04ASPSH

校对：吴敏伦(中国香港香港大学医学院)完成时间：2006年8月

达到健康是所有社会优先达成的目标。为了达到全面健康的目的，必须促进和维持性健康。通过再一次强调性健康忧虑和性健康问题，美洲区域内的卫生保健的许多方面将会有相当程度的改善。尤其在生殖健康和HIV/AIDS的预防和控制的领域，已经取得了重大的成就。本专家工作小组经过协商认为，如果从更广泛的途径对性展开研究，譬如在本报告里所提议的这种概念化的理论研究，改善健康的基本目标可能会以更有效率的方式达成。

性健康是一个广义的概念。针对达到和维持性健康所采取的行动方案和策略应该会增进健康状况，并因此而改善个人与社会的健康状态。

除了改善健康的广泛途径以外，本专家工作小组协商后认为，人权的公认是一个推动社会、政治、法律和文化改变的有效途径。世界卫生组织已经承认健康是一项基本人权40。必不可少的性健康促进将会改变社会、政治、法律和文化，因此，推荐在人权框架之下来促进性健康。

例如，联合国开发计划署(UNDP)制定了一项官方政策，其声明如下：

人权是基于对人类的尊严和价值的尊重，是基于寻求确保免予恐惧和短缺的自由。人权源自道德原则(并通常载于一个国家的宪法与法律框架内)，它对于每一个男人、女人和儿童的健康是必不可少的。人权以基本的和不可侵犯的准绳为前提，它们是一项普遍的和不能让渡的权利41。

本专家工作小组向美洲区域各国政府与非政府机构以及包括卫生部门在内的公共机构推荐下列五个目标：

目标 3：为工作在性健康相关领域的专业人员提供教育、培训和支持

目标 4：为全区域人口制定和提供他们有权使用的全面的性卫生保健服务

为了实现上述列举的目标，本专家工作小组也确认了许多促进性健康行动策略。现予分述如下。

目标 1：促进性健康，包括消除对性健康的障碍

性健康将会在社会的所有成员中来促进。本专家工作小组强调必须承认包括精神和生理残障者在内的所有个体的性权利。

如果兼顾到了性的所有组成方面，促进性健康的努力将会更加有效。因此，欲要把性健康整合于公共卫生保健规划，则应该给国民提供全方位的性健康 (例如：情感依恋/情欲发展、性别发展和生殖健康等)服务。

性快乐(Erotic pleasure)常常被人否定，其实它是人类积极、有益、促进健康的基本需要。近来的证据已经证明，甚至从生理层面上看，性爱体验也含有重要意义42。

当把性快乐作为自体性行为(常常称为手淫)来体验的时候，它甚至受到更严厉的指责。可是，在科学研究文献中，还没有证据显示这种行为有有害的效应。而且，临床性学家一致认为，促进自体性行为有益于治疗各种各样的性功能障碍。另外，有研究者发现了自体性行为的价值，它是促进安全性行为的重要手段43。

再之，对性快乐的这种诬蔑，已经导致在许多性教育项目中排除了任何快乐的内容。这种不必要的忽略会影响以寻求行为方式为手段的卫生保健作用。有一项有关性健康问题的疾病流行程度研究显示，对性快乐有迷惑或担忧的人寻求专家咨询的频率比所期望的要低许多44。

人们还不能理解情感依恋/情欲在健康中的重要性。长期以来，行为科学家已经获悉和谐与亲爱的生活环境的重要意义。更有从生物学角度所做的研究证明，人生早期所涉及到的触摸体验对于个体发育和中枢神经系统的发育成熟是必不可少的45。

策略 1.1：把性健康整合于公共卫生保健规划

有大量的证据显示，如果把预防和治疗行为整合于范围更广的公共卫生保健项目里，就会较顺利地解决公共健康忧虑和公共健康问题。尽管需要在特殊项目中采用行动方案，却需要把性健康整合于公共卫生保健规划。

