006). Schooling and adolescent reproductive behavior in developing countries. Background paper to Public
Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development Goals. UN
McKay, A. (2000). Prevention of sexually transmitted infections in different populations: a review of behaviourally
effective and cost-effective interventions. The Canadian Journal of Human Sexuality, 9, 95-120.
Ministerio de Educación, Chile. (2002) Oportunidades para la Educación Sexual en el Nuevo Curriculum. Santiago de
Chile: Ministerio de Educación.
PAHO (2000). Promotion of Sexual Health: Recommendations for Action. Pan American Health Organization.
Shafii, T., Stovel, K., Davis, R., & Holmes, K. (2004). Is condom use habit forming? Condom use at sexual debut and
subsequent condom use. Sexually Transmitted Diseases, 31, 366-372.
SIECUS. (1991). Guidelines for Comprehensive Sexuality Education: Kindergarten – 12th Grade. New York, NY:
UN Millennium Project. (2006). Public Choices, Private Decisions: Sexual and Reproductive Health and the
Millennium Development Goals. UN Millennium Project.
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WHO. (2006). Defining Sexual Health: Report of a technical consultation on sexual health, 28-31 January 2002,
Geneva: Author, Switzerland: World Health Organization. Retrieved March 28, 2007 from
Ensure that Reproductive Health Programs Recognize the Centrality of Sexual Health
Reproduction is one of the critical dimensions of human sexuality
and may contribute to strengthening relationships and personal
fulfillment when desired and planned. Sexual health is a more
encompassing concept than reproductive health. Current
reproductive health programs must be broadened to address the
various dimensions of sexuality and sexual health in a
Sexuality is among the most fundamental aspects of our lives and yet it has long
been the silent partner in sexual and reproductive health (SRH) programming.
Securing the recognition that promoting reproductive health is an important and
legitimate component of the sustainable development of communities and societies
has been slow, uneven, and tenuous. Furthermore, conceptually uniting sexual health
with reproductive health under the unitary banner of Sexual and Reproductive Health
has, particularly in the international development dialogue, been particularly
inadequate. Agreement upon and implementation of high quality sexual and
reproductive health programming has often been sacrificed to political, religious, and
ideological interests; the end result being the considerable, but avoidable, increased
morbidity, mortality and infringement of fundamental human rights.
literature, and the background paper written by Angela Heimburger/Victoria Ward (see Appendix IV and V).
This chapter provides an overview of the growing recognition that access to sexual and
reproductive health care is necessary in order to reach the United Nations Millennium
Development Goals (MDGs). This is followed by a discussion of the lack of a positive
approach to human sexuality in reproductive health programming, the importance of
fully integrating sexuality and sexual health within such programming, and the necessity
to adequately train health care providers in human sexuality and sexual health.
The 4th International Conference on Population and Development (ICPD) held in
Cairo, Egypt in 1994 and attended by government representatives from 179 countries
has been accurately described as a “watershed” in international agreement and
acceptance of the concepts of reproductive rights and sexual and reproductive health
(Haslegrave, 2004). The conference attendees not only collectively called for universal
access to sexual and reproductive health services by 2015, the ICPD definition of
reproductive health produced at the conference represented a quantum leap forward in
recognizing and understanding the true breadth of reproductive health and the degree
to which sexual health and reproductive health are a single entity that cannot be
segmented. The definition of reproductive health developed at the ICPD conference
appeared to make explicitly clear that sexual health cannot be ignored or extracted
from the concept of reproductive health. Not only was reproductive health now
legitimately recognized as crucial to the development process, but sexual health was
recognized as being inextricably interwoven with it. The full definition of reproductive
health that emerged from ICPD bears repeating here:
Reproductive health is a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity, in all
matters relating to the reproductive system and to its function and
processes. Reproductive health therefore implies that people are able to
have a satisfying and safe sex life and that they have the capability to
reproduce and the freedom to decide if, when and how often to do so.
Implicit in this last condition are the right of men and women to be
informed and to have access to safe, effective, affordable and acceptable
methods of family planning of their choice, as well as other methods of
their choice for regulation of fertility are not against the law, and the right
of access to appropriate health-care services that will enable women to go
safely through pregnancy and childbirth and provide couples with the
best chance of having a healthy infant. In line with the above definition
of reproductive health, reproductive health care is defined as the
constellation of methods, techniques and services that contribute to
reproductive health and well-being by preventing and solving
reproductive health problems. It also includes sexual health, the purpose
of which is the enhancement of life and personal relations, and not
merely counseling and care related to reproduction and sexually
transmitted diseases (UN, 1995).
Among the significant aspects of the ICPD definition of reproductive health was that
it did not incorporate sexual health only in terms of fertility control and STI/HIV
prevention but also conceptualized sexual health in terms of “enhancement of life and
personal relations” and a “satisfying and safe sex life”. In other words, the ICPD
definition of reproductive health went beyond looking at sexual health simply as a
matter of problem prevention and progressively defined it in positive terms. This
represented an important shift away from the traditional negatively oriented approach
to sexuality to a more positive, life enhancement approach that had long been
advocated by health promotion workers addressing reproductive health.
Despite the advances in conceptualizing sexual and reproductive indicated by the
ICPD definition, as Correa and Parker (2004) have observed, “…since Cairo, sexuality
has increasingly been ignored in (or taken off) the reproductive health agenda” (p. 20).
To compound the situation further is the seeming de-emphasis of reproductive health
more generally within the global development agenda as evidenced most profoundly
be the omission of sexual and reproductive health from the Millennium Development
Goals (MDGs) (Glasier et al., 2006). This, despite the fact that advances in sexual and
reproductive health are so clearly necessary if the overall objectives of the MDGs are
to be achieved. Various explanations for the de-emphasis or outright disappearance of
sexual and reproductive health have been proffered, ranging from the notion that the
ICPD conceptualization of reproductive health was too ambitious to the prioritization
of HIV/AIDS in the global health agenda. Others have been more forthright. Glasier
et al., (2006) state emphatically that
Sexual and reproductive health services are absent or of poor quality and
underused in many countries because discussion of issues such as sexual
intercourse and sexuality make people uncomfortable. The increasing
influence of conservative political, religious, and cultural forces around
the world threatens to undermine progress made since 1994, and
arguably provides the best example of the detrimental intrusion of
politics into public health (p. 1).
