Sexual Health for the Millennium
A Declaration and Technical
Document
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Table of Contents
Sexual Health for the Millennium: A
Declaration and Technical Document 5
Synopsis. 5
1.
Recognize, promote, ensure and protect sexual rights for all 6
2.
Advance toward gender equality and equity. 6
3.
Condemn, combat, and reduce all forms of sexuality related violence. 7
4.
Provide universal access to comprehensive sexuality education and information. 7
5.
Ensure that reproductive health programs recognize the centrality of sexual
health. 8
6.
Halt and reverse the spread of HIV/AIDS and other sexually transmitted
infections. 8
7.
Identify, address and treat sexual concerns, dysfunctions and disorders. 9
8.
Achieve recognition of sexual pleasure as a component of holistic health and
wellbeing. 9
Conclusion. 10
Recognition
of the Importance of Addressing Sexuality and Sexual Health as Key Elements in
Realizing the United Nations Millennium Development Goals. 11
Sexual
Health for the Millennium Reflects the State of the Art in the Science of
Sexual Health Promotion. 14
The
Sexual Health for the Millennium Declaration. 15
Conclusion. 16
References. 16
Chapter
1
Recognize, Promote, Ensure and Protect Sexual Rights for All. 17
Introduction. 17
Sexual
Rights: Some Hurdles to be Cleared. 18
The
Need for Sexual Rights. 20
Overcoming
the Complexities of and Challenges to Sexual Rights. 26
Conclusion. 28
Necessary
Actions. 29
References. 29
Chapter
2
Advance Toward Gender Equality and Equity. 34
Introduction. 34
The
Imbalance of Power: Sexual Scripts Enact Gender Inequality. 36
Promoting
Gender Equitable Sexuality. 38
Conclusion:
Promoting Change at All Levels of Society. 39
Necessary
Actions. 40
References. 41
Chapter
3
Condemn, Combat, and Reduce all Forms of Sexuality Related Violence. 41
Introduction. 42
The
Role of Reducing Sexual Violence in Achieving the Millennium Development Goals. 42
Defining
Sexual Violence. 43
Prevalence
of Sexual Violence. 44
Consequences
of Sexual Violence. 46
The
Context and Root Causes of Sexual Violence. 47
Strategies
to Reduce/Eradicate Sexual Violence. 48
Necessary
Actions. 49
References. 50
Chapter
4
Provide Universal Access to Comprehensive Sexuality Education and Information. 50
Introduction. 51
Comprehensive
Sexuality Education in the Context of Global Sexual Diversity. 52
Necessary
Actions. 57
References. 57
Chapter
5
Ensure that Reproductive Health Programs Recognize the Centrality of Sexual Health. 58
Introduction. 58
The
Recognition of Access to Sexual and Reproductive Health Care as Essential to
Global Development 59
The
Disconnect Between Reproductive Health Care and a Positive Approach to
Sexuality. 61
Putting
the Sexual Back into Sexual and Reproductive Health. 62
Conclusion. 63
Necessary
actions. 64
References. 64
Chapter
6
Halt and Reverse the Spread of HIV/AIDS and other Sexually Transmitted Infections. 65
Introduction. 65
HIV/AIDS
and STI Prevention: A Prerequisite for Global Development 67
Evidence-based
Interventions for HIV/STI Prevention. 68
The
Need for Effective HIV/STI Prevention Interventions and Programs in the
Developing World. 70
Conclusions. 74
Necessary
Actions. 75
References. 76
Chapter
7
Identify, Address and Treat Sexual Concerns, Dysfunctions and Disorders. 77
Introduction. 77
The
Connection between Sexual Function and Overall Health and Well-being. 78
The
Prevalence of Sexual Concerns, Problems and Dysfunctions. 79
Effective
Education and Treatment for Sexual Concerns, Problems and Dysfunctions. 84
Necessary
Actions. 85
References. 86
Chapter
8
Achieve Recognition of Sexual Pleasure as a Component of Well-being. 87
Introduction. 88
Sexual
Pleasure in Historical Context 89
Sexual
Pleasure is Necessary and Contributes to Well-being, Happiness and Health. 91
The
Ongoing Struggle to Incorporate Positive Sexual Rights in Sexual Health
Promotion Programs. 92
The
Need for a Discourse of Desire and Pleasure in Sexual Health Education Programs
for Youth and People with Disabilities 93
Conclusion. 94
Necessary
Actions. 94
References. 94
Appendix
I 97
Description
of the World Association for Sexual Health. 96
Activities. 96
Current
officers and Committee Members. 97
WAS
Membership. 98
Appendix
II 103
WAS
Declaration of Sexual Rights. 102
Appendix
III 104
World
Health Organization (WHO) Working Definitions of Sex, Sexuality, Sexual Health
and Sexual Rights* 103
Appendix
IV. 105
Methodology
of the Development of the Sexual 104
Health
for the Millennium Declaration and Technical Document 104
Appendix
V. 107
Acknowledgements. 106
Funding. 110
Photo
credit 110
Sexual
Health for the Millennium: A Declaration and Technical Document
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
of peace.
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.
Necessary Actions:
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.
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.
Necessary Actions:
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
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
masculinity.
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
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 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.
Necessary Actions:
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.
Necessary Actions:
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.
Necessary Actions:
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.
Necessary Actions:
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
program effectiveness.
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.
Necessary Actions:
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
care.
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.
Necessary Actions:
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
sexual rights.
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
progress.
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
nations.
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
increasingly effective.
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
communities involved.
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).
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
declaration.
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
violence.
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.
http://www.guttmacher.org/pubs/eurosyth_rpt.pdf
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
http://www.paho.org/english/HCP/HCA/PromotionSexualHealth.pdf
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.
http://www.guttmacher.org/pubs/addingitup.pdf
United Nations. (1994). International
Conference on Population and Development Programme of Action. Report of
The International Conference on Population
and Development. Cairo, Egypt: United Nations.
UN. (1995). Report of the Fourth World
Conference on Women. New York, NY: United Nations. Retrieved March
28, 2006 from
http://www.un.org/womenwatch/confer/beijing/reports/
UN. (2000). Resolution 55/2. United Nations
Millennium Declaration. Fifty-fifth Session of the United Nations
General Assembly. Retrieved March 29, 2006
from www.un.org/millenium/declaration/ares552e.htm
UNFPA. (2003). Achieving the Millennium
Development Goals: Population and Reproductive Health as Critical
Determinants. Population and Development
Strategies Series, Number 10. New York, NY: United Nations
Population Fund.
U.S. Surgeon General. (2001). The Surgeon
General’s Call to Action to Promote Sexual Health and Responsible
Sexual Behavior. Rockville, MD: The Office of
the Surgeon General.
http://www.surgeongeneral.gov/library/sexualhealth/
WAS. (1999). World Association for Sexual
Health Declaration of Sexual Rights. World Association for Sexual
Health. Retrieved March 28, 2007 from
http://www.worldsexology.org/about_sexualrights.asp
WHO. (2007, in press). Developing Sexual
Health Programmes: A Conceptual Framework for Action. Geneva,
Switzerland: World Health Organization.
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
http://www.who.int/reproductive-health/publications/sexualhealth/index.html
WHO. (2004a). What constitutes sexual health?
Progress in Reproductive Health Research, No. 67, 2-3.
WHO. (2004b). Reproductive Health Strategy to
Accelerate Progress Towards the Attainment of International
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).
Theoretical Concerns
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-
Making
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
Integrity
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,
2002b).
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-
Making
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
all parties.
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.
UK, France).
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
MDG.
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
punishment.
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
constitution.
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 &
Medina, 2002).
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
International Consensus
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
them.
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
communities.
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
several fronts.
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
individual.
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
health.*
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
government.
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
2005).
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
health rights.
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,
clandestine abortions.
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
women.
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
promotion programs.
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
societies.
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
health.
These rights, however, cannot be
fully realized without basic equality of power within
sexual relationships.
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
equality.
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
masculinity.
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
services.
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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
sexual violence.
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
children;
* 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
(UN, 1993).
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).
Sexual Assault/rape
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%
in Peru.
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.
Physical Consequences
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
subsequently murdered.
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,
2000).
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
violence prevention.
Community-Based Actions
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
sexual 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
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Laubsher, R. (2004). Sexual violence against intimate partners in Cape
Town: prevalence and risk factors reported by
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Bott, S., Morrison, A. & Ellsberg, M.
(2005). Preventing and Responding to Gender-based Violence in Middle and
Low Income Countries: A Global Review and
Analysis. World Bank Policy Research Working Paper 3618.
Washington, DC: The World Bank.
Gottschall, J. (2004). Explaining wartime
rape. The Journal of Sex Research, 41, 129-136.
Holmes, M.M., Resnick, H.S., Kilpatrick, D.G.
& Best, C.L. (1996). Rape-related pregnancy: estimates and descriptive
characteristics from a national sample of
women. American Journal of Obstetrics and Gynecology, 175, 320-
324.
Kelly, L. (2005). Promising Practices
Addressing Sexual Violence. Expert paper prepared for an expert group
organized by the UN Division for the
Advancement of Women, May 17-20 2005, Vienna, Austria.
Laylor, K. (2004). Child sexual abuse in
sub-Saharan Africa: a literature review. Child Abuse and Neglect, 28, 439-460.
Maman, S., Campbell, Sweat, MD. & Gielen,
AC. (2000). The intersections of HIV and Violence: directions for future
research and interventions. Social Science
and Medicine, 50, 459-478.
Obando, A.E. (2004). How Effective is a Human
Rights Framework in Addressing Gender-Based Violence?
WHRnet, retrieved March 22, 2006 from
http://www.choike.org/nuevo_eng/informes/3982.html
Population Council (2004). The Adverse Health
and Social Outcomes of Sexual Coercion: Experiences of Young
Women in Developing Countries. New Delhi: The
Population Council.