策略 1.2：促进性别平等和公正及消除基于性别的歧视

自从理论学派与经验学派的女权主义著述破茧而出以后，越来越多的证据显示在性别和健康之间有着关联47。特别是在国际人口与发展大会(ICPD)和北京第四届世界妇女大会上，已经提出了这样的观点：除非把性别因素考虑在内，不然，与性健康有关的社会发展目标则难以达到。

为了达到这个策略目标，性健康促进行动方案必须涵盖从调整各项政策(指那些似乎与卫生保健事务无关的那些政策)到洞悉男女不断增长的各种特殊的健康需要这样一个非常广泛的范围。这些行动方案超出了性关系就是性别关系这样的认识范围。尽管从概念上是把性别(gender)归于性(sexuality)的范畴，还是把它们作为一个系统内的两个部分？尚有争议；显然，如果没有充分考虑到性别及其深刻的含意，要想达到性健康是不可能的。

提倡引导和改变那些对性别不和谐有影响作用的公共政策，例如促进女孩接受学校和正规的教育。

在计划和实施性卫生保健服务中引入性别观念。例如，可以考虑男女分时段地使用卫生保健服务设施这样的简单方法。

确保全面的性教育始终要包括性别分析，尤其要特别强调男女在性别公平和性别平等方面的权利。

鼓励男性讨论和理解促进性别角色转变和“新的男性”(the new masculinity)的行动方案。由于存在着女性向男性提出要求改变地位的可能趋势，尤其在男性占统治地位和霸主地位的社会，实施这种鼓励策略尤为重要。

策略 1.3：促进负责任的性行为

负责任的性行为是在个体、人际之间和社会的层面来体现的。它在于对性快乐和性健康方面体现出自主、相互关联、诚实、尊重、允诺、保护和寻求快乐的特点。个人所展示的负责任的性行为并不是在性的方面意欲引起伤害，而是摒弃自私的利用、骚扰、操纵和歧视。社会通过提供知识、资源和公正来促进负责任的性行为，而个人则必须要参与促进负责任的性行为的实践活动。

为了达到性健康，个人必须以负责任的方式去作为；所以，责任是一项需要促进的最重要的价值观。强调负责任的性行为能够为社会在疾病发病率和改善健康状态方面减轻负担，产生低成本的效果。本策略的方案是：

实施成人教育计划，特别要针对父母的需要实施成人教育计划，因为他们在促进负责任的性行为中是最直接和最有效的代理人。

将大众媒体纳入在内，让它们在各种传播信息中引介负责任的性行为，尤其在广播或出版物中直接针对这个话题开展教育活动，或者在媒体上建立专栏和专题节目。

策略 1.4：消除涉及到性和性少数(性少数群体)的恐惧、偏见、歧视和仇恨

涉及到性与性少数群体的恐惧、偏见、歧视和仇恨都是性健康的妨碍因素。恐惧源自无知和误传。有大量的证据表明当个人的知识增加的时候，他们会养成更健康的行为48。

研究已经表明带有恐惧和负面心理的人有更大的不健康行为举止的危险。性爱恐怖就是一种对性的快乐成分做出负面情感价值判断的反应。性爱恐怖者可能在将来更少有性交行为，并且对公开谈论性显示有各种更负面的反应，而且未能在性活动之前获取避孕药具49。

同性恋憎恶是对有同性性取向个体的非理性的恐惧。在许多案例里，这种憎恶是犯罪行为的基础。有研究报告指出同性恋憎恶与认知抑制有关联。对男女同性恋者的公然否决、歧视或暴力与各种各样的健康和发展问题有关联50，这些否定同性恋者的作为还与以拒绝和孤立的方式对待男女同性恋者51、与发展亲密举止的能力52、与更频繁地谈论性行为53以及与贬低由卫生保健专业人员提供的卫生保健的质量有关联54。在其它一些对健康所造成的威胁和妨碍的因素中，有学者暗示这种同性恋否定观会加强对同性恋者负面态度理解的心理社会动力55。