Fortunately, a number of positive developments have occurred since the exclusion of
explicit reference to sexual and reproductive health in the Millennium Declaration.
Firstly, several influential non-governmental organizations have issued extensive,
research-based reports demonstrating the importance of addressing sexual and
reproductive health in order to achieve the MDGs. These included the Alan
Guttmacher Institute report Adding it Up: The Benefits of Investing in Sexual and
Reproductive Health (Singh, Darroch, Vlassoff, & Nadeau, 2003) and Family Care
International’s (2005) Millennium Development Goals and Sexual and Reproductive
Health. The World Health Organization has also played a key role in re-establishing the
centrality of reproductive health with it’s Reproductive Health Strategy to Accelerate
Progress Towards the Attainment of International Development Goals and Targets
(WHO, 2004a) and more recently, Accelerating Progress Towards the Attainment of
International Reproductive Health Goals: A Framework for Implementing the WHO
Global Reproductive Health Strategy (WHO, 2006). Most importantly, world leaders
officially recognized that providing access to reproductive health services as envisaged
by ICPD was necessary in order to make progress toward attaining the MDGs as
outlined in the World Summit Outcome document (UN, 2005).
Finally, this work has culminated in the United Nations (2006) report Public Choices,
Private Decisions: Sexual and Reproductive Health and the Millennium Development
Goals. This report acknowledges clearly and explicitly that improved access and
delivery of sexual and reproductive health services will significantly contribute to
combating HIV/AIDS, promoting gender equality, improving maternal and child
health, and fighting poverty. The report specifically recommends incorporating sexual
and reproductive health into both national poverty reduction campaigns and national
health systems as well as provides an outline of strategies to accomplish these goals.
In sum, although the years following the watershed ICPD conceptualization of
reproductive health, that placed sexual health front and center within it, was followed
by disappointment, particularly with the exclusion of sexual and reproductive health
from the MDGs, recent years have seen significant progress in the re-emphasis of
sexual and reproductive health as an instrumental part of the global development
process. In addition, it has been noted that access to and delivery of reproductive
health services has improved in many parts of the developing world (Haslegrave, 2004;
Langer, 2006; UN, 2006). For example, Haslegrave points out that:
Countries such as Mexico, Ghana, South Africa and Thailand, to name
only a few examples, have show considerable success in integrating
sexual and reproductive health care into primary health care. In doing so,
they have shown that sexual and reproductive must be seen within the
context of health in general and not as a separate component. Sexual and
reproductive health must be considered in this way so as to ensure that it
continues to be regarded as part of “mainstream” health services (p. 16).
Glasier et al. (2006) note that sexual and reproductive health is now fully recognized as
being essential for achieving the MDGs, that the World Summit reaffirmed the goals
of universal access to reproductive health care by 2015, and that if these two
developments are translated into actions, significant progress in sexual health
promotion is possible.
As the ICPD definition of reproductive health makes clear, reproductive health entails
much more than reproductive function, fertility control, and the prevention of
STI/HIV, it also includes the “enhancement of life and personal relations.” In terms of
its impact on human development, the function of human sexuality extends well
beyond reproduction as it plays a pivotal role in interpersonal relationships as an
expression of intimacy and affection and sexuality is potentially a source of immense
pleasure that contributes significantly to quality of life for many people. Sexuality and
sexual health are pertinent throughout the lifespan, not just during the reproductive
years. Sexuality and sexual health are central to all people whether they are homosexual,
bisexual, or heterosexual and whether they reproduce or not. In reality, sexuality
should not be viewed as a component of, or add-on to reproductive health. Rather,
reproductive health is more accurately seen as one key aspect of a broader, more
encompassing sexual health.
The integration of sexuality into public health generally and reproductive health
specifically is to conceptualize and define sexuality as a matter of health and well-being
rather than as something that should be seen in terms of morality (see Giami, 2002).
While public health approaches to sexuality have not excluded moral concerns and
have emphasized the importance of equitable and mutually respectful behavior, the
acceptance of sexual and reproductive health programs continues to meet ideological
resistance. As Langer (2006) points out with regard to successes and setbacks for
Increased conservatism in some donor countries has taken a heavy toll
on the efforts to advance the international agenda on sexual and
reproductive health and rights. Indeed, contrary to scientific evidence,
conservative forces interpret the ICPD Programme of Action’s call for
information and services for young people as promoting promiscuity and
irresponsible behaviour. This situation exposes millions of women, men,
and young people to HIV/AIDS, unwanted pregnancies, and unsafe and
illegal abortions (p.1553).
The disconnect between sexual health and reproductive health is clearly grounded in a
traditional and deeply rooted negatively oriented conceptualization of the nature and
purpose of human sexuality. Within this paradigm, sexuality and sexual health are not
often discussed openly between health care providers and their clients. At the public
policy level, in many cases, initiatives aimed explicitly at sexual health are themselves
At another, but equally important level, when and where the concept of sexual and
reproductive health has been recognized as a legitimate aspect of public health, it has
been overwhelmingly oriented towards a conceptualization of human sexuality that
emphasizes negative outcomes rather than positive outcomes such as satisfactory
sexual activity and relationships. Clearly, the sole emphasis on preventing negative
outcomes is more congenial to ideological perspectives that fear that integrating
positive outcomes will subvert traditional conceptions of sexual morality. This has led,
in many respects, to a desexualization of many reproductive health programs. Parker,
DiMauro, Filiano and Garcia (2004) discuss the distinction between negative sexual
rights and positive sexual rights; negative sexual rights concern freedom from, for
example, violence and abuse, whereas positive sexual rights concern freedom for, for
example, sexual expression and pleasure. Parker et al., note that it has been far easier to
advance negative sexual rights than positive sexual rights. To fully integrate sexual
health with reproductive health requires that programming appropriately balance
positive and negative sexual rights.
