Sexual Health for the Millennium

A Declaration and Technical Document

 

© Sexual Health for the Millennium. A Declaration and Technical Document. is a publication of

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World Association for Sexual Health. (2008). Sexual Health for the Millennium. A

Declaration and Technical Document. Minneapolis, MN, USA: World Association for

Sexual Health.

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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

Synopsis

 

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.

 

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.

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.

 

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.

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.

 

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.

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.

 

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.

 

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.

 

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.

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.

 

6. 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.

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.

 

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.

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.

 

8. Achieve recognition of sexual pleasure as a component of holistic health and wellbeing

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.

 

Conclusion

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.

 

Recognition of the Importance of Addressing Sexuality and Sexual Health as Key Elements in Realizing the United Nations Millennium Development Goals

Parallel to the recognition of sexual rights as human rights has been the growing

recognition that the attainment and maintenance of sexual health for individuals,

couples, and families is a necessary prerequisite for the sustained social and economic

development of communities and nations. According to Girard (2005), at the

international level, the years that began with the 1994 International Conference on

Population and Development (ICPD) have been marked by significant progress in the

recognition by governments of sexual health as an essential dimension of overall health

and consequently, of human development. The ICPD Programme of Action (PoA)

adopted by 184 countries provided the first definition of sexual health negotiated and

agreed upon by national governments from around the globe. It situated sexual health

within a broader rubric of reproductive health care and recognized the important

multifaceted contribution that sexual health makes to human well-being.

...Reproductive health care is defined as the constellation of methods,

techniques, and services that contribute to reproductive health and wellbeing

by preventing and solving reproductive health problems. It also

includes sexual health, the purpose of which is the enhancement of life

and personal relations, and not merely counseling and care related to

reproductive and sexually transmitted diseases (UN, 1994, par. 7.2.).

Other international documents have recognized and emphasized the importance of

sexual health within the broader constellation of human well-being. For example, the

PAHO (2000) Promotion of Sexual Health: Recommendations for Action stressed

that if overall health is to be achieved, sexual health must be promoted and maintained.

Sexual health concerns and problems are important to address and find

solutions for not only because they undermine sexual health, and

therefore the general health of the individual, family, and society, but also

because their presence might signal other health problems. Moreover,

sexual health concerns and problems may generate, and/or perpetuate

other problems in the individual, family, community and population at

large (p. 15).

In September of 2000, the United Nations General Assembly adopted Resolution

55/2, the United Nations Millennium Declaration (UN, 2000). The Millennium

Declaration was rooted in fundamental values: freedom, equality, solidarity, tolerance,

respect for nature, and shared responsibility. The Millennium Development Goals

(MDGs) that were derived from the Millennium Declaration and adopted by world

leaders at the United Nations Millennium Summit in 2000 articulate objectives for

resolving some of the most complicated and urgent social problems of our time. They

are commonly accepted as a framework for measuring development progress and as a

tool to help governments and advocates mobilize resources and implement programs

that ensure sustainable and equitable development worldwide. At the United Nations

Millennium Summit, world leaders committed, through the MDGs, to measurable

goals for addressing a basic range of problems including poverty, hunger, disease,

illiteracy, environmental degradation and discrimination against women. To varying

degrees, these issues affect all the regions and peoples of the world. At their essence,

the MDGs are aimed at improving the human condition and promoting the most basic

of human rights.

 

UNITED NATIONS MILLENNIUM DEVELOPMENT GOALS

1. Eradicate Extreme Poverty and Hunger

2. Achieve Universal Primary Education

3. Promote Gender Equality and Empower Women

4. Reduce Child Mortality

5. Improve Maternal Health

6. Combat HIV/AIDS, Malaria and Other Diseases

7. Ensure Environmental Sustainability

8. Develop a Global Partnership for Development

The MDGs are necessarily broad in scope, placing eight basic objectives at the centre

of the global agenda. Meeting these broad global objectives must inevitably require

addressing those specific factors that make the attainment of the broader objectives

possible. For most of the MDGs, these specific factors directly or indirectly involve

sexuality and sexual and reproductive health. The WHO’s global Reproductive Health

Strategy adopted at 57th World Health Assembly in May 2004 explicitly recognized the

links between the MDGs and sexual and reproductive health. At a broad level, the

WHO (2004b) strategy recognizes not only that sexual and reproductive health is an

important determinant of the well-being of individuals, couples, and families, it is also

fundamental to the development of communities and nations. With respect to the

MDGs specifically, The WHO (2004b) notes that,

Of the eight Goals, three – improve maternal health, reduce child

mortality and combat HIV/AIDS, malaria and other diseases – are

directly related to reproductive and sexual health, while four others –

eradicate extreme poverty and hunger, achieve universal primary

education, promote gender equality and empower women, and ensure

environmental sustainability – have a close relationship with health,

including reproductive health (p. 7).