促进对男性和女性性别认同性象谱的理解；性别认同的性象谱依次包括异性恋的、同性恋的、双性恋的、双性的和跨性的组成成分。

策略 1.5：消除性暴力

大量的证据已经证明性暴力的危害效应56。性健康促进和作为人权的性权利将会为减少和消除性暴力发挥作用。显而易见，性别平等、性别公平、消除性别歧视以及全面的性教育将会降低暴力的发生率。消除性暴力的行动方案包括：

鉴于许多性侵犯者可能从治疗中受益(即通过治疗矫正性暴力倾向——译者注)，促进他们的卫生保健。

目标 2：大规模地为全区域人口提供全面的性教育

本专家工作小组完全达成了共识：考虑到全面的性教育是一个提供和转化非正式与正式的涉及人类性学所有方面的知识、态度、技能和价值的终生教育过程，所以，当一个社会在其国民中促进性健康时57，能够做到的最好投入莫过于全面的性教育。

全面的性教育应该在生命的早期就要着手；应该适合于年龄与发育阶段需要；应该对性采取正面的态度来展开58。

性教育必须为国民提供性学的知识素养。此外，人们认识到仅有性知识是不够的；所以，性教育除了让人获得性知识以外，也必须让人获得生活技能的发展。

策略 2.1：提供以学校为基地的全面的性教育

以学校为基地的全面的性教育是个人终生性健康的基石，所以需要特别地引起关注。在大多数国家里，学校几乎是人人在其生命的某个时期与之接触的专一的公共机构。这为提供性教育创造了绝好的条件；因此，政府需要以法规的方式委托学校开展这项教育。已经有相当多的研究确认了有效的性教育的特色59^,60,61。附件III以概要的形式介绍了全面的性教育的这些特色。

策略 2.2: 把性教育适当地整合于公共教育机构的普通课程

除了基于学校的性教育以外，为了达到对全民终生提供全面的性教育的目的，所有的公共教育机构必须扮演好它们的角色。尤其是高等学校能够以设置成人人类性学课程的方式促进性健康。

策略 2.3: 为精神和身体残障者提供全面的性教育

精神与生理残障者与其它人一样有获得全面性教育的同等权利。因为精神与生理残障者可能有特殊的需要和处于特殊的境况，并且可能在做出涉及性的决定的能力上不时会显得力不从心，所以，这些人群应该优先获得全面的性教育。

策略 2.4: 为特殊群体(例如:囚犯、非法移民、被收容者和无家可归者)提供他们有权得到的全面的性教育

历史上，人们忽视了两个群体的性教育需要。被收容者(囚犯、住院病人和长期受”护理”者)和那些无身份的人或社会边缘群体(包括非法移民和无家可归者)无权使用教育资源。

凡被收容者得到关怀的地方，就是那些从法律责任上对这些人具有道德责任、给他们提供享用教育资源的地方；当要避免重大风险的时候(例如：HIV和其它性传播疾病)，那些地方会帮助这些人提升他/她的性健康水平。至于在那些缺乏享用教育资源的地方，那里的政府有道德责任为这些人提供尽可能的服务和教育。

策略 2.5: 为其它群体(例如：合法移民、持少数民族语言群体和难民)提供他们有权得到的全面的性教育

如同被收容者和未受教育者一样，另一个群体就是那些有较大障碍享用教育资源者。据确认，他们在性健康忧虑方面有更大的风险。那些不会讲一国主导语言的移民(包括难民)有得到全面的性教育的权利。在尽可能的地方，应该把对这些群体的教育整合于现有的教育计划之中。

策略 2.6: 整合大众媒体的力量，让其做出努力以传播和促进全面的性教育

在影响社会规范方面，大众媒体的重要性业已被广泛认可。任何促进健康的举措都应该包含大众媒体的参与，要利用所有现时的和将来的传媒渠道：电子传媒(无线电广播和电视)、纸质传媒和互联网传媒等所有手段。大众传媒从业人员负有对其社会的责任，尤其在性健康方面，不应该规避这种责任。