Another difficulty that predisposes the sexual and reproductive health field towards a
focus on negatives outcomes is that negative outcomes are, in most cases, far easier to
quantify and measure as compared to positive outcomes. For example, the incidence
and prevalence of sexually transmitted infections can be objectively measured in a
number of ways whereas individual’s necessarily subjective assessments of their own
sexual well-being including improvements in sexual and relationship satisfaction are far
more difficult to measure. As the UN (2006) report on sexual and reproductive health
puts it, attaining good health is much more than simply avoiding diseases, and this is
more the case with respect to sexuality than in other aspects of health:
Indeed, much of our personal identity as well as our social and personal
relationships hinge on this part of our lives – which is closely related to
our overall health and well-being. Today’s measurement tools are not
able to capture such positive aspects of health and well-being (p. 32).
As Parker, et al., (2004) point out “Currently, feminists, gay and lesbian activists, and
HIV/AIDS nongovernmental organizations (NGO) are fighting to extend the
definition of sexual rights to the enablement and even celebration of sexual diversity
and sexual pleasure” (p. 368). And, there have been some successes: the focus on
positive sexuality in the ICPD definition of reproductive health being first and
Although not an official policy of the organization, it is encouraging that the WHO
(2004b) working definitions of sexual rights includes the right to “pursue a satisfying,
safe and pleasurable sexual life” (p. 3) as this may enhance the focus on positive sexual
health outcomes for sexual and reproductive health programmers who look to the
WHO for guidance. We are increasingly seeing more balance between negative
outcomes and positive outcomes in approaches to sexual and reproductive health.
For example, Health Canada’s (2003) Canadian Guidelines for Sexual health Education
conceptualize sexual health education as being aimed both at sexual health behavior to
prevent sexual problems (i.e., unwanted pregnancy, STI/HIV, sexual
harassment/abuse, sexual dysfunction) as well as “sexual health enhancement” (e.g.,
positive self-worth and self-image in acceptance of one’s own sexuality, integration of
sexuality into mutually satisfying relationships) (p. 15).
Equally significant is the growing awareness and understanding that “pleasure and
prevention” go hand in hand. Recognizing, accepting, and incorporating the fact that
people experience sexual desire and seek sexual pleasure into programs aimed at sexual
and reproductive health problem prevention will contribute to the effectiveness of
such programs (Philpott, Knerr, & Boydell, 2006; Philpott, Knerr, & Maher, 2006).
Programs and services addressing reproductive health must fully recognize and
account for the reality that reproductive health is deeply and inextricably linked to
sexuality and that our sexuality is an expression of our human desire for pleasure and
interconnection with others.
The growing recognition that sexual health and reproductive health are inseparable as
evidenced by ICPD and that the promotion of sexual and reproductive health is an
important in striving to achieve the MDGs as evidenced by the UN (2006) Public
Choices, Private Decisions document are extremely positive developments. But, as
noted previously, most societies around the world are primarily sex negative in
orientation and/or anxiety ridden with respect to sexuality. And not surprisingly, as a
result, many reproductive health care providers and their clients are uncomfortable
with the prospect of discussing what has often been a highly taboo subject. Despite the
fact that this culturally imposed silence around sexuality has served to increase the
potentially negative outcomes of not addressing sexuality in reproductive health
programs, very few reproductive health care providers have been trained specifically to
address sexuality issues with their clients.
The importance of training reproductive health care workers to fully integrate issues of
sexuality in their work has been recognized by the Pan American Health Organization
(PAHO) (2000) Promotion of Sexual Health: Recommendations for Action.
According to PAHO, “Due to the obvious connection between reproductive health
and human sexuality, it is often assumed that taking care of the reproductive aspects of
health will be enough to satisfy the needs posed by the right to sexual health, but this
assumption is incorrect” (p. 43). The PAHO recommendations indicate that
reproductive health care workers require in-depth training in human sexuality and
suggest that sexual health training curricula be adapted to the cultural context in which
they are delivered.
The integration of sexuality and reproductive health within reproductive health
programs has, despite notable setbacks, advanced considerably in recent years. The
ICPD definition of reproductive health clearly established the inherent interconnection
of sexual health and reproductive health. Although the exclusion of reproductive
health from the MDGs was regrettable, the omission has been substantially rectified by
the UN (2005; 2006) recognition that promotion of sexual and reproductive health is
necessary in order to achieve the MDGs.
THE PAHO RECOMMENDATIONS FOR REPRODUCTIVE HEALTH CARE WORKERS TRAINING IN HUMAN SEXUALITY
* Basic knowledge of human sexuality
* Extensive knowledge in human reproduction and the means for its
regulation that takes into account broader sexual rights concerns
* Awareness of personal attitudes towards one’s own and other people’s
sexuality which should include a respectful attitude towards persons with
different sexual orientations and sexual practices
* Basic skills in identifying, counseling and, if necessary, referring to the
appropriate professional, problems of sexual health.
PAHO, 2000 (p.44)
The UN (2006) Public Choices, Private Decisions: Sexual and Reproductive Health
and the Millennium Development Goals provides an operational strategy and a
comprehensive series of recommendations including:
* Integrating sexual and reproductive health analyses and
investments into national poverty reduction strategies
* Integrating sexual and reproductive health services into
strengthened health systems
* Systematically collecting data pertinent to sexual and
* Acting on the UN Millennium Project reproductive health Quick
* Meeting the sexual and reproductive health needs of special
populations with unmet needs (e.g., adolescents, men).