Sapp, M.V. & Vandeven, A.M. (2005).
Update on childhood sexual abuse. Current Opinion in Pediatrics, 17, 258-264.
Stewart, F.H., & Trussell, J. (2000).
Prevention of pregnancy resulting from rape: a neglected preventive health
measure. American Journal of Preventive
Medicine, 19, 228-229.
Tavara, L. (2006). Sexual violence. Best
Practice & Research Clinical Obstetrics and Gynaecology, 20, 395-408.
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All forms of Discrimination Against Women. United Nations Division
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and the Millennium Development Goals. New
York: United Nations Population Fund.
Van Berlo, W. & Ensink, B. (2000). Problems
with sexuality after sexual assault. Annual Review of Sex Research. Vol.
11, 235-257
Watts, C. & Zimmerman, C. (2002).
Violence against women: global scope and magnitude. Lancet, 359, 1232-1235.
Wood, W. & Eagly, A.H. (2002). A
cross-cultural analysis of the behavior of women and men: implications for the
origins of sex differences. Psychological
Bulletin, 128, 699-727.
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Organization.
WHO (2002). World Report on Violence and
Health. Geneva: World Health Organisation.
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for Victims of Sexual Violence. Geneva, World Health Organization.
WHO (2005a). WHO Multi-country Study On
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Women and Achieving the Millennium Development Goals. Geneva,
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
V).
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
sexuality education.
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.
Comprehensiveness
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
MDGs.
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
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.
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
Publishers.
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-
1536.
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
Millennium Project.
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:
SIECUS.
UN Millennium Project. (2006). Public
Choices, Private Decisions: Sexual and Reproductive Health and the
Millennium Development Goals. UN Millennium
Project.
WHO. (2002a) Working Definitions. Retrieved
20 January, 2006 from World Health Organization:
http://www.who.int/reproductive-health/gender/sexual_health.html
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
http://www.who.int/reproductive-health/publications/sexualhealth/index.html
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
comprehensive manner.*
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.
*This chapter was informed by the WAS Expert
Consultation in Oaxaca, Mexico, a thorough review of the
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
ICPD:
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
taboo.
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
foremost.
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
reproductive health
* Acting on the UN Millennium Project reproductive
health Quick
Impact initiative.
* 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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Development Goals and Sexual and Reproductive Health. New York,
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
Organization.
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.
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the Attainment of International Reproductive Health Goals: A
Framework for Implementing the WHO Global
Reproductive Health Strategy. Geneva, Switzerland: World
Health Organization
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.
*This chapter was informed by the WAS Expert
Consultation in Oaxaca, Mexico, a thorough review of the
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)
(PAHO, 2007).
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,
2002).
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
(UNAIDS, 2001).
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
Group, 2006).
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, &
Scheltema, 2002).
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
UNAIDS (2006)
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
(p. 2)
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,
UNAIDS, 2007).
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
sexual transmission.
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
recipients.
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).
Several studies from sub-Saharan
Africa have clearly shown that gender power
imbalances (Langen, 2005) and
gender-based violence (Dunkle et al., 2004) increase
women’s risk for HIV infection.
Women who are economically dependant on and/or
fear violence from their male
partners, and who often play a subservient role in sexual
activity are in a poor position
to ask for or demand condom use.
While much of the empowerment of
women must come in the specific realm of
sexuality and sexual health decision
making, change must ultimately begin and end at a
larger systemic level. As Langen
(2005) concluded from her study of women in South
Africa and Botswana “Across all
levels of society, there is a need to see a social
paradigm shift that transforms relationships
between women and men, from one of
inequality and dominance as is
the case in patriarchal societies, to equality, respect and
consideration for one another”
(p. 188). For example, a stronger commitment to
universal and equal access to
education for girls will not only allow women to advance
economically and share in
community social and political leadership, it also linked in
numerous was to reduced STI/HIV.
As noted by UNAIDS (2006), “Higher education
levels for girls are associated
with a higher age of marriage, reduced fertility, improved
health seeking behavior, lower
vulnerability to genital mutilation, and reduced risk of
HIV and other sexually
transmitted infection” (p. 136).
In Uganda, one sub-Saharan
African country where multiple prevention strategies and
structural change has coincided
with a significant decline in HIV/AIDS, the linkage
between advances toward gender
equality and a decline in HIV incidence is apparent.
In the words of the Ugandan
President, Yoweri Museveni,
Permit me to tell you the
obvious. In the fight against HIV/AIDS,
women must be brought on board.
In sub-Saharan Africa, most women
have not yet been empowered and
men dominate sexual relations. To
fight this epidemic, the women
must be empowered to take decisions
about their sexual lives, and
women in Uganda have been empowered to
participate at all levels of
governance. This has made them more assertive
of their lives than ever before.
To fight AIDS effectively, we must
empower women (cited in Murphy et
al., 2006, p. 1444).
Success in halting and eventually
reversing the impact of STI/HIV on the global
community, and in particular on
the developing world, will require a cooperative effort
at the international, national,
and community levels. For areas hit hardest by
HIV/AIDS and who are invariably
struggling with widespread poverty, the
international community must
build upon and add to its considerable, but still
unfortunately insufficient
allocation of funding and resources to halt and reverse the
spread of STI/HIV. The experience
of Uganda teaches us that effective national
leadership is indispensable in an
effective HIV/AIDS strategy.
Implementing a strong national
HIV prevention programme involves more than the
selection of an appropriate mix
of programmatic actions. It also requires a strong
national policy framework that
encourages safe behaviors, reduces vulnerability,
maximizes the accessibility and
effectiveness of HIV prevention services, promotes
gender equality and women’s
empowerment, and reduces stigma and discrimination
(UNAIDS, 2006, p. 145).
Efforts to reduce the impact of
STI/HIV will be largely futile unless communities take
active roles in supporting and
leading programs to address STI/HIV. In short,
communities must not simply
accept programs; they must take ownership of them. In
particular, community opinion
leaders ranging from religious and civic authorities to
cultural and sports figures must
band together in leading their communities in the
necessary social and behavioral
change that is required to halt and reverse the impact of
STI/HIV on communities.
UNAIDS (2005; 2006) has issued
wide-ranging and comprehensive recommendations
to underpin national HIV
prevention plans including 12 essential policy actions for
HIV prevention which are as
follows:
* Ensure that human rights are promoted, protected
and respected
and that measures are taken to
eliminate stigma and
discrimination.
* Build and maintain leadership from all sections
of society,
including governments, affected
communities, nongovernmental organizations,
faith-based
organizations, the education sector,
media, the private sector and
trade unions.
* Involve people living with HIV in the design,
implementation
and evaluation of prevention
strategies, addressing their distinct
prevention needs.
* Address cultural norms and beliefs, recognizing
both the key role
they play in supporting
prevention efforts and the potential they
have to fuel HIV transmission.
* Promote gender equality and address gender norms
and relations
to reduce the vulnerability of
women and girls to HIV infection,
involving amen and boys in this
effort.
* Promote widespread knowledge and awareness of
how HIV is
transmitted and how infection can
be averted.
* Promote the links between HIV prevention and
sexual and
reproductive health.
* Support the mobilization of community-based
responses
throughout the continuum of
prevention, care and treatment.
* Promote programs targeted at HIV prevention
needs of key
affected groups and populations.
* Mobilize and strengthen financial, human and
institutional
capacity across all sectors,
particularly in health and education.
* Review and reform legal frameworks to remove
barriers to
effective, evidence-based HIV
prevention, eliminate stigma and
discrimination, and protect the
rights of people living with HIV
or vulnerable to or at risk of
HIV infection.
* Ensure that sufficient investments are made in
the research and
development of, and advocacy for,
new prevention technologies.
6.1 Current funding and resources
for STI/HIV prevention in the
developing world are 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 program
effectiveness.
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.
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Identify, Address and Treat
Sexual Concerns, Dysfunctions and Disorders
Since sexual concerns,
dysfunctions and disorders all have an
impact on quality of life,
general and sexual health; they
should be recognized, prevented
and treated.*
Sexual health is increasing
recognized as a fundamental component of overall
health and well-being and
adequate sexual functioning must therefore be seen as
a legitimate and central aspect
of health. Yet, nearly all, if not all, cultures around
the globe have been reluctant to
openly recognize sexual function as a legitimate health
issue, even as our medical/scientific
understanding of health and sexuality has
progressed enormously,
particularly over the last century. In other words, while our
understanding of sexual function
and its role in overall individual and relationship
functioning and happiness has
evolved, our integration of sexual function into the
broader rubric of health has
lagged at the level of social and public health policy and
political discourse.
Although the identification and
treatment of sexual dysfunction and disorders has not
been at the top of the health
policy agenda, it is important to recognize the necessity of
addressing sexual concerns,
sexual dysfunction and disorders in a broadly-based
initiative aimed at meaningfully
improving the health and well-being of a population.
*This chapter was informed by the WAS Expert
Consultation in Oaxaca, Mexico, a thorough review of the
literature, and the background paper written
by Emil Ng (see Appendix IV and V).
Increasingly, public health
institutions are recognizing not only the importance of
integrating sexual health into
overall health programming but they are also realizing
that sexual health entails more
than HIV/STI prevention and reproductive health and
includes aspects such as sexual
function. For example, the World Health Organization
(WHO, 2004) Department of
Reproductive Health and Research has begun to focus
on sexual health and this new
emphasis is based, in part, on the public health
importance of sexual dysfunction.
It has been commonly thought that
sexual dysfunction has been primarily an issue of
concern in North American and
Western European countries and was less of a
concern in other parts of the
world.