已经有了利用大众媒体促进生殖健康和预防性传播疾病的实例，并且据报道的结果表明：媒体对健康促进能够达到良好的收益62。

目标 3: 对工作在性健康相关领域的专业人员提供教育、培训和支持

为了在国民中有效地促进性健康，有必要为各行各业的专家、其它专业人员和涉及性健康促进的辅助专业人员(包括内科医生、护士、治疗专家、HIV/AIDS防治专家、计划生育服务人员、教育家和社会活动家)提供性健康教育和培训。

策略 3.1: 为卫生保健及其相关人员提供性健康教育和培训

为卫生保健专业人员开展的性健康教育，至少应该在四个不同的层面来展开：

为所有卫生保健专业人员提供既包括基础训练也包括继续教育的基本的性健康教育。卫生保健专业人员包括医生、护士、临床心理医生、社会工作者、卫生保健从业者和性健康倡导者。

为专门从事生殖健康项目推广的卫生保健专业人员提供性健康教育。

为专门从事性传播疾病与HIV/AIDS预防和控制项目的专业人员提供性健康教育。

为专门从事包括性教育、临床性科学(性医学、性外科学、性咨询和性心理疗法)和基础理论性学研究的性学专业人员提供性健康教育与培训。

有关为这四类人员提供的相关培训需要，在附录IV作了详细介绍。附录IV阐述了培训各学科专业人员的通常方法。

策略 3.2: 为学校教师提供性健康教育和培训

作为培训内容之一，学校教师必须接受有效的传授性教育知识和技能的培训。既然性教育作为普遍和整体的教育课程的组成部分被提出，这样的培训就应该被看作是任何教师培训课程的必修课。

策略 3.3: 促进性科学(性学)成为一个专业/学科

性科学(也称为性学——译者注)作为一门学科于1907年被首次提出63。在过去的50年里，性科学学科领域已经有了巨大的进步。从历史上看，性科学有三个主要领域：教育、研究和临床治疗，其中主要集中在性功能障碍的临床服务。当今，新学科与性科学发生了融合。人口的性健康需要已经扩展了我们对于性科学的认识。从其它严重的性传播流行性疾病中凸现出的HIV，已经导致了行为流行病学家和传染病公共卫生专业人员在危险性行为的研究中的专业化发展。继而，这已经导致了对大规模人口的性行为研究。从HIV威胁最为严重的社会里，涌现出了公共卫生教育家、专门从事降低HIV威胁的咨询服务和管理受HIV威胁者的辅助人员。在许多诊所，护理教师(nurse-educators)在促进预防性的涉及体格检查(例如：乳房检查)、性知识传授(例如：涉及疾病的性健康风险知识教育)和生殖健康咨询的卫生保健方面起着关键的作用。辅助生殖技术的进步和促进性功能的药物创新从其它学科已经吸引了各类专家共同关注于病人的性健康需要。妇女健康中心和性少数健康中心已经针对性少数群体和受劣质服务者的卫生保健采取了改进措施，同时在社会层面促进性卫生保健服务。在兴起的性少数运动中，涌现出一批专门从事维护性少数群体权益的律师和倡导促进安全行为的社团。最近，性侵犯者管理的新方法已经把临床性科学(性医学、性外科学、性咨询和性心理治疗——译者注)扩展到了性侵犯者的治疗方面。

显而易见，性科学的将来发展将会涉及许多新的和不同的学科，性科学与这些学科将会针对性健康需要在不同的层面和不同的服务功能上展开合作。作为一门交叉科学，性科学独特地把专家的知识和技能、各种各样的倡导性健康团体的不同议题和不同学科的研究方法和兴趣融合在了一起。有鉴于此，关键或紧要的是要把性科学作为一门学科/专业来推动。来源于其它学科的专家运用其自身的专业领域的技能尚不足以能够研究性健康。我们还需要训练有素的专注于性健康忧虑的性健康专家，请他们致力于不同的和特殊的由“性”*和性*所引发的各种性健康忧虑。