These recommendations are laudable and necessary and success in reaching the MDGs
will be significantly dependant on the extent to which they are reflected in policy that is
translated into concrete action. Furthermore, the relevance to people’s lives, as well as
effectiveness and success of these initiatives will be dependant upon the degree to
which sexuality and sexual health issues are recognized and integrated with
reproductive health in programming.
5.1 Government and transnational policy and policy statements regarding
reproductive health funding and mandating of services must include, in
accordance with International Conference on Population and
Development (ICPD), specific reference to sexual health.
5.2 Sexual and reproductive health programming should include a clear
commitment that such programming will fully reflect and incorporate the
WHO working definitions of sexual rights.
5.3 Sexual and reproductive health programming should recognize and
reflect the positive aspects of human sexuality and be aimed in a balanced
way toward positive as well as negative outcomes.
5.4 All reproductive health providers should receive, through pre-service
and in-service training the knowledge, comfort level, and skills to
effectively address sexuality and sexual health in their work.
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NY: Family Care International.
Giami, A. (2002). Sexual health: the emergence, development, and diversity of a concept. Annual Review of Sex
Research, 13, 1-35.
Glasier, A., Gulmezoglu, A.M., Schmid, G.P. et al. (2006). Sexual and reproductive health: a matter of life and death.
The Lancet, (published online November 1, 2006).
Haslegrave, M. (2004). Implementing the ICPD Programme of Action: What a Difference a Decade Makes.
Reproductive Health Matters, 12, 12-18.
Health Canada. (2003). Canadian Guidelines for Sexual Health Education. Ottawa, ON: Health Canada.
Langer, A. (2006). Cairo after 12 years: success, setbacks, and challenges. The Lancet, 368, 1552-1554.
PAHO. (2000). Promotion of Sexual Health: Recommendations for Action. Washington, DC: Pan American Health
Parker, R., Dimauro, D., Filiano, B., & Garcia, J. (2004). Global transformations and intimate relations in the 21st
century: social science research on sexuality and the emergence of sexual health and rights frameworks.
Annual Review of Sex Research, 14, 362-398.
Philpott, A., Knerr, W., & Boydell, V. (2006). Pleasure and prevention: when good sex is safer sex. Reproductive
Health Matters, 14 (28), 23-31.
Phippott, A., Knerr, W., Maher, D. (2006). Promoting protection and pleasure: amplifying the effectiveness of barriers
against sexually transmitted infections and pregnancy. The Lancet, 368, 2028-2031.
Singh, S., Darroch, J.E., Vlassoff, M., & Nadeau, J. (2003). Adding It All Up: The Benefits of Investing in Sexual and
Reproductive Health Care. New York, NY: The Alan Guttmacher Institute.
UN. (1995). Report of the International Conference on Population and Development, Cairo, September, 1994. New
York, NY: United Nations.
UN. (2005). World Summit Outcome. New York, NY: United Nations.
UN. (2006). Public Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development
Goals. New York, NY: United Nations.
WHO. (2004a). Reproductive Health Strategy to Accelerate Progress Towards the Attainment of International
Development Goals and Targets. Geneva, Switzerland: World Health Organization.
WHO. (2004b). Progress in Reproductive Health Research, No. 67, Geneva Switzerland: World Health Organization.
WHO. (2006). Accelerating Progress Towards the Attainment of International Reproductive Health Goals: A
Framework for Implementing the WHO Global Reproductive Health Strategy. Geneva, Switzerland: World
Halt and Reverse the Spread of HIV/AIDS and other Sexually Transmitted Infections
Universal access to effective prevention, voluntary
counseling and testing , comprehensive care and treatment
of HIV/AIDS and other STI are equally essential to
sexual health. Programs that assure universal access must
be scaled up immediately.*
The importance of addressing HIV/AIDS as a fundamental and necessary
component of the global development process is clearly recognized and
accepted by the international community as evidenced by the United Nations
Millennium Declaration (UN, 2000) and the eight Millennium Development Goals
(MDGs) which include specific reference to the need to halt and reverse the growth of
the HIV/AIDS pandemic. The majority of the over 4 million HIV infections that are
currently acquired every year are sexually transmitted, primarily through unprotected
sexual intercourse. This fact places sexual health promotion, particularly through
interventions intended to reducing risk of exposure to the virus without hampering
sexual satisfaction and wellbeing, front and center in the broader effort to stem the
HIV/AIDS epidemic and achieve the MDGs.
literature, and the background paper written by Sarah Hawkes (see Appendix IV and V).
This chapter begins by documenting the extent and impact of sexually transmitted
infections (STI) and HIV/AIDS on the global community with particular emphasis on
the developing world. Evidence for the behavioral and cost-effectiveness of STI/HIV
prevention and control programming will be presented. In particular, the effectiveness
of STI/HIV sexual risk reduction interventions is stressed.
Insufficient availability of effective programs along with a lack of access to methods of
prevention (e.g. condoms) represent an important obstacle to efforts to contain and
reverse the STI/HIV epidemics that are striking the developing world.
The importance of respecting the right to informed decision making and the
empowerment of young people, women, and men in all aspects of the funding,
implementation, and promotion of STI/HIV prevention is discussed. This chapter
concludes with recommendations that emanate from this discussion presented in
conjunction with UNAIDS (2007) policy recommendations for HIV prevention.
HIV/AIDS: The Numbers Tell the Story
A comprehensive report on global HIV/AIDS statistics is presented in the UNAIDS
2006 Report on the Global AIDS Epidemic. The numbers clearly indicate the extent
to which HIV/AIDS represents a monumental global health challenge and an
immense obstacle to development.
According to WHO (2006) and UNAIDS (2006) it is estimated that by the end of
2005, between 33.4 million and 46.0 million people were living with HIV, an estimated
4.1 million adults and children became newly infected with HIV in 2005 and
approximately 2.8 million people died of AIDS.