This perception has,
historically, been reinforced by the fact that most of the research
investigating the prevalence and
impact of sexual dysfunction has been conducted in
Western countries. However, in
recent years research on sexual dysfunction has
expanded dramatically to cover
diverse populations from around the world.
For example, The Global Study of
Sexual Attitudes and Behaviors assessed sexual
function among adults from 29
countries around the world including non-Western
countries such as Algeria, South
Africa, Turkey, Morocco, China, Indonesia, Malaysia,
Philippines and Thailand. This
study concludes, along with other considerations, that
despite considerable cultural
variation among the countries studied, a consistent finding
was that sexual well-being was
correlated with overall happiness in both men and
women (Laumann, Paik, &
Glasser, 2006).
It is clear that sexual
dysfunctions are strongly correlated with other health conditions.
That is, there are common risk
factor categories associated with sexual dysfunction for
men and women (Lewis, Fugl-Meyer,
Bosch, 2004). The directionality of cause and
effect between sexual
dysfunctions and other health conditions has, with many
categories of sexual dysfunction,
yet to be fully elucidated but it is clear that there is a
close interactive association. In
effect, people suffering with sexual dysfunctions are
more likely to develop other
conditions (e.g., depression) and people with other
conditions such as cardiovascular
disease are more likely to develop sexual dysfunction
(e.g., erectile dysfunction). In
any case, there is a close association and it illustrates that
adequate sexual functioning is
properly seen as an important component of not only
sexual health but overall health
and well-being. According to Sadovsky and Nusbaum
(2006):
Sexual problems have a clear
negative impact on both the quality of life
and emotional state regardless of
age. Learning about specific sexual
dysfunctions among men can reveal
a variety of as-yet-diagnosed comorbid
pathologic conditions such as:
(i) depression and other emotional
illnesses; (ii) psychosocial
stress; (iii) actual cardiovascular disease as well
as related risk factors such as
hypertension, diabetes, and/or
hyperlipidemia; (iv)
hyperprolactinemia; and low serum testosterone.
Specific sexual dysfunctions
among women can reveal pathologic
conditions such as: (i)
depression and other….psychosocial conditions;
(ii) low serum estrogen or
testosterone; and/or (iii) vaginal or pelvic
disorders (p. 3).
Given the role of sexuality in
fundamental aspects of life including reproduction and
relationships, it is not
surprising that problems with sexual functioning are correlated
with reduced subjective
well-being. Sexual problems have been linked to and cause
diminished quality of life, low
physical satisfaction, low emotional satisfaction, and low
general happiness (Sadovsky &
Nusbaum, 2006). The National Health and Social Life
Survey in the United States found
significant associations between sexual dysfunction
feelings of general well-being
(Laumann, Paik, & Rosen, 1999). The authors conclude
from the data that “With the
strong association between sexual dysfunction and
impaired quality of life, this
problem warrants recognition as a significant public health
concern” (p. 544).
The precise relationship between
sexual satisfaction and relationship satisfaction is
complex; however research does
indicate that people with greater relationship
satisfaction also report greater
sexual satisfaction (Byers, 2005; Yeh, Lorenzo,
Wickrama, et al. 2006). Yeh et al.
concluded from their longitudinal study of 283
American married couples that
“Those who were satisfied with their sexual relations
tended to be satisfied and happy
with their marriages, and better marital quality, in turn,
helped reduce marital instability”
(p. 342). This linkage between sexual satisfaction and
relationship satisfaction is not
limited to couples in North America. The Global Study
of Sexual Attitudes and Behaviors
found that 82% of men and 76% of women agreed
with the statement “satisfactory
sex is essential to maintain a relationship” (Nicolosi,
Laumann, Glasser et al., 2004).
As West, Vinikoor, and West (2004) suggest from their
review of research on the
prevalence and predictors of female sexual dysfunction,
For the individual with sexual
dysfunction, there is a personal cost to her
and her partner with respect to
their relationship. But there may be
societal costs as well, as
reflected in divorce rates, domestic violence,
single-parent families, and
future relationships. These ancillary costs are
rarely measured, but without a
better understanding of their magnitude,
female sexual dysfunction, as a
health outcome, will continue to be
underappreciated, to the
detriment of the individual or society (p. 167).
Determining the prevalence of
sexual concerns, problems, and sexual dysfunctions is
very much dependant on the
definition used and the methodologies used to assess
them.
Sexual Concerns
There is a severe lack of data to
indicate the number of individuals who have questions
and concerns about their sexual
functioning. However, questions and concerns are
ubiquitous. People of all ages
often perceive that they lack accurate and
comprehensive information on a
wide range of sexuality related issues including::
* HIV and STI transmission
* Sexual orientation and identity
* Gender roles
* Sexual function
* The appropriate frequency and normalcy of
different sexual behaviors
* Infertility
* Contraception and abortion
* Sexual violence and abuse
* Sexuality related aspects of mental and physical
illness
* Medical treatments for sexual problems and
dysfunctions
* The impact of medications on sexual function
* The impact of physical and developmental
disabilities on sexuality and
relationships
* Masturbation
* Sexual/reproductive anatomy
* Body image
* Breast and genital size and appearance
Often, the lack of accurate
information on these and other aspects of sexuality lead to
concerns or uncertainty and anxiety
that can have severe impact on self esteem,
identity, well-being and the
capacity to be involved in intimate relationships.
Most of these concerns could be
could be addressed through comprehensive sexual
education or other forums for
providing basic information that dispels myths and
misinformation. In some cases,
the provision factual information is not enough as
such concerns may be symptomatic
of deeper underlying anxieties and fears.
Unfortunately, many people do not
feel comfortable addressing these concerns with
their health care provider nor do
they feel that their health care provider would be
sensitive or comfortable enough
to address these issues (Marwick, 1999).
Sexual Dysfunctions
A number of definitions for both
sexual function and sexual dysfunction can be found
in the medical sexological
literature and a variety of definitions have been used in their
measurement.
Nevertheless, there is a general
consensus that adequate sexual functioning consists of
the three basic stages of desire,
arousal, and orgasm. There are also sexual pain
disorders.
Thus, sexual dysfunction can be
defined, at least in part, as an impairment or
disturbance in one of these
stages (Winze & Carey, 2001). The most common sexual
CLASSIFICATION OF SEXUAL DYSFUNCTIONS
* Sexual interest/desire dysfunctions (men and
women)
* Female Sexual Dysfunctions:
* Sexual arousal disorders
* Genital sexual arousal dysfunctions
* Subjective sexual arousal dysfunction
* Combined genital and subjective sexual arousal
dysfunction
* Persistent sexual arousal disorder
* Orgasmic dysfunction
* Dyspareunia
* Vaginismus
* Sexual aversion disorder
* Male Sexual Dysfunctions
* Erectile dysfunction
* Early ejaculation
* Delayed Ejaculation
* Orgasmic dysfunction
* Anejaculation
2ND International
Consultation on Sexual Dysfunction Lewis, R.W., Fugl-Meyer, K.S.,
Bosch, R. Fugl-Meyer, A.R., Laumann E.O., Lizza, E.,
Martín-Morales, A. (2004).
dysfunctions are as follows
(Lewis, Fugl-Meyer, Bosch, Fugl-Meyer, Laumann, Lizza,
& Martín-Morales, 2004):
Most population studies have
asked respondents if they have experienced problems
related to these stages. The
results of these studies indicate problems with sexual
functioning are very common
within adult populations.
A review of the existing
epidemiological data indicates that about 40-45% of adult
women and 20-30% of adult men
have at least one sexual dysfunction (Lewis, Kersten,
Fugl-Meyer, et al., 2004). The
Global Study of Sexual Attitudes and Behaviors found
that among sexually active people
aged 40 to 80 years, 28% of men and 39% of
women reported at least one
problem with sexual functioning in the previous year. For
men, the most common problems
were early ejaculation (14%), erectile difficulties
(10%) while for women the most
common were lack of sexual interest (21%), inability
to reach orgasm (16%), and
lubrication difficulties (16%) (Nicolosi et al., 2004).
It should be noted that
participants were sexually active and it is likely that reported
sexual dysfunction rates would
have been higher if people who were not sexually active
were included. The occurrence of
sexual dysfunction is often age related with
prevalence increasing as people
grow older. However, this is not always the case. For
example, in the National Health
and Social Life Survey in the United States, problems
such as inability to reach orgasm
and pain during sex were more common among
younger women (18-39) than older
women (40-59) (Lauman, Paik & Rosen, 1999).
Recent studies have found high
levels of sexual dysfunction among women in Nigeria
(Ojomo, Thacher, & Obadofin,
2006), Malaysia (Sidi, Puteh, Abdullah, & Midin, 2006)
and Ecuador (Yanez,
Castelo-Branco, Hidalgo, & Chedraui, 2006) showing that
problems with sexual function are
truly a global phenomenon that transcend culture.
Sexual Disorders
Sexual disorders are usually
classified into paraphilic and non-paraphilic types
(Coleman, 1991). The paraphilias
are clearly classified in the Diagnostic and Statistical
Manual of the American
Psychiatric Association (APA) (DSM-IV). Eight paraphilias
are listed.
Money (1986) has identified more
than 40 different types of paraphilias, including
zoophilia (bestiality),
asphyxiophilia (cutting off oxygen to enhance arousal or orgasm),
and necrophilia (sex with dead people).
Paraphilias are marked by an obsessive
preoccupation with a socially
unconventional sexual behavior that involves nonhuman
objects, children or other
nonconsenting persons, or the suffering or humiliation of
oneself or one’s partner.
These behaviors are also
considered by the majority of people to be socially deviant..
It is important to note that to
meet clinical criteria for having a paraphilia, the person
must have sexually arousing
fantasies, sexual urges, and behaviors that cause clinically
significant distress in social,
occupational, or other important areas of functioning.