目标 4.: 为全区域人口制定和提供他们有权享用的全面的性卫生保健服务

遗憾的是，现有的许多性健康问题的影响范围之大使得现有的预防措施捉襟见肘。许许多多的人存在着需要临床保健的性健康问题。梦想预防措施在将来会能够消除所有的性健康问题也是不现实的。所以，全面的性卫生保健对所有社会都是一种紧迫的需要，照现在的样子为全区域人口提供他们有权享用的保健服务。

策略 4.1: 把性健康事务整合于现有的公共卫生保健计划

性健康是一个关键的公共卫生保健问题。虽然特殊行动方案曾经在特殊目标项目中实施(正如在上节所概述的那样)，尚必需把性健康整合于现存的公共卫生保健计划。鉴于此，本专家工作小组推荐以下策略方案：

把性卫生保健方法整合于卫生保健计划。卫生保健 [例如：心血管保健促进项目、反吸烟项目(获益于戒烟后的勃起能力)]与性卫生保健、癌症预防项目(乳房切除术中的早期乳腺癌探测、子宫颈癌常规筛检)]和健康教育项目(把预防性的保健和性能力联系起来)有直接或间接的关系。

当客户前来接受公共卫生保健服务时，把性健康问题纳入常规卫生保健评估范畴。这可以通过(舆论)评论来加以改进，并且在必要时，修改现存的公共卫生保健协议条款，以确保人们足以专注于性健康忧虑。例如：全科医师(general practitioner)、家庭医生和公立卫生保健诊所医生应该把性健康常规筛查/性健康既往病史合并到常规卫生保健评估。

策略 4.2: 为全区域人口提供他们有权享用的全面的性卫生保健服务

有权享用全面的卫生保健是人的基本需要。同时，本专家工作小组完全认可性卫生保健预防方法的实用性和成本效率，我们也认为社会持续存在着大量的遭受性健康忧虑和性健康问题煎熬的不幸的人们，这向社会提出了保健服务的急迫需求。提供保健服务将会确保有效治疗。

性健康忧虑和许多性健康问题能够和应该由初级卫生保健系统予以处理和解决。遗憾的是，缺乏对初级卫生保健提供者的培训可能是实现这一目标的障碍。

要解决某些性健康问题，则需要特殊的训练有素的人员来介入。所以，必须建立治疗性健康问题的特殊诊所，以专门处理一系列严重的性健康问题。

策略 4.3: 为精神和生理残障者提供他们有权享用的全面的性卫生保健服务

只要有可能，性卫生保健服务都应该整合于现有的为精神和生理残障者的服务体系中去。

策略 4.4: 为特殊群体(例如：囚犯、非法移民、受收容者和无家可归者)提供他们有权享用的全面的性卫生保健服务

只要有可能，性卫生保健服务都应该整合于现有的为特殊群体(例如：囚犯、非法移民、被收容者和无家可归者)的服务体系中去。

策略 4.5: 为其它群体(例如：合法移民、少数民族语言群体和难民)提供他们有权享用的全面的性卫生保健服务

只要有可能，性卫生保健服务都应该整合于现有的为其它群体(例如：合法移民、少数民族语言群体和难民)的服务体系中去。

目标 5: 促进与赞助性*和性健康领域的研究和评估，传播由性与性健康所衍生的知识

为了增强对“性”*、性*、性健康和性行为的理解，需要开展性研究；为了评估性卫生保健预防策略、卫生保健计划、性教育课程和性治疗的功效，也需要开展性研究。

策略 5.1: 促进性*研究和性评估。

为了提升个体与群体的性健康水平，紧迫的问题是既需要性研究也需要性评估。所谓性研究在此被定义为：为了获得新知识，对包括假设检验在内的性的整个领域的系统研究。所谓性评估在此被定义为：为了决策和详尽地评价性健康计划的效力目的，所进行的资料收集和分析。