With respect to reproductive health, women without access to sexual and reproductive

health information and services will be less able to plan their families and will be at

increased risk for STI/HIV and other negative health consequences, all of which

directly facilitate poverty. The implications are clear. “Reproductive health is thus

crucial, not only to poverty reduction, but to sustainable human development”

(UNFPA, 2003, p. iv). More generally, the reciprocal relationship between establishing

sexual rights, the attainment and maintenance of sexual health, and the achievement of

the broader objectives of the MDGs is increasingly recognized.

If they are to achieve sexual and reproductive health, people must be

empowered to exercise control over their sexual and reproductive lives,

and must have access to related health services. While these rights, and

the ability to exercise them, constitute an important value in themselves,

they are also a condition for well-being and development. The neglect

and denial of sexual and reproductive health and rights are at the root of

many health-related problems around the world (WHO, 2004a, p. 2).

Awareness of the reciprocal relationship between sexual and reproductive health

problems and specific fundamental indicators of over-all well-being, such as poverty,

are increasingly recognized. Sexual and reproductive health problems are both a cause

and a consequence of poverty. This linkage is explicitly and succinctly pointed out by

Family Care International (2005) who point out that,

Poor sexual and reproductive health impacts the economic well-being of

individuals, families, and communities by decreasing individuals’

productivity and participation in the labour force. For example, early

childbearing perpetuates the cycle of poverty by disrupting girls’

schooling, limiting women’s and girls’ employment opportunities, and

reducing investments in the well-being of women and their children. At

the same time, the costs of treating sexual and reproductive injuries and

illnesses can drain meager incomes, exacerbating individual and

household poverty (p. 3).

Over the years it has been increasingly recognized that sexual and reproductive health

promotion efforts have a direct beneficial impact on these aspects of people’s lives.

What has been perhaps less clear to policy makers, but which is of crucial importance,

is the recognition that breaking the cycle of poverty requires the provision of effective

sexual health education and services delivered in an environment that encourages

individuals to act on their own behalf. For example, the report, Adding It Up: The

Benefits of Investing in Sexual and Reproductive Care (Singh, Darroch, Vlassoff &

Nadeau, 2003) extensively documents the extent to which investments in sexual and

reproductive health care services can make valuable contributions to wider

development goals. Indeed, with respect to the MDGs specifically, the report

concludes that “sexual and reproductive health is essential to achieving all of these

goals” (p. 30).

The recent WHO (2007, in press) Developing Sexual Health Programmes: A

Conceptual Framework and Basis for Action provides a comprehensive approach to

sexual health promotion recognizing that there are a wide variety of determinants of

sexual health including legal, political, religious, economic, and socio-cultural

influences. Effective societal wide sexual health promotion must not only involve the

health and education systems but must also be addressed through the implementation

of appropriate laws and policies. These efforts must include addressing the economic

inequalities that are associated with and underlie the occurrence of many sexual health

related problems. The WHO conceptual framework recognizes and incorporates the

crucial fact that to be successful, sexual health promotion programming must be

designed and implemented with the input, cooperation and acceptance of the

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).

 

Sexual Health for the Millennium Reflects the State of the Art in the Science of Sexual Health Promotion

The WHO (2007, in press) provides a conceptual framework for developing and

implementing effective sexual health promotion programs that reflect a multi-sector

approach. The Sexual Health for the Millennium technical document provides a

complementary and in-depth research-based examination of key issues in sexual health

promotion that provides additional evidence-based support for the WHO conceptual

framework. A key component of the timeliness and relevance of Sexual Health for the

Millennium and technical document is that they come at a time when advances in the

extraordinarily diverse discipline of sexology make it increasingly evident that well

supported and well designed sexual health promotion programs can be successful in

reaching their objectives and, as a result, have a significant and wide-ranging positive

impact on the health and well-being of the people they reach. For example, advances in

behavioral science applied to STI/HIV and unintended pregnancy prevention as well

as sexual health education for youth have dramatically increased the potential

effectiveness of such programs. Epidemiological understanding of the biological and

social dynamics that drive the spread of STI/HIV within communities and across

borders has advanced significantly. Studies in the fields of sociology and anthropology

have given us a much greater understanding of sexual norms and practices within

diverse social and cultural contexts. Medical knowledge and clinical intervention related

to sexual function as well as reproduction and fertility control now have a growing

potential to improve quality of life.