Many men and women, for example,
cross-dress to varying degrees but do not
experience sexual arousal that
causes distress.
They have been able to integrate
their activities into their overall identity and
interpersonal relationships. By
nature, paraphilic behavior interferes with a person’s
feeling of well-being and ability
to have or form reciprocal love relationships.
There is a lack of
epidemiological data on the prevalence of the paraphilic disorders,
however they are well recognized
as clinical syndromes and some of them are root
causes of sexual violence, abuse,
and interference in intimate relationships. Many more
men than women suffer from
paraphilic disorders (APA, 2000). The lack of
epidemiological data is due in
part to the absence of a clear definitions and clinical
criteria. In addition, many
people may have problematic sexual behaviors but do not
meet the clinical threshold for
paraphilic disorders. Even many sexual offenders, who
have violated norms and laws of
their societies, do not necessarily meet clinical criteria
for paraphilia, although they may
be suffering from and need treatment for some other
type of psychiatric disorder,
(Miner & Coleman, 2001).
While not classified per se in
the Diagnostic and Statistical Manual of the American
Psychiatric Association (APA,
2000), there has been growing recognition that there are
another set of sexual disorders
which are similar to the paraphilias but involve
normative or conventional sexual
behavior but in a similar manner they involve
sexually arousing fantasies,
sexual urges, and behaviors which cause clinically significant
CLASSIFICATION OF PARAPHILIAS
* Pedophilia
* Exhibitionism
* Voyeurism
* Sexual masochism
* Sexual sadism
* Transvestic fetishism
* Fetishism
* Frotteurism
Diagnostic and Statistical Manual
of the American Psychiatric Association (APA) (DSM-IV)
distress in social, occupational,
or other important areas of functioning (Coleman,
Raymond & McBean, 2003).
There is even poorer
epidemiological data on this type of disorder but have been
extensively described in the
literature. This type of sexual disorder has been called
hypersexuality, hyperphilia,
erotomania, perversion, nymphomania, satyriasis, and,
more recently, compulsive sexual
behavior (CSB) or sexual addiction (Coleman, 1991).
While some of these are exotic
terms and the nosology and etiology is highly debated
among professionals in the area,
there is no question that this is a serious mental,
sexual, and physical health
problem. Nonparaphilic CSB can be impulsive, obsessive
and compulsive, driven, out of
control, and distressing. No clear category exists for this
type of CSB in the DSM
nomenclature, but an example is given under Sexual Disorder
Not Otherwise Specified (NOS):
“distress about a pattern of repeated sexual
relationships involving a
succession of lovers who are experienced by the individual
only as things to be used” (APA,
1994). There are at least 7 subtypes of nonparaphilic
CSB (Coleman, Raymond &
McBean, 2003).
There is a growing body of
literature suggesting an association between CSB and HIV
and STI risk behaviors (Kalichman
& Rompa, 1995; 2001; Miner, Coleman, Center,
Ross,& Rosser, 2007; Reece,
Plate, & Daughtry, 2001).
Whether paraphilic or
nonparaphilic compulsive sexual behavior, these problems are
associated with many other
comorbid psychiatric disorders and are linked to sexual
health problems – particularly
sexually transmitted infections, sexual violence and
abuse (Black, Kehrberg, Flumerfelt, & Schlosser, 1998; Kafka,
& Prentky, 1994;
Raymond, Coleman, Ohlerking,
Christenson & Miner, 1999). In order to effectively
address the MDGs, it is critical
that these types of sexual disorders are identified,
assessed, and given proper
treatment. Beyond structural factors, these individual
psychiatric factors can be
responsible for a large number of negative sexual health
consequences.
SUBTYPES OF NONPARAPHILIC COMPULSIVE
SEXUAL BEHAVIOR
* compulsive cruising and multiple partners
* compulsive fixation on an unattainable partner
* compulsive autoeroticism (masturbation)
* compulsive use of erotica
* compulsive use of the Internet for sexual
purposes
* compulsive multiple love relationships
* compulsive sexuality in a relationship
Coleman, Raymond & McBean,
2003
Gender Identity Disorders
Comfort with ones gender is a
necessary requisite for sexual health and well-being.
Individuals who are uncomfortable
with their gender identity or suffer from gender
identity disorders are at high
risk for negative sexual health consequences. Gender
identify disorders are defined as
an incongruence between one’s physical phenotype
(male or female) and one’s gender
identity that is, the felt and self identification as man
or woman (APA, 1994). The
experience of this incongruence is termed gender
dysphoria. In the most extreme
form of gender dysphoria, individuals wish to make
their body congruent with their
gender identity and this is called transsexualism.
The most recent prevalence
information from the Netherlands for the transsexual end
of the gender identity disorder
spectrum is 1 in 11,900 males and 1 in 30,400 females
(WPATH, 2001). Even if
epidemiological studies established that a similar base rate of
gender identity disorders existed
all over the world, it is likely that cultural differences
from one country to another would
alter the behavioral expressions of these
conditions. Moreover, access to
treatment, cost of treatment, the therapies offered and
the social attitudes towards
gender variant people and the professionals who deliver
care differ broadly from place to
place. While in most countries, crossing gender
boundaries usually generates
moral censure rather than compassion, there are striking
examples in certain cultures of
cross-gendered behaviors (e.g., in spiritual leaders) that
are not stigmatized (WPATH,
2001).
Between the publication of APA’s
DSM-III and DSM-IV, the term "transgender"
began to be used in various ways.
Some employed it to refer to those with unusual
gender identities without a
connotation of psychopathology. Some people informally
used the term to refer to any
person with any type of gender variance. Transgender is
not a formal diagnosis, but many
professionals and members of the public find this to
be a preferred term because of
its inclusiveness and lack of assumed pathology
(WPATH, 2001). When the wide
variety of gender identities and expressions are taken
into account, there are no good
estimates on the prevalence of individuals who might
be defined as transgender.
What is most important is to
recognize that not all people identify as either male,
female, boy or girl, man or
woman. Depending on cultural norms, individuals who do
not fit into the binary face
varying challenges in developing positive sexual identities,
being granted sexual citizenship,
healthy relationships and well-being. It is important
that these individuals be
identified and assisted in their process of positive sexual
identity development (Bockting
& Coleman, 2007).
Many difficulties that people
experience related to sexual concerns, problems and
dysfunctions can be effectively
addressed with the provision of factual information to
counter misunderstandings, myths,
and ignorance. A lack of scientifically valid
information concerning sexual
function within the general population is pervasive and
the negative impact of this
ignorance is felt around the world. In addition, many
instances of sexual difficulties
can be satisfactorily resolved through the provision of
short-term solution focused
therapy delivered by a sufficiently trained counselor,
therapist, or front line health
care provider.
Physicians and other primary care
health providers are ideally placed to inquire about
sexual concerns, problems and
dysfunction in a non-judgmental and professional
fashion that is welcomed by
patients (Nusbaum & Hamilton, 2002). Brief assessment
of sexual concerns, problems and
dysfunction can and should become a standard
component of the general health
assessment and people should be invited and
encouraged by the health care
provider to ask questions concerning these issues. For
example, individuals experiencing
difficulties with sexual function will benefit from
factual information on sexual
anatomy, the sexual response cycle of both sexes,
psychosocial factors (e.g.,
relationship function, stress) affecting sexual function as well
as sexuality related changes
associated with aging, pregnancy, menopause, medical
conditions, illnesses, and
medications. However, data from the Global Study of Sexual
Attitudes and Behaviors showed
that few physicians in the 29 countries surveyed
routinely assess the sexual
health of their patients (Moreira, Brock, Glasser, et al.,
2005). Although nearly half of
the men and women in the survey reported sexual
problems, less than 20% sought
help from their physicians and only 9% of both men
and women reported that their
physician had inquired about their sexual health in the
previous three years.
Numerous studies have found that
physicians are often uncomfortable talking to their
patients about sexuality or
taking a sexual history, that most medical school curricula
do not train them to do so, and
that even brief training interventions designed to
increase and improve
physician-patient communication about sexuality can be effective
(Council on Scientific Affairs,
1996; McCance, Moser, & Smith, 1991; Ng & McCarthy,
2002; Rosen, Kountz, Post-Zwicker, T. et al., 2006; Solursh,
Ernest, Lewis, et al., 2003;
Tsimtsiou, Hatzimouratidis,
Nakopoulou, et al., 2006). Barriers to physician-patient
communication includes lack of
provider comfort, bias, fears of offending the patient,
lack of training, and time
constraints (Maheux, Haley, Rivard & Gervais, 1999). These
findings indicate that physicians
and other primary health providers require more and
better training to effectively
communicate with and educate their patients about
sexuality.
Evidence-based recommendations
for the treatment of sexual dysfunctions in women
(Basson, Althof, Davis, et al.,
2004) and men (Lue, Giuliano, Montorsi, et al., 2004) are
available. With respect to
clinical sexual dysfunctions diagnosed by a health
professional, there is growing
evidence that medical interventions to treat sexual
dysfunctions among men can be
effective and can have a meaningful positive impact
on health and well-being. For
example, research has demonstrated that medical
treatment for erectile
dysfunction can result in improved long-term psychosocial
quality of life for men including
increased self-esteem, sexual relationship satisfaction,
and relationship satisfaction
(Althof, O’Leary, & Cappelleri, et al., 2006a; Althof,
O’Leary, & Cappelleri, et
al., 2006b). In comparison to men, for women,
understanding of the
bio-physiology and psychology of sexual function and research
on sexual dysfunction including
effective treatment is less well developed (Verit, Yeni,
& Kafali, 2006). Although
safe and effective pharmacologic therapies for female sexual
dysfunction have not been firmly
established, recommendations for treatment include
cognitive-behavioral therapy
aimed at changing maladaptive thoughts and
unreasonable expectations,
correcting misinformation about sexuality, and exploring
strategies to improve couple
emotional closeness and communication (Basson, 2006).