In sub-Saharan Africa, the region with the largest burden of HIV/AIDS, it is estimated
that 24.5 million people aged 15-49 years are infected with HIV. While HIV prevalence
appears to have declined in several African countries such as Kenya and Zimbabwe, it
has levelled off at what UNAIDS calls “exceptionally high levels” in others and in
other African countries, most notably South Africa where 18.8% of the adult
population is HIV+ the epidemic continues to expand (UNAIDS, 2006). With respect
to sub-Saharan Africa, it is important to note that half of all new HIV infections occur
among people under the age of 25 (Monasch & Mahy, 2006).
A similar situation is reported in the Caribbean, the second most affected region in the
world after sub-Saharan Africa (in terms of prevalence among the adult population)
According to UNAIDS (2006), at the end of 2005, 8.3 million people in Asia aged 15-
49 were living with HIV. Two thirds of them were living in India. About 1.6 million
people in Latin America and 1.5 million in Eastern Europe and Central Asia were
living with HIV. The prevalence of HIV in the various regions of the world at the end
of 2005 was 6.1% in sub-Saharan Africa, 1.6% in the Caribbean, 0.8% in Eastern
Europe and Central Asia, 0.5% in Latin America, 0.5% in North America, Western
and Central Europe, 0.4% in Asia, 0.3% in Oceania, and 0.2% in North Africa and the
Middle East. Overall, these statistics demonstrate that HIV is a disease that
disproportionately affects poor and developing countries.
STIs: A Significant but Often Neglected Global Health Problem
Sexually transmitted infections (STI) account for a significant portion of the morbidity
and mortality in the developing world because of their damaging effects on
reproductive and child health and their role in facilitating HIV transmission (Aral,
Over, Manhart & Holmes, 2006). STI are important co-factors in the growth of the
HIV epidemic because they increase the susceptibility of STI infected individuals to
HIV infection when they are exposed to the virus and also because they augment the
infectivity of people living with HIV by causing an increase in the shedding of HIV in
genital secretions. An estimated 340 million curable STIs (Gonorrhoea, Chamydia,
Syphilis, Chancroid, Trichomoniasis) are contracted each year and in developing
countries, complications from STI’s are among the top five reasons that adults seek
health care (WHO, 2001). Incidence rates of curable STIs are disproportionately high
in the developing world. For example, the curable STI incidence per 1000 rates in 1995
were 254 in sub-Saharan Africa, 160 in South and South East Asia, 145 in Latin
American and the Caribbean but only 91 in North America (WHO). Viral STIs
(Human papillomavirus [HPV], Herpes simplex virus) are among the most common
human infections and also have significant negative health outcomes. The list of
negative outcomes resulting from STI is long and includes pelvic inflammatory disease,
ectopic pregnancy, chronic pelvic pain in women, miscarriage, premature delivery,
neonatal and infant infections, infant blindness, infertility in both women and men,
cervical cancer, other genital cancers, liver failure/cancer, and central nervous system
disorders (Aral, et al). Complications from STI disproportionately affect women and
children, particularly in developing countries where women are relatively
disempowered and access to health care is limited. Cervical cancer, caused primarily by
HPV, is a leading cause of cancer deaths among women globally and the highest rates
of cervical cancer are found in the developing world (Schiffman & Castle, 2005).
STI/HIV and the MDGs
In many developing countries HIV/AIDS has such a profoundly crippling effect on
the larger society that it inhibits the ability of key social institutions such as schools,
health care facilities, law enforcement, civil and social services to function properly if at
all. It has been estimated that in developing countries HIV/STI account for 17% of
economic losses caused by ill-health (Mayaud & Mabey, 2004).
The devastating impact of HIV/AIDS on the economic development of Africa is well
documented. It is estimated that the HIV/AIDS epidemic has already reduced average
economic growth rates by 2-4% a year across Africa (Dixon, McDonald, & Roberts,
The prevention of STIs is a major public health priority in its own right and can be
linked to the MDGs in multiple ways such as, for example, the linkage between access
to effective STI prevention and treatment services and a subsequent beneficial impact
on maternal and child health. For example, with an estimated two million pregnant
women affected by ‘active’ syphilis infections annually it is estimated that up to 80% of
these pregnancies will be adversely affected by the infection (Schmid, 2004).
Reducing STI prevalence also contributes to the MDGs in that it is well established
that persons with ulcerative or non-ulcerative STI are by several orders of magnitude at
increased risk for infection when exposed to HIV (Fleming and Wasserheit, 1999).
Lack of access to STI prevention, diagnosis, and treatment feeds the HIV epidemic in
many developing countries. In other words, effective STI prevention and control
programming will not only have a beneficial impact in of-it-self, it will contribute to
curbing HIV/AIDS incidence.
Efforts to achieve MDG 6 to reverse and halt the spread of HIV/AIDS will require
the commitment of massive but limited resources. It is therefore crucial that STI/HIV
prevention and control programs be efficiently delivered and cost-effective.
STI/HIV Prevention Interventions are Cost-Effective
Several highly sophisticated cost-effectiveness analyses of the implementation an array
of HIV/AIDS strategies in Africa have been performed (Creese, Floyd, Alban, &
Guinness, 2002; Hogan, Baltussen, Hayashi, et al., 2005; Stover, et al., 2006). Hogan et
al, assessed the cost-effectiveness of HIV prevention interventions in sub-Saharan
Africa and South East Asia such as mass media campaigns, Voluntary Testing and
Counseling (VTC), peer education and STI treatment for sex workers, STI treatment
for the general population, school-based STI/HIV education, prevention of mother to
child transmission, antiretroviral therapy and found that to varying degrees, and
depending on the setting, these interventions can be cost effective. In their analysis of
the impact and costs of different HIV prevention strategies in Africa, Saloman, Hogan,
Stover et al., (2005) concluded that a comprehensive approach that combines
prevention and treatment will be most effective in terms of infections prevented and
efficient use of resources. From their research on the global impact of scaling up
HIV/AIDS prevention programs in the developing world, Stover et al., conclude that,
Our analyses suggest that both national governments and donor
countries would be well advised to ensure that prevention programs are
scaled up as soon as possible, because early investment in prevention will
both prevent a greater proportion of future infections and reduce future
costs for treatment and care by more than the cost of prevention
programs (p. 1476).