The eight declaration statements of Sexual Health for the Millennium and technical

document represent and give substance to the next logical and progressive step in the

global promotion of sexual health (See Appendix IV and V for a description of the

process of developing the Declaration and the technical document and

acknowledgements of those who participated in this process). The declaration

statements identify eight key areas in the realm of sexual health where we must move

forward. Sexuality and sexual health are broad and diverse concepts that touch on

innumerable aspects of the human condition. Sexual Health for the Millennium not

only confirms the role that promoting sexual health must play in achieving the MDGs,

this document specifies and elaborates on eight distinct but inter-related aspects of

sexual health that play important roles in affecting human development. To

meaningfully and effectively contribute to the achievement of the MDGs, sexual health

promotion programs must address the totality of human sexuality. For example, to

effectively promote HIV sexual risk reduction, sexual health promotion programs

must reflect and incorporate the reality that sexual relationships include gender and

power dynamics and that the desire for intimacy and pleasure plays an instrumental

role in shaping sexual behavior. In sum, Sexual Health for the Millennium

conceptualizes sexual health as multi-dimensional and specifically identifies and

examines eight specific goals that together encompass an integrated and

comprehensive approach to sexual health promotion. Finally, this technical document

describes specific necessary actions that are specific to each of the eight goals of the

declaration.

 

The Sexual Health for the Millennium 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

 

Conclusion

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.

 

References

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.

 

 

Chapter 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 standard

of health. Sexual health cannot be obtained or

maintained without sexual rights for all.*

 

Introduction

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.

 

Sexual Rights: Some Hurdles to be Cleared

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.

 

The Need for Sexual Rights

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.

 

Overcoming the Complexities of and Challenges to Sexual Rights

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.

 

Conclusion

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.

 

Necessary Actions

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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Chapter 2

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.*

 

Introduction

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.

 

 

The Imbalance of Power: Sexual Scripts Enact Gender Inequality

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.

 

Promoting Gender Equitable Sexuality

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.

 

Conclusion: Promoting Change at All Levels of Society

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.

 

Necessary Actions

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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Chapter 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.*

 

Introduction

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).

 

 

The Role of Reducing Sexual Violence in Achieving the Millennium Development Goals

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.

 

Defining Sexual Violence

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).

 

Prevalence of Sexual Violence

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.

 

Consequences of Sexual Violence

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.

 

The Context and Root Causes of Sexual Violence

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).

 

Strategies to Reduce/Eradicate Sexual Violence

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.

 

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

 

References

Abrahams, N., Jewkes, R., Hoffman, M., & Laubsher, R. (2004). Sexual violence against intimate partners in Cape

Town: prevalence and risk factors reported by men. Bulletin of the World Health Organization, 82, 330-337.

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.

UN (1979). Convention on the Elimination of All forms of Discrimination Against Women. United Nations Division

for the Advancement of Women. Department of Economic and Social Affairs. New York: United Nations.

UN (1993). United Nations General Assembly. Declaration on the Elimination of Violence Against Women.

(A/RES/48/104). New York: United Nations.

UNFPA (2005). State of the World Population 2005. The Promise of Equality: Gender Equity, Reproductive Health

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.

WHO (2000). Female Genital Mutilation. Fact sheet No 241. Geneva: World Health Organization.

WHO (2001). Violence Against Women and HIV/AIDS: Setting the Research Agenda. Geneva: World Health

Organization.

WHO (2002). World Report on Violence and Health. Geneva: World Health Organisation.

WHO (2003). Guidelines for Medico-Legal Care for Victims of Sexual Violence. Geneva, World Health Organization.

WHO (2005a). WHO Multi-country Study On Women’s Health and Domestic Violence against Women: Initial

Results on Prevalence, Health Outcomes and Women’s Responses. Geneva: World Health Organization.

WHO (2005b). Addressing Violence Against Women and Achieving the Millennium Development Goals. Geneva,

World Health Organization.

 

 

Chapter 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

ser vices throughout the life cycle.*

 

Introduction

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.

 

Comprehensive Sexuality Education in the Context of Global Sexual Diversity

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.

 

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.

 

References

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

 

 

Chapter 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 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.*

 

Introduction

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 Recognition of Access to Sexual and Reproductive Health Care as Essential to Global Development

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.

 

The Disconnect Between Reproductive Health Care and a Positive Approach to Sexuality

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).

 

 

Putting the Sexual Back into Sexual and Reproductive Health

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.

 

Conclusion

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.

 

Necessary actions

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.

 

References

Family Care International. (2005). Millennium 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.

WHO. (2006). Accelerating Progress Towards the Attainment of International Reproductive Health Goals: A

Framework for Implementing the WHO Global Reproductive Health Strategy. Geneva, Switzerland: World

Health Organization

 

 

 

Chapter 6

 

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.*

 

Introduction

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).

 

HIV/AIDS and STI Prevention: A Prerequisite for Global Development

 

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).

 

Evidence-based Interventions for HIV/STI Prevention

 

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).

 

The Need for Effective HIV/STI Prevention Interventions and Programs in the Developing World

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, an