Among some guidelines issued by
medical associations, there is support for local
estrogen therapy for dyspareunia
associated with vulval atrophy and cautious support
for selective use of low dose
testosterone provided the patient understands the risks
involved (for review see Basson,
2006). There is a clear need for more research on the
management of female sexual
dysfunction that includes long-term treatment outcome
studies (Basson et al., 2004).
Evidenced-based treatment for
sexual disorders is not as well established. However,
there is guidance based upon
extensive clinical experience (Bradford, 2000; Coleman,
Raymond & McBean, 2003).
Combinations of psycho- and pharmacotherapy are
often helpful. However, there is
clear need for further research to support various
types of treatments.
Treatment of gender identity
disorders has been carefully outlined by the Standards of
Care of the World Professional
Association for Transgender Health (Meyer, Bockting,
Cohen-Kettenis, Coleman, DiCeglie, Devor, Gooren, Hage, Kirk,
Laub, Lawrence,
Menard, Monstrey, Patton,
Schaefer, Webb, & Wheeler, 2001) and international
experts in this field (Ettner,
Monstrey, & Eyler, 2007). As with sexual disorders, there
is still much research and work
to be done to develop evidenced-based treatments.
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 care.
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 society at large.
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Achieve Recognition of Sexual
Pleasure as a Component of Well-being
Sexual health is more than the
absence of disease.
Sexual pleasure and satisfaction
are integral
components of well-being and
require universal
recognition and promotion.*
Most of the previous seven
chapters in Sexual Health for the Millennium
document the ability for sexual
health promotion programming to
contribute to the Millennium
Development Goals (MDGs) by halting and
reversing negative outcomes such
as STI/HIV, sexual violence, and sexual
dysfunction. While these
objectives are no doubt of primary importance, they reflect
the tendency of the sexual health
promotion field as well as policy makers to focus on
negative sexual and reproductive
health outcomes.
Far less prominent in health
promotion policy and programming is a sustained
recognition that sexual pleasure
is an elemental aspect of human sexuality. That sexual
pleasure is the final statement
does not reflect a hierarchy of importance with pleasure
coming last. Although often
ignored or stigmatized, sexual pleasure cannot be an
afterthought in sexual health
promotion.
*This chapter was informed by the WAS Expert
Consultation in Oaxaca, Mexico, a thorough review of the
literature, and the background paper written
by Terence Hull (see Appendix IV and V).
To be effective and meaningful in
making its contribution to development and human
well-being, sexual health promotion
cannot segment the essence of human sexuality
into parts and address some and
pretend that others do not exist. Sexual health
promotion programming must
recognize and engage the whole of a person’s sexuality.
Pleasure is arguably, if not
definitively the single most powerful motivating factor for
sexual behavior. To ignore the
role of sexual pleasure in contributing to human
fulfillment and happiness would
be a serious mistake. To ignore pleasure in any aspect
of sexual health promotion
programming is to present a conceptualization of sexuality
and sexual health that is not
real and will not connect with people in a way that
meaningfully addresses their
needs, aspirations, desires and concerns.
That the positive, enriching and
pleasure aspects of sexuality are essential to sexual
health was recognized within the
original internationally accepted definitions of sexual
health that were articulated by
the World Health Organization (WHO, 1975):“Sexual
health is the integration of the
somatic, emotional, intellectual and social aspects of
sexual being, in ways that are
positively enriching and that enhance personality,
communication and love.” It was
also noted that “Fundamental to this concept are the
right to sexual information and
the right to pleasure.” Pleasure was seen as a
fundamental human right. The WHO
document concluded, “Thus the notion of
sexual health implies a positive
approach to human sexuality, and the purpose of sexual
health care should be the
enhancement of life and personal relationships and not
merely counseling and care
related to procreation or sexuality transmitted diseases.”
The link between sexual health
and overall health was clearly articulated in the U.S.
Surgeon General’s (2001)
definition of sexual health and the importance of pleasure
was also clearly articulated.
Sexual health is inextricably
bound to both physical and mental health.
Just as physical and mental heath
problems can contribute to sexual
dysfunction and diseases, those
dysfunctions and diseases can contribute
to physical and mental health
problems. Sexual health is not limited to
the absence of disease or
dysfunction, nor is its importance confined to
just the reproductive years. It
includes the ability to understand and weigh
the risks, responsibilities,
outcomes and impacts of sexual actions and to
the practice abstinence when
appropriate. It includes freedom from
sexual abuse and discrimination
and the ability to integrate their sexuality
into their lives, derive pleasure
from it, and to reproduce if they so
choose (U.S. Surgeon General,
2001, p. 1).
Finally, in a revision the 1975
definition of sexual health, the WHO (2002; 2006)
reasserted these basic principles
but clearly added the notion of pleasure in their
recently released working
definitions.
Sexual health is a state of
physical, emotional, mental and social wellbeing
related to sexuality; it is not
merely the absence of disease,
dysfunction or infirmity. Sexual
health requires a positive and respectful
approach to sexuality and sexual
relationships, as well as the possibility of
having pleasurable and safe
sexual experiences, free of coercion,
discrimination and violence. For
sexual health to be attained and
maintained, the sexual rights of
all persons must be respected, protected
and fulfilled.
This definition clearly
challenged government policies and public health approaches to
not just to avoid problems of
illness or healthy reproduction, but to promote pleasure
as an essential ingredient of
well-being (Coleman, 2007). The importance of
recognizing and integrating
considerations of the role of pleasure in human sexuality
does not simply apply to what
some might consider the more esoteric aspects of sexual
health promotion such as the
treatment of sexual dysfunction, it applies in equal
measure to programs aimed at
STI/HIV prevention, assisting the victims of sexual
violence/abuse, sexuality
education of youth, fertility control, etc. The preceding
chapters of this document make
clear the vital role that the promotion of sexual health
must play if the MDGs are
ultimately to be achieved. This chapter illustrates the often
overlooked fact that sexual
pleasure is a fundamental component of sexual health and
of overall human health and
well-being. The more that sexual health promotion
programs embody the totality of
human sexuality, educate, counsel and assist people in
ways that recognize and
incorporate pleasure, the more likely these programs will meet
people’s needs, correspond to the
reality of the human experience, ultimately reach
their objectives and, therefore,
have the most impact in contributing to the MDGs.
Throughout much of human history,
passionate love and sexual desire have been
viewed as dangerous, a threat to
the social, political and religious order (Hatfield &
Rapson, 1993). During the current
historical period, religion and medicine have had
powerful influences on societal
norms for sexual health and sexual behavior (Hart &
Wellings, 2002) and in some
important respects these institutions have inherited and
continued the tradition of
viewing sexual desire, and by extension, pleasure with
varying degrees of suspicion.
It is not possible to make tidy
generalizations about the extent to which the major
religions have held either “sex
negative” or “sex positive” perspectives toward pleasure
and sexuality. However, it may be
said that in various historical periods, many religions,
including Christianity and Islam
have focused on the reproductive aspects and function
of sexuality. Consequently, they
have sought strict controls on sexual behavior
particularly outside of marriage
between a man and a woman, behavior that does not
lead to reproduction (e.g.,
masturbation) and viewed sexual pleasure, particularly that of
women and homosexual men and
women, with contempt (For extensive
documentation and analysis of
religious perspectives toward sexuality throughout
history see Bullough, 1980,
Hawkes, 2004). Numerous scholars have documented the
disdain for sexual pleasure
expressed by Christian theologians and institutions
throughout much of the church’s
history (e.g., Pagels, 1988).
Masturbation, in particular, has
been a contentious topic as its primary purpose is to
produce pleasure (Coleman, 2002).
Research on masturbation has indicated that
contrary to traditional beliefs,
masturbation has been found to be a common sexual
behavior and linked to indicators
of sexual health. While there are no general
indicators of ill health
associated with masturbation, it can generate powerfully negative
or positive emotions for many
individuals. It can be powerfully negative or positive,
depending on the interaction
between the prevailing societal attitudes and individual
attitudes and behaviors (Coleman,
2002).
In fact, research has indicated
that masturbation begins early and is an important part
of healthy sexual development
(Langfeldt, 1981). It is often a marker of sexual
development (Bancroft, Herbenick,
D., & Reynolds, 2002). Many young people learn
about their bodies and sexual
responsiveness through masturbation (Atwood &
Gagnon, 1987). Masturbation also
continues throughout the life span. For example,
many adults continue to
masturbate even though they are married and have ready
access to sexual intercourse
(Laumann et al., 1994). Masturbation can also help older
people who do not have an
available partner to maintain sexual functioning and
expression (Leiblum &
Bachmann, 1988). It is also a safe alternative to behaviors that
carry a risk of a sexually
transmitted infection, including HIV. The benefits of
masturbation are illustrated by
its wide acceptance in sex therapy as a means of
improving the sexual health of
the individual and/or couple (Heiman & LoPiccolo,
1988; Leiblum & Rosen, 1989;
Zilbergeld, 1992).
Addressing masturbation within
sexual health promotion programming can be
controversial. However the
available evidence suggests that including masturbation as a
topic within comprehensive sexual
health promotion is important and necessary.
There is a need for more
research, including theory development and hypothesis
testing, on the impact of
masturbation on self-esteem, body image, sexual functioning
and sexual satisfaction and the
effective incorporation of education about masturbation
within sexual health promotion
programs.