Evaluated interventions focusing on STI treatment in Africa have been effective in
reducing STI and one such intervention conducted in Tanzania reduced HIV
prevalence in the adult population by 38% (Auerbach, Hayes, & Kandathil, 2006).
Broader cost-effectiveness analysis suggests that management of STIs can substantially
reduce the health burden of HIV/AIDS (Hogan, Baltussen, Hayashi, et al., 2005).
Both STI and HIV are transmitted primarily through sexual contact and therefore
prevention education interventions for HIV and STI are targeting the same behaviors.
As a result it is both possible and necessary for HIV and STI efforts to be coordinated
Multiple Prevention Strategies are Required
From their overview of the evidence to date concerning the effectiveness of HIV
prevention efforts, Auerbach, Hayes, & Kandathil (2006) state that “There is a large
quantity of evidence from experimental and observational research as well as from
practical real-world experience in both developed and developing countries. This
evidence supports the implementation and scale-up of a number of interventions and
strategies” (p. 43). There is widespread recognition that reducing the burden of
STI/HIV on developing countries will require the implementation of a variety of
prevention, testing, and treatment strategies (Global HIV Prevention Working Group,
2003). Among the strategies that potentially contribute to this goal include STI/HIV
prevention behavioral interventions, VTC, anti-retroviral therapy, injection drug use
treatment and safe injection programs, integration of HIV prevention into family
planning programs to reduce mother to child transmission, male circumcision,
consistent and correct use of condoms, and effective treatment for STIs, testing of the
blood supply (Auerbach, Hayes, & Kandathil, 2006; Bunnell, Mermin, De Cock, 2006,
UNAIDS, 2006). To be effective these specific STI/HIV focused strategies must be
implemented in conjunction with broader programs to address social, economic, and
gender inequalities that underpin the HIV epidemic in the developing world. As
observers of the HIV/AIDS epidemic in Africa and Asia have repeatedly pointed out,
with respect to prevention efforts in particular, many women and girls are not in
position to act on prevention messages related to abstinence or condom use because
these are not under their control (e.g., Murphy, Greene, Mihailovic, & Olupot-Olupot,
2006). Other methods for STI/HIV prevention currently under investigation may
improve girls and women’s ability to protect themselves from infection. These include
improved diaphragms and female condoms; microbicides, drugs for pre-exposure
prophylaxis, and eventually effective vaccines (Global HIV Prevention Working
Sexual Risk Reduction Interventions are at the Core of STI/HIV Prevention
Valdiserri, Ogden, and McCray (2003) summarize HIV prevention as consisting of
behavior change interventions, HIV counselling and testing, community level
interventions aimed at changing social norms (e.g., mass media campaigns, social
marketing within a target group), structural level interventions (e.g., changes in social
policies and laws related to HIV risk behavior) in addition to STI diagnosis and
treatment. There is evidence to support all of these avenues of intervention: however it
is HIV prevention education focused on equipping individuals with the information
and skills to avoid acquiring HIV through sexual transmission that is, and must be, at
the core of broader HIV prevention objective. Research has consistently shown that
well developed and implemented interventions are effective in reducing STI/HIV
sexual risk behavior. In other words, “…HIV prevention works” (UNAIDS, 2006).
UNAIDS points to successful prevention efforts in Brazil, Thailand, Uganda,
Cambodia, Zimbabwe, Haiti, Kenya, and the United Republic of Tanzania.
In general, sexual risk reduction behavior change interventions seek to help individuals
delay the onset of sexual intercourse, reduce the number of sexual partners, and/or
increase condom use or other methods of safer sex. For a number of reasons,
evaluating the impact of behavioral interventions on human behavior, particularly
sexual behavior, with precision is difficult. Nevertheless, over the course of the
HIV/AIDS epidemic, thousands of evaluations of behavior change interventions have
been conducted. While these studies have varied in their methodological rigor, metaanalytic
and systematic reviews of the HIV/AIDS sexual risk reduction evaluation
literature provide strong scientific support for the behavioral effectiveness of these
interventions. These reviews establish that HIV/AIDS sexual risk reduction
interventions have been successful with people living in developing countries (Merson,
Dayton, & O’Reilly, 2000), school youth in developing countries (Kirby, Obasi, &
Laris, 2006), people living with HIV (Crepaz, Lyles, Wolitski, et al., 2006), men who
have sex with men (Herbst, Sherba, Crepaz, et al., 2005), adolescents (Johnson, Carey,
Marsh, et al., 2003), drug users (Semaan, De Jarlais, Sogolow, et al., 2002), adults
(Neumann, Johnson, Semaan, et al, 2002), and women (Mize, Robinson, Bockting, &
Despite substantive progress in our knowledge to design and implement effective
STI/HIV prevention interventions, we are far from where we need to be in terms of
providing access to prevention programming to those who need it most. As noted by
The steady growth of the AIDS epidemic stems not from the deficiencies
of available prevention strategies but rather from the world’s failure to
use the highly effective tools at its disposal to slow the spread of HIV.
Some 25 years after the epidemic was first recognized, most people at
high risk of HIV infection have yet to be reached by HIV prevention, as
many policy-makers refrain from implementing approaches that have
been shown to work (p. 124).
According to UNAIDS (2007) HIV/STI prevention interventions must treat people
with respect and dignity. The voluntary engagement and participation of individuals
and communities will empower them to act constructively and on their own behalf.
A) The Need to Ensure Wide Access to Effective Interventions
Despite gradual progress, STI/HIV prevention interventions with strong evidence of
effectiveness still only reach a minority of those who need them.