It must be noted that positive
and progressive perspectives toward pleasure and
sexuality are emerging from
groups from a variety of religious faiths. Nevertheless, it
must also be acknowledged that
the legacy of a largely negative interpretation of sexual
pleasure, particularly if it is
experienced in a context contrary to particular religious
norms for sexual conduct, by many
religious institutions is still with us today and
continues to hinder the
recognition of pleasure in sexual health promotion efforts in
many parts of the world. With
respect to international efforts to promote sexual health,
the alliance of the United
States, the Vatican and conservative Muslim and Catholic
states in opposing the
recognition of diverse sexual rights, including those related to
pleasure, is testimony to the
continued influence of conservative religious forces in
shaping polices related to sexual
health (Ilkkaracan, 2005).
Since the latter half of the 19th
century, medicine and medical science has, particularly
in the Western world, exercised
considerable authority over sexuality and here too we
find that sexual pleasure was
often seen as pathology. As Hart and Wellings (2002)
suggest “The long tradition of
representing illness as a punishment for sin was
continued when sexual behavior
was medicalized and transformed into morbidity” (p.
896). For example, masturbation,
homosexual desire and overt sexual interest,
particularly if expressed by
women was until quite recently seen by medicine as
symptomatic of psychiatric illness
and perversion.
Although contemporary medicine
and some religious institutions have turned the
corner in recognizing the
positive and beneficial aspects of sexual expression, many
remnants of the propensity to
focus on the negative outcomes of sexual expression
remains with us. “Today’s public
discourse about sexuality is almost exclusively about
risks and dangers: abuse,
addiction, dysfunction, infection, pedophilia, teen pregnancy,
and the struggle of sexual
minorities for their civil rights” (Planned Parenthood
Federation of America [PPFA],
2003. p. 1).
Although, in most cultures,
sexual desire and pleasure receive their widest endorsement
within the context of a
relationship, sexual desire and pleasure are increasingly coming
to be seen as intrinsically
positive and rewarding aspects of human experience. While a
concern with pleasure is
sometimes thought of as a decadent preoccupation of a
secular Western culture, it is
important to note that many diverse cultures have strong
traditions of affirming sexual
pleasure. For example, within Brazilian culture the
concept of tudo or “Everything”
refers to the world of erotic experiences and
pleasures (de Freitas, de
Oliveira, & Rega, 2004). Indeed, a contemporary discourse of
pleasure can be found in many non-western
cultures. For example, in Turkey, a
country not known for its
affirmation of women’s sexual pleasure, a grassroots
program that emphasized sexual
pleasure as a women’s human right was conducted
(Ilkkaracan & Seral, 2000).
Organizations such as the South and Southeast Asian
Resource Centre on Sexuality
(Patel, online) are raising the issue of pleasure in the
context of sexual health. From
their review of historical and cross-cultural perspectives
on passionate love and sexual
desire, Hatfield and Rapson (1993) conclude that the tide
of history is in the direction of
“….an increasing acceptance of passionate love and
sexual desire as legitimate,
expressible feelings” (p. 91).
Romantic love is a primary
feature of couple relationships and is expressed through
sexuality and sexual passion for
the partner (Esch & Stefano, 2005). Although social,
political and economic
differences across time and place can markedly impact upon
sexual attitudes and behavior,
cross-cultural research has found that people in all
societies place a high value on
being with a partner for whom there is “mutual
attraction-love” (Buss et al.,
1990). Sexual desire and pleasure are embedded in and a
fundamental aspect of the mutual
attraction between partners.
The mutual sharing of sexual
pleasure has been shown to increase bonding within
relationships (Weeks, 2002). As
Tepper (2000) writes with respect to the neglected
rights of people with
disabilities to enjoy their sexuality, “Pleasure is an affirmation of
life…It can add a sense of
connectedness to the world or to each other. It can heal a
sense of emotional isolation so
many of us feel even though we are socially integrated”
(p. 288).
In sum, the enjoyment of sexual
pleasure plays an important role in contributing to the
establishment, maintenance and
stability of couple relationships and, without doubt,
the quality of couple
relationships is fundamental to the health and well-being of
individuals and families. While
sexual pleasure can be seen as an end in-of-itself, for
many, if not most people, sexual
pleasure is intertwined with feelings of intimacy and
affection for their partner.
Sexual desire and pleasure not only facilitate reproduction,
they function as a mechanism of
social attachment for the couple relationship, an
essential kinship structure in
all cultures of the world (Fisher, 2002).
At the most foundational level,
sexual pleasure is rooted in the most basic of human
functions as has been recognized
by evolutionary psychology.
In the context of adaptive
behavior and its necessity in evolution, it
would appear that the pleasure
generated by sexual stimulation, orgasm
or intercourse would be
selected-for evolutionarily. Consequently,
pleasure can be seen as an
effective and important adaptive mechanism,
the function of which is to
ensure the procreation and survival of the
species (Esch & Stefano,
2005, p. 182).
To the extent that a society is
concerned with the well-being and stability of families
generally, and couples
specifically, it is in the interests of policy makers to recognize the
importance of sexual pleasure and
to implement sexual health promotion programs
that address sexual pleasure as
fundamental to individual and couple health and wellbeing.
The recent Global Study of Sexual
Attitudes and Behaviors that examined various
aspects of sexual health among a
sample of 27,500 men and women aged 40 to 80
from 29 culturally diverse
countries around the world offers strong evidence of the
importance of pleasure and sexual
satisfaction for the happiness and well-being of
individuals and couples (Laumann
et al., 2006: Nicolosi et al., 2004). The survey asked
participants, among other things,
questions about the degree to which they found their
relationships to be physically
pleasurable and how important sex is to their overall
happiness. Over three quarters of
men (82%) and women (76%) agreed that
satisfactory sex is essential to
maintain a relationship and the authors concluded from
their findings that despite
substantial cultural variation in sexual norms and values,
subjective sexual well-being was
associated with overall happiness in both men and
women.
A White Paper published by the
Planned Parenthood Federation of America (PPFA,
2003) in cooperation with the
Society for the Scientific Study of Sexuality extensively
catalogues the scientific
evidence demonstrating the health benefits of sexual
expression. Taken together, the
studies cited suggest that partnered sexual activity
and/or masturbation can be
associated with improved longevity, immunity, pain
management, self-esteem and a
reduction in stress.
In sum, sexual pleasure helps to
cement the primary kinship structure of the couple
relationship, contributes to the
overall happiness in life of both men and women
(whether they are in partnerships
or not) and is associated with various aspects of good
health. Seen in this way sexual
pleasure is not frivolous or unnecessary: it is essential.
It is noted elsewhere in this
document in relation to reproductive health that the
United Nations (UN, 1995) 4th
International Conference on Population and
Development (ICPD) was, in some
senses, a breakthrough in that paragraph 96 of the
document defined reproductive
health in a positive way, acknowledging that sexual
health involves the “enhancement
of life and personal relations” and that “people are
able to have a satisfying and
safe sex life.” These can be seen as pleasure positive
statements. According to Parker
et al., (2004) the key distinction in developing a
concept of sexual rights to guide
sexual promotion is the distinction between negative
rights (e.g., freedom from sexual
violence and abuse) and positive sexual rights.
“Conceptually, positive sexual
rights have been described as enabling conditions
necessary for the expression of
sexual diversity, health, and pleasure” (Parker et al., p.
374). And yet, it is clear that
positive sexual rights, including pleasure affirming
approaches to sexual and
reproductive health, particularly as they relate to public health
policy have, and will continue to
meet resistance. As Correa (2002) has noted with
respect to ICPD,
…to call for sexual rights as a
protection against pregnancy, rape, disease
and violence, is a different
matter from affirming these rights in relation
to eroticism, recreation and
pleasure. This second interpretation was in
the minds of many of those who
struggled for Paragraph 96. But there
are political and conceptual
obstacles that make it difficult for the
discourse on sexual rights to
shift towards this “positive concept”
interpretation. In the political
domain, persistent attacks by conservative
forces on sexuality-related issues
constantly push them back under the
cover of more acceptable
(well-behaved) reproductive, health and
violence agendas. In addition,
within the health field the dominance of
biomedical frameworks constantly
pressures “sexual subjects” to remain
contained in disciplinary domains
(particularly epidemiology and
behaviorist frames) (p. 5).
Although ICPD did represent a
step forward, progress in implementing sexual health
promotion programs that embody a
positive conception of sexual rights to include a
“discourse of pleasure” (Tepper,
2000) will require international organizations and
public health agencies,
governments and other public institutions to further expand
their conceptualizations of
sexual health beyond traditional notions of preventing
morbidity and mortality. These
institutions, in both policy and practice, must explicitly
recognize the importance of
positive sexual rights to sexual pleasure and expression in
conjunction with the emphasis on
the right to freedom from disease, dysfunction and
abuse.
The Pan American Health
Organization (PAHO, 2000) document Promotion of
Sexual Health: Recommendations
for Action provides an example of an expanded
vision of sexual health that
acknowledges positive sexual rights and addresses sexual
health concerns related to
eroticism that according to PAHO “….demand actions
from governmental and
non-governmental agencies and institutions including the
health sector” (p. 17). As
articulated by PAHO, these concerns are:
* Need for knowledge about the body, as related to
sexual
response and pleasure
* Need for recognition of the value of sexual
pleasure enjoyed
throughout life in safe and
responsible manners within a
values framework respectful of
the rights of others
* Need for promotion of sexual relationships
practice in safe
and responsible manners
* Need to foster the practice and enjoyment of
consensual,
non-exploitive, honest, mutually
pleasurable sexual
relationships (p. 17).
The gradual acceptance of the
rights of youth and people with disabilities to sexual
health education has led to the
implementation of programs for these audiences in
some parts of the world. While
some programs have had some success in reaching
behavioral targets related to
negative outcomes such as STI/HIV infection among
youth (e.g. see Kirby, 2005), it
is clear that a problem prevention emphasis combined
with a near total silence
regarding desire and pleasure distorts the reality of human
sexuality and may result in
programs for youth and the disabled that are irrelevant to
their needs (Fine &
McClelland, 2006; Nyanzi, 2004; Tepper, 2000).
Sexual health education for young
people with physical or developmental disabilities
can empower them to enjoy
personal sexual fulfillment but few people with disabilities
have access to such programs (Di
Giulio, 2003; Murphy & Young, 2005). Sexual health
education programs for youth in
nearly, if not all parts of the world focus primarily on
the negative aspects of human
sexuality and ignore pleasure and sexuality within
relationships.
From her ethnographic research on
sexuality in both East and West Africa, Nyanzi
(2004) concluded that sexuality
education programs for youth that emphasized risks
and “disastrous consequences”
with a “concomitant denial of pleasure” have the effect
of “putting off adolescents
rather than capturing their attention” (p.13). Adolescents,
just like adults, are motivated
by the search for intimacy and sexual pleasure in their
pursuit of relationships (Ott,
Millstein, Ofner & Halpern-Felsher, 2006). Sexual health
promotion programs for youth and
people with disabilities require much more
emphasis on positive sexual
rights that incorporate basic human needs related to sexual
pleasure and fulfillment.
From the standpoint of
comprehensive and effective sexual health promotion, sexual
pleasure is not frivolous; it is
not destructive as it has and often is portrayed. In this
chapter, it has been demonstrated
that sexual pleasure contributes to human happiness
and well-being and is a normal
part of human development and development of
positive identity and powerful
glue for the intimate attachment between partners.
Within the totality of human
development, the experience of sexual pleasure and
fulfillment must be recognized
for what it truly is; a basic human need on par with
other basic requirements
necessary for a healthy and productive life. This reality must
be reflected in sexual health promotion
policy and programs aimed at contributing to
healthy community development.
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 sexual
rights.
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.
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Zilbergeld, B. (1992). The new male
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Appendix I
The World Association for Sexual
Health (WAS) is an
international organization
founded in Rome as the World
Association for Sexology (WAS) in
1978. The name was officially
changed to the World Association
for Sexual Health in 2005.
WAS membership is composed of,
International Organizations, National Societies and
Institutes and individual
supporting members. WAS currently has 124 member
organizations and numerous
individual members, representing over 53 countries in 5
continents. There are five
Federations that group members in each of the main regions
of the World: North America,
Latin America, Europe, Asia-Oceania and Africa. The
WAS brings individuals and
organizations together to share scientific information,
form networks and promote
international and intercultural exchange.
Mission:
The World Association for Sexual
Health promotes sexual health
throughout the lifespan and
through the world by developing, promoting
and supporting sexology and
sexual rights for all.
WAS accomplished this by advocacy
actions, networking, facilitating the exchange of
information, ideas and
experiences and advancing scientifically- based sexuality
research, sexual education and
clinical sexology, with a trans-disciplinary approach.
The purpose of the WAS is to
advance international cooperation in the field of
sexology and by coordinating the
activities designed to increase research and
knowledge in sexology, including
sexuality education, sexual health and the alleviation
of sexual suffering.
The WAS believes in the
importance of both the production of quality research and
the application and communication
of that sexual knowledge. WAS activities include:
* Sponsorship of the World Congresses of Sexual
Health
* Sponsorship of regional or interregional
meetings
* International exchanging of information
* Working relations with the World Health
Organization, the Pan American
Health Organization, the World
Psychiatric Association, the International
Society of Sexual Medicine, the
International Society for the Study of Women’s
Sexual Health, and other
international organizations
* Recognizing outstanding contributions in the
field of sexology.
World Congresses for Sexual
Health
Beginning in Rome in 1978 through
Sydney in 2007, the WAS has successfully
sponsored 18 international
congresses, attracting thousands of participants from
around the world. The 19th World
Congress will be held in Gothenburg, Sweden in
2009.
Forming Networks
In addition to its worldwide
membership, the WAS has developed formal ties with five
prominent regional sexological
organizations:
* AOFS (Asian-Oceania Federation of Sexology)
* EFS (European Federation of Sexology)
* FLASSES (Latin American Federation of Sexology)
* AFSHR (African Federation for Sexual Health and
Rights)
* NAFSO (North American Federation of Sexuality
Organizations)
Intercultural Exchange &
Promoting Sexual Health
In furthering its goals of
promoting sexual health worldwide and developing cultural
and international exchange, the
WAS is:
* Assisting in the creation of regional libraries,
especially in underdeveloped
areas of the world
* Addressing HIV-prevention efforts around the
world
WAS Position Statements
In August, 1999, the WAS adopted
a “Universal Declaration of Sexual Rights.”
The WAS has also adopted position
statements condemning:
* Genital circumcision of women
* Sexual torture in prisons
* Gender biased-related incidents
* Discrimination based on gender or sexual
orientation
President: Eusebio Rubio-Aurioles
(Mexico)
Vice President: Rosemary Coates
(Australia)
Secretary General: Beverly
Whipple (USA)
Past President: Marc Ganem
(France)
Associate Secretaries Uwenedimo
Esiet (Nigeria)
Emil Ng (China)
Antonio Palha (Portugal)
Mónica Rodríguez (USA)
Presidents of Regional
Federations Antonio Pahla (EFS)
Verapol Chandeying (AOFS)
Ruben Hernandez (FLASSES)
Joseph DiNorcia (NAFSO)
Uwemedimo Esiet (AFSHR)
Advisory Committee: Kevan Wylie
(United Kingdom)
Pierre Assalian (Canada)
Walter Bockting (USA)
Jaqueline Brendler (Brazil)
Francisco Cabello (Spain)
Mariela Castro Espin (Cuba)
Prakash Khotari (India)
Reiko Ohkawa (Japan)
Oswaldo Rodrigues (Brazil)
Lillemor Rosenqvist (Sweden)
Chiara Simonelli (Italy)
Past Presidents: Romano Forleo
(Italy)
Fernando Bianco (Venezuela)
Alan Wabrek (USA)
Rubén Hernández Serrano (Venezuela)
Eli Coleman (USA)
Ex-Officio Members: Juan Jose
Borrás (Sexual Rights Committee)
Esther Corona (International
Liaison Committee)
Eli Coleman WHO-PAHO Liaison
Officer
Margaret Redelman (18th World
Congress)
Lars-Gosta Dahlof (19th World
Congress)
To Contact WAS:
http://www.worldsexualhealth.org
WAS Regional Federations:
African Federation for Sexual
Health and Rights
Asia-Oceania Federation for
Sexology
European Federation of Sexology
Federación Latinoamericana de
Sociedades de Sexologia y Educacion Sexual
North American Federation of
Sexuality Organizations
International Organizations
International Society for the
Study of Women's Sexual Health (ISSWSH)
World Professional Association for
Transgender Health (WPATH)
National Societies
Argentina Asociacion Argentina de
Sexologia y Educacion Sexual (AASES)
Consexuar, Capitulo de Sexología
de La Asociación de Psiquiatras Argentinos APSA
Federación Sexológica Argentina
(FESEA)
Sociedad Argentina de Sexualidad
Humana
Australia Australian Society of
Sex Educators, Researchers and Therapists, The (ASSERT)
Austria Austrian Society for Sex
Research
Sexualwissenschaftliche Gesellschaft Ostorreichs (SGO)Austrian
Society for Sexology
Brazil Associacao Brasileira de
Terapia Sexual
Sociedad Brasileira de Estudos em
Sexualidade Humans
Sociedade Brasileira De Sexologia
Canada Association des Sexologues
du Quebec
Sex Information and Education
Council of Canada
Chile Sociedad Chilena de
Sexologia y Educacion Sexual
Sociedad Chilena para el Estudio
de la Impotencia
China Hong Kong Association of
Sexuality Educators, Researchers & Therapists
Hong Kong Sex Education
Association
Taiwan Association of Sexuality
Education
Costa Rica Costa Rican
Association of Sexologists and Related Professionals
Cuba Sociedad Cubana
Multidisciplinaria para el Estudio de la Sexualidad
Czech
Republic Ceska Lekarska
Spolecnost
Denmark Dansk Forening for
Klinisk Sexologi
Ecuador Sociedad Ecuatoriana de
Sexologia y Educacion Sexual (Sesex)
Egypt Egyptian Association of
Marital and Sexual Health
Estonia Estonian Academic Society
for Sexology
Finland Finnish Association for
Sexology,(Soumen Seksologinem Seura)
Sexpo Finnish Foundation for Sex
Education and Therapy
France Association Interhospitalo
Universitaire de Sexologie (AIHUS)
Societe Francaise de Sexologie Clinique
Germany Deusche Gesellschaft fur Sozialwissenschaftliche
Sexualforschung e V
Deutsche Gesellschaft fur Geschlechtserziehung e V. DGG e.V. Bonn
Greece Greek Society of Sexology
India Indian Association of Sex
Education, Counselling and Therapy (IASECT)
Israel Israel Society for Sex
Therapy
Italy Federazione Italiana di
Sessuologia Scientifica
Societa Italiana di Sessuologia
Societa Italiana Di Sessuologia
Scientifica
Societa Italiana per le Ricerca e
la Formazione in Sessuologia
Japan Japan Family Planning
Association, Inc
Japan Society for Adolescentology
Japanese Association for Sex
Education
Japanese Society for Impotence
Research
Japanese Society of Sexual
Science
Korea Korean Society of Sexology
Mexico Asociación Mexicana de
Sexología AC
Federacion Mexicana de Educacion
Sexual y Sexologia AC (FEMESS)
Sociedad Mexicana de Andrología
Medicina Sexual y para Estudio del
Hombre Añoso
Netherlands Nederlandse Vereniging Voor Seusuologie
Norway Norwegian Society for
Clinical Sexology
Poland Polish Sexological Society
Portugal Sociedade Portuguesa de
Sexologia Clinica
Puerto Rico Sociedad Sexológica y
de Educación Sexual de Puerto Rico
Singapore Society for the Study
of Andrology & Sexology
South Africa The South African
Sexual Health Association
Spain Asociacion Española de
Especialistas en Sexología
Asociacion Española de Sexologia
Clinica
Asociación Estatal de
Profesionales de la Sexología
Asociacion pro Derechos Sexuales
Federacion Española de Sociedades
de Sexologia
Sociedad Medica Española de
Sexología
Societat Catalana de Sexología
Sweden Swedish Association for
Sexology
Switzerland Association des
Sexologues Cliniciens Francophones (ASCLIF)
Thailand Association for the
Promotion of Women Status
Turkey Society for Sexual
Education, Treatment and Research (CETAD)
United Kingdom British
Association for Sexual and Relationship Therapy
Uruguay Sociedad Uruguaya de
Sexología
USA American Association of
Sexuality Educators Counselors and Therapists
National Coalition for Sexual
Freedom INC
Sexual Health Network
Sexuality Information &
Education Council of the US
Society For Sex Therapy and
Research (SSTAR)
Society for the Advancement of
Sexual Health
Society for the Scientific Study
of Sexuality (SSSS)
Venezuela Sociedad Venezolana de
Psicologia Sexologica
Sociedad Venezolana de Sexologia
Medica
Professional Institutes
Argentina Circulo Argentino de
Sexología
Instituto de Sexologia del
Desarrollo
Brazil Centro De Sexolgia de
Brasilia
CEPCos - Center for Studies and
Research on Human Behavior and Sexuality
Instituto Paulista de Sexualidade
Mestrado em Sexologia
Universidade Gama Filho
Sathya Institute Cultural
Canada Canadian Sex Research
Forum
Centre for Sexuality, Gender Identity
and Reroductive Health of the Vancouver
Hospital
Department de Sexologie de
L'Universitite du Quebec a Montreal
Colombia CRESALC – Colombia
Central Médica de
Sexología-C.M.S.