In their most recent annual report on the global AIDS epidemic, UNAIDS (2006)
indicates that some progress has gradually been made in scaling-up HIV prevention
interventions but notes that “…while some countries have significantly increased
prevention coverage, prevention programs still only reach a small minority of those in
need” (p. 11). In a report titled Access to HIV Prevention: Closing the Gap, the Global
HIV Prevention Working Group (2003), using data provided from UNAIDS,
indicated that globally, among people at risk for HIV, only 5% had access to
interventions targeting mother-to-child HIV transmission, 12% had access to VTC,
24% had access to AIDS education, and only 42% had access to condoms. More
specifically, in sub-Saharan Africa, 8% of out-of-school youth and a little over one
third of in-school youth had access to prevention programs; 6% had access to VTC
and only 14% had access to STI services. In East Asia and the Pacific region, HIV
prevention behavior change programs reach only 5% of sex workers, 3% of out-ofschool
youth and 10% of men who have sex with men (MSM). In Eastern Europe and
Central Asia, 40% of in-school youth and 3% of out-of-school youth are reached by
behavior change programs; such programs reach only 4% of sex workers and 9% of
MSM. UNAIDS has characterized the situation in sub-Saharan Africa more
optimistically, noting that every year increasing numbers of people are exposed to HIV
prevention programming but UNAIDS also cautions that “…prevention programmes
still reach only a small minority of those in need” (p. 11).
According to the most recent report of the Global HIV Prevention Working Group
(2007) Bringing HIV Prevention to Scale: An Urgent Global Priority, the full potential
of existing prevention strategies is not utilized. Some compelling examples are
provided, such as the fact that:
Only 9% of risky sex acts worldwide are undertaken while using a
condom and the global supply of condoms is millions short of what is
needed: fewer than 20% of people with a sexually transmitted infection
are able to obtain treatment, and prevention services only reach 9% of
men who have sex with men, 8% of drug users, and 20% of sex workers
Ultimately, reducing the crippling burden of HIV on developing countries will rely on
wide-spread access by young people to effective STI/HIV prevention education. In
areas of the world with generalized HIV epidemics, such as sub-Saharan Africa and the
Caribbean, the primary mode of HIV transmission is through heterosexual sex
particularly among young people (Monasch & Roeland, 2006). In sub-Saharan Africa,
nearly half of all new HIV infections occur among young people aged 15 – 24 and
women in this age group represent a majority of those infected (UNAIDS, 2006).
Although there has been gradual progress in implementing STI/HIV prevention
education in the developing world, most youth in these countries do not have adequate
access to these programs. In particular, school-based HIV prevention education is
lacking. As summarized by Monasch and Roeland, among 30 countries with
generalized HIV epidemics in Sub-Saharan Africa participating in a global HIV/AIDS
survey, 11 reported that AIDS education was not part of their primary school
curriculum and in 6 of the countries, AIDS education was not part of the secondary
curriculum. Monasch and Roeland also note that much of the AIDS education being
delivered to youth is likely ineffective due to a lack of teacher training and teacher
discomfort with teaching about HIV/AIDS and sexuality.
B) The Need to Increase Access to Condoms
The findings of the STI/HIV prevention intervention literature clearly indicate that
increasing condom use is among the most likely and substantive positive outcomes of
sexual risk reduction interventions. Therefore, the success of STI/HIV behavior
change interventions in the developing world will inevitably be dependant on the
extent to which condoms are made readily accessible to individuals receiving the
interventions. UNAIDS (2006) notes that “Correct and consistent condom use
reduces the risk of sexual transmission of HIV by 80-90% - an efficacy rate that
exceeds those reported for many of the worlds vaccines” (p. 127). An analysis of the
HIV/AIDS prevention literature clearly indicates that the promotion of condom use is
an important element of behavior change interventions to reduce HIV infection risk. A
meta-analysis of over 350 evaluation studies assessing condom promotion
interventions found that programs that contained educational information as well as
attitudinal and behavioral skills elements were effective in increasing condom use
(Albarracin, Gillette, Earl, et al. 2005). There is also an unequivocal body of research
evidence demonstrating that STI/HIV prevention education that includes the
promotion of condoms does not result in more frequent sexual activity or an increase
in sexual partners (Smoak, Scott-Sheldon, Johnson, & Carey, 2006). Furthermore, a
cost-effectiveness analysis of interventions to reduce the incidence of HIV in Africa
concluded that, along with blood screening, prevention of mother to child
transmission, and provision of STI treatment, targeted condom distribution should be
a priority area for funding of HIV/AIDS prevention in Africa (Creese et al, 2002).
However, according to UN agencies, the global supply of condoms is below 50% and
what is needed and that funding for condom procurement and distribution must
increase at least threefold if the HIV/AIDS epidemic is to be halted (UNICEF, WHO,
C) The Need for Adequate Funding for STI/HIV Prevention Programming that
Respects the Right to Informed Decision Making
Even if political commitment to face HIV has grown stronger and financing for
country programs has increased, the effort to prevent the occurrence of new infections
has not been completely successful. The almost exclusive focus on treatment access,
while it has helped to save many lives, it has obscured a worrisome fact. According to
UNAIDS (2006) for every patient who initiated antiretroviral therapy, six other
individuals became infected with HIV. This is an unacceptable situation considering
the availability of effective means to prevent every mode of transmission, particularly
The past quarter century of HIV prevention behavioral intervention research has
provided substantial advances in the science of preventing HIV infection (Valdiserri,
Ogden, & McCray, 2003). We know a great deal about how to create effective
HIV/STI prevention interventions. However, as Ferguson, Dick, and Ross (2006)
point out, a projected US $10 billion may well be spent on HIV/AIDS prevention,
treatment, and care in the developing world in 2007; “Unfortunately, much of this
spending has not been allocated according to the evidence of effectiveness” (p. 318).