Costa Rica Instituto Costaricense
de Sexologia (ICOSEX)
Croatia Komaja - Society for the
Developmentof Love and Consciousness
Cuba Centro Nacional de Educacion
Sexual
Germany Komaja Society for the
Culture of Love
France Academie de Sciences
Sexologiques
Arab Insitute for Sexology and
Somato Therapy
Ecole Francaise de Sexologie
Institute de Sexologie
Israel Association of Rabbinical
Marriage and Family Counselors
Italy Centro Interdisciplinare
per la Ricerca e la formazione in Sessuologia
Centro Italiano Di Sessuologia
Istituto Corpo I Mente
Istituto di Sessuologia Clinica
Istituto Internationale di
Sessuologia
Istituto Per La Ricerca in
Sessuologia Clinica
Korea Severance Institute of
Andrology
Mexico Asociación Mexicana de
Educación Sexual (AMES)
Asociación Mexicana para la Salud
Sexual AC (AMSSAC)
Centro de Educación y Atención en
La Salud y la Sexualidad A.C.
El Armario Abierto
Pro Salud Sexual y Reproductiva
AC
Macedonia Komaja - Society for
the Development of the Art of Living
Nigeria Action Health
Incorporated
Paraguay Centro Privado de
Sexología Clínica y Manejo del Stress
Panama Instituto de Orientación
Familiar y Sexual (INOFYS)
Spain Cepteco
Instituto de Psicologia,
Sexologia y Medicina Espill
Instituto de Terapia de
Reencuentro
Switzerland Institut Sexocorporel
International – Jean-Yves Desjardins (ISI)
Komaja Foundation
Thailand Consortium of Thai
Training Institutes of STDs and AIDS
United
Kingdom The Sheffield Society for
the Study of Sexuality and Relationships
USA Health Horizons Associates
Institute for Advanced Study of
Human Sexuality, The
Lifetime Productions
International
Program in Human Sexuality.
University of Minnesota
The Women’s Sexual Health
Foundation
Center for Education of The
Widener University
Venezuela Unidad de Terapia y
Educación Sexual
Individual Supporting Members
Australia Kelwyn Craig Browne
Cheryl Matthews
Gareth J Merriman
Gemma M. O'Brien
Catherine Helen Thorne
Austria Helmut Graupner
Franz Michael Reistenhofer
Karl F Stiefer .
Bangladesh Colonel Azim
Canada Lidia Calb
Maryanne Doherty
Stacy Elliott
Kanwal Kukreja
Sylviane Larose
R. Oliver Robinow
Chile Eduardo Ulises Pino Aravena
Pedro Edgardo Rivera Garay
Elena Sepúlveda Parada
Colombia Lucia Nader M
Leonardo Romero Salazar
Ecuador Consuelo Camacho Murillo
Carlos Rodolfo Rodriguez
Carrión
Germanico Zambrano Torres
France Alain Jules Giami
India Arun Gupta
Naresh Mittra
Padmini Prasad
K. Promodu
Sathyanarayana Rao
Girish J. Sanghavi
Ambrish Singal
Indonesia Andik Wijaya
Italy Claudio Cappotto
Rosaria Damiani
Bruno Carmine Gargiollo
Mariateresa Molo
Domenico Trotta
Japan Ryukichi Kato
Isaka Masanori
Korea Cheng Kim
Won-whe Kim
Min Whan Koh
Malaysia Chua Chee Ann
Mexico Eduardo Alonso Aguirre
Sandoval
Jose Manuel Gaytan Galindo
Gema Ortiz Martínez
Muscat
Sultanate of
Oman Abdullah Hamood Issa Al-Taie
Netherlands Luca Incrocci
Northern
Ireland Richard John Marcus Ekins
Norway Kristina Hernborg
Thore Langfeldt
Pakistan Muhammad Haris Burki
Qaiser Javied
Peru Tomas Alejandro Angulo
Mendoza
Mercedes Tong de Tang
Portugal Bruno Jose de Oliveria
Carrraca
Ana Garrett
Puerto Rico Sylvia Cabrera-Otero
Edward Fankhanel
Alejandro Lopez Deynes
Carmen Valcarcel-Mercado
Russia Oleg Konstantinovich
Yatsenko
Yuri Zarkov
Spain Josep Ma Farreny Tarrago
Sauro Yague
Switzerland Johannes Bitzer
Dominique Chatton
Thailand Verapol Chandeyng
United
Kingdom James Barret
Sara Nasserzadeh
Tadhg O’Seaghdha
Julie Shankly
Sauren Solanki
Uruguay Carlos Moreira
USA Raquel Blanco Camacho
Michael L Brownstein
Bill Cohen
Berta Davis
Mingyu Deng
Mary A. Gutierrez
Andrea Irvin
Judy Kuriansky
Mark Kim Malan
Melinda Masters
Anagloria Mora
Deborah Rogow
B. R. Simon Rosser
Glen L. Stimmel
Titus Varghese
Winston Wilde
Venezuela Ana Cecilia de Blejman
Appendix II
Sexuality is an integral part of
the personality of every human being. Its
full development depends upon the
satisfaction of basic human needs such
as the desire for contact,
intimacy, emotional expression, pleasure,
tenderness and love.
Sexuality is constructed through
the interaction between the individual and social structures. Full
development of sexuality is
essential for individual, interpersonal, and societal well being.
Sexual rights are universal human
rights based on the inherent freedom, dignity, and equality of all human
beings. Since health is a
fundamental human right, so must sexual health be a basic human right. In
order to assure that human beings
and societies develop healthy sexuality, the following sexual rights must
be recognized, promoted,
respected, and defended by all societies through all means. Sexual health is
the
result of an environment that
recognizes respects and exercises these sexual rights.
1. The right to sexual freedom. Sexual
freedom encompasses the possibility for individuals to express their full
sexual potential. However, this excludes all
forms of sexual coercion, exploitation and abuse at any time and situations
in life.
2. The right to sexual autonomy, sexual
integrity, and safety of the sexual body. This right involves the ability
to make autonomous decisions about one’s
sexual life within a context of one’s own personal and social ethics. It also
encompasses control and enjoyment of our own
bodies free from torture, mutilation and violence of any sort.
3. The right to sexual privacy. This
involves the right for individual decisions and behaviors about intimacy as
long
as they do not intrude on the sexual rights
of others.
4. The right to sexual equity. This
refers to freedom from all forms of discrimination regardless of sex, gender,
sexual orientation, age, race, social class,
religion, or physical and emotional disability.
5. The right to sexual pleasure.
Sexual pleasure, including autoeroticism, is a source of physical,
psychological,
intellectual and spiritual well being.
6. The right to emotional sexual
expression. Sexual expression is more than erotic pleasure or sexual acts.
Individuals have a right to express their
sexuality through communication, touch, emotional expression and love.
7. The right to sexually associate freely.
This means the possibility to marry or not, to divorce, and to establish
other types of responsible sexual
associations.
8. The right to make free and responsible
reproductive choices. This encompasses the right to decide whether
or not to have children, the number and
spacing of children, and the right to full access to the means of fertility
regulation.
9. The right to sexual information based
upon scientific inquiry. This right implies that sexual information
should be generated through the process of
unencumbered and yet scientifically ethical inquiry, and disseminated in
appropriate ways at all societal levels.
10. The right to comprehensive sexuality
education. This is a lifelong process from birth throughout the lifecycle
and should involve all social institutions.
11. The right to sexual health care.
Sexual health care should be available for prevention and treatment of all
sexual
concerns, problems and disorders.
Sexual Rights are Fundamental and
Universal Human Rights
Declaration of the 13th World Congress of
Sexology, 1997, Valencia, Spain. Revised and approved by the General
Assembly of the World Association for
Sexology (WAS) on August 26th, 1999, during the 14th World Congress of
Sexology, Hong Kong, People’s Republic of
China.