Given the accumulated evidence concerning the relative effectiveness of sexual
abstinence and condom-based sexual risk reduction interventions in general, it is
disturbing that some donor countries, such as the United States through it’s PEPFAR
program (Office of the U.S. Global AIDS Coordinator, 2006), disproportionately
direct funds towards sexual abstinence interventions for which there is relatively little
empirical support and which may deny program recipients, particularly youth,
potentially life-saving information and access to condoms. Given the magnitude and
consequences of the HIV/AIDS epidemic, it is nothing less than a moral imperative
that government and non-governmental funding of HIV prevention efforts in the
developing world be directed towards programs that are evidence-based. At the same
time, these programs must respect the right of informed sexual health decision-making.
The A (abstinence), B (be faithful), C (use condoms) condoms approach to
HIV/AIDS prevention, encouraged and funded by PEPFAR, that has been the basis
for Uganda’s successful campaign to reduce HIV prevalence in that country has been
the subject of considerable debate with respect to the degree to which each of the ABC
components contributed to the decline (e.g., Green, Halperin, Nantulya, & Hogle,
2006; Murphy, Greene, Mihailovic, & Olupot-Olupot, 2006; Okware, Kinsman,
Onyango, et al., 2006). Although settling such questions definitively is unlikely, it
appears that all three components played a role and as Green et al., suggest “…it
makes epidemiological sense to address all three ABC behaviors rather than to
promote only one or two components of ‘ABC’” (p. 342). Indeed, sexual health
promotion programming should, on principle, be aligned with a comprehensive
approach to sexuality education that is adapted to local community needs. The
comprehensive sexuality education approach suggests that people should receive
broadly-based information and skills building opportunities that allow them to make
informed choices about their sexual health. Such an approach necessarily includes
information on the sexual risk reducing strategies of delaying first intercourse (A),
reducing number of sexual partners (B), and adopting safer sex practices (C). It is
however also vitally important that the funding and implementation of ABC-based
programs reflect the principle of informed decision-making and are therefore balanced
in their presentation.
While PEPFAR funding has been crucial to the success of HIV/AIDS programming
in Africa, there is a legitimate concern regarding the extent to which what appear to be
the ideologically motivated funding requirements of PEPFAR preclude a balanced
implementation of programming that is consistent with the comprehensive sexuality
education approach. In other words, do PEPFAR funding requirements violate the
principle of informed choice in sexual health decision-making that is quite rightly
viewed as a human right? According to Murphy et al., (2006),
PEPFAR’s ABC guidance contains rules for country teams to follow in
developing and implementing their sexual prevention strategies, including
parameters on the prevention messages that may be delivered to youths.
Specifically, although funds may be used to deliver age-appropriate AB
information to in-school youths, ages 10-14 years, the funds may not be
used to provide information on condoms to these youths or distribute
condoms in any school setting, let alone to youth out of school. And yet
as many as 16% of all women in Uganda have sex before the age of 15
years (p. 1446).
It has been suggested that PEPFAR’s funding requirements pertaining to the
promotion of abstinence and the exclusion of information on condoms and the
curtailing of their availability is a reflection of a particular sexual ideology rather than of
sound evidence-based public health practice. It is here that PEPFAR’s requirements
are likely at odds with a comprehensive sexuality education approach based on the
right to informed decision making and a balanced presentation of risk reduction
strategies. The ideological tension between these two approaches is well expressed by
Blum (2004) who writes that,
For a number of advocates of abstinence there is a fundamental
opposition to any sexual contact outside of heterosexual, mutually
monogamous marriage, as well as opposition to condoms and a
moral/religious opposition to contraception. For many who challenge
abstinence-only education it is not the abstinence but the only that is
most problematic. At its core are reproductive rights and freedoms vs.
the morality of nonmarital sex and the role contraception may play in
encouraging it (p. 431).
As Green et al., (2006) note, the debate over the ABC approach “…appears more
related to the culture wars in the USA than to African social reality” (p. 335) and as
Blum (2004) suggests “The next tragedy for Africa, however, would be if it were to be
the battleground for American reproductive politics” (p. 431).
With regard to the moral perspectives towards human sexual behavior that are
transmitted in, or reflected by, STI/HIV prevention education programs, a critical
distinction must be made between the prerogatives of external governments and
bodies that fund interventions and the prerogatives of the communities that will
implement them. Funding sources, whether they are national governments, nongovernmental
organizations, or individuals, are exercising a legitimate prerogative if
they insist that donated funds contribute to programs that respect basic sexual and
reproductive health rights, UN declarations and agreements. However, funding sources
are not exercising a legitimate prerogative if they insist that programs reflect the
funding sources sexual ideology including norms for preferred or acceptable sexual
behaviors such as sexual abstinence outside of heterosexual marriage. In turn,
communities that accept and implement STI/HIV prevention programs funded by
external donors should respect the sexual and reproductive health rights of program
D) The Need to Reduce and Eliminate Social Inequality Related to Sexual
Orientation and Gender
Many cultures exhibit profoundly destructive prejudices, norms, and laws toward
sexual minorities. These discriminatory acts are a major contributing factor to increased
sexual risk behavior. For example, due to the intense homophobia, hatred,
stigmatization, and violence directed at sexual minorities, particularly gays, lesbians,
bisexuals and transgendered people, individuals are forced to conceal their true selves
and to live their lives in a state of alienation and fear. Not only is such an environment
disempowering with respect to lowering STI/HIV risk but it also makes reaching
sexual minorities with effective prevention education and services extremely difficult.
Furthermore, people who live in fear because of their sexual orientation are much less
likely to access the health care system which further increases risk. Often, reluctance to
access health care is perpetuated by health and medical personal who react to sexual
minorities with scorn and rejection. Clearly, this must change.
There is a clear and direct linkage between the empowerment of women in the
developing world and reducing the burden of HIV/AIDS on these societies and in
achieving all of the MDGs. On multiple levels, gender inequality contributes to the
spread of STI/HIV. For example, forced or coerced sex directed against sex workers,
trafficked girls and women, and girls and women in intimate relationships plays a
significant role in STI/HIV transmission and the global epidemic (WHO, 2000).