策略 5.2: 促进性科学成为一门理论学科。

与其它健康研究领域比较，性科学在资金、关注度和研究成果的质量方面是被忽略的。这些被忽略的方面并不是孤立的。研究人类的性及人类所从事的最高质量的性行为绝对是紧迫的任务。欲达此目标，作为一个科学领域，性科学需要研究者在每一个研究层面发展知识技能和具备研究潜能。

策略 5.3: 促进性科学的跨学科 (例如：护理学、社会学、人类学、心理学和流行病学等等)研究。

对性和性健康的研究并不限于性科学专业内训练有素的研究者。促进其它相关学科的研究会有益于扩建知识基础，并且通常有可能对涉及性和性健康的复杂事物会有新的视野。促进此类研究能够对达到和维持性健康做出新的贡献。

策略 5.4: 确保在性科学的研究成果充分地传播给政策制定者、教育家、健康保健服务提供者，以给他们的工作提供研究基础。

光有研究尚且不够。为了确保从事于性健康的各类人员受益于通过可靠的研究所建立起来的这个知识基础，传播研究成果则是至关紧要的策略。尤其需要在拉丁美洲大多数地区传播研究成果，需要在那里营造和促进研究成果传播的文化氛围。

Actions and Strategies to promote Sexual Health

The attainment of health is a priority in all societies. For comprehensive health to be achieved, Sexual Health must be promoted and maintained. The considerable advances in the Region of the Americas in many areas of health care would be reinforced by a renewed emphasis on the prevention and care of sexual concerns and problems. In particular, there have been significant efforts in the area of reproductive health and the prevention and control of HIV/AIDS. The expert working group agreed that the basic goal of improving health could be achieved in a more efficient manner if a more comprehensive approach to sexuality, such as the conceptualization proposed in this document, is taken.

Sexual health is a comprehensive concept. Actions and strategies aimed to its attainment and maintenance should improve health and, therefore, increase personal and societal well being.

In addition to a comprehensive approach to improving health, the expert working group agreed that recognition of human rights is an effective way of promoting social, political, legal, and cultural changes. The WHO has recognized health as a basic human right ⁴⁰. Promotion of Sexual Health required changes in society, policies, laws and culture and therefore its promotion within a human rights approach is recommended.

For example, the United Nations Development Program (UNDP) established an official policy that states:

Human rights are based on respect for the dignity and worth of all human beings and seek to ensure freedom from fear and want. Rooted in ethical principles (and usually inscribed in a country's constitutional and legal framework), human rights are essential to the well being of every man, woman and child. Premised on fundamental and inviolable standards, they are universal and inalienable⁴¹.

The expert working group recommended the following five goals for governmental and non-governmental agencies and institutions including the health sector of the Region of the Americas:

The expert working group also identified a number of strategies for the implementation of the above list of goals. They are considered in the following sections.

Goal 1.: Promote Sexual Health including the elimination of barriers to Sexual Health

Sexual health is to be promoted in all members of society. The expert working group stressed the need to recognize the sexual rights of all individuals, including persons with mental and physical disabilities.

Efforts to promote Sexual Health will be more efficient if all components of sexuality are taken into account, instead of utilizing only partial approaches. Accordingly, integration of Sexual Health into public health programs should include provisions for the dimensions of Sexual Health (e.g., emotional attachment/love development, gender development and, reproductive health).

Erotic pleasure is a dimension of the human being that has been frequently denied as a positive, rewarding, health promoting and basic human need. Recent evidence has shown that the importance of erotic experience has implications even at the physiological level ⁴².

Erotic pleasure has been even more strongly stigmatized when it is experienced as autoeroticism (usually referred to as masturbation). However, there is no evidence in the scientific literature of the deleterious effects of this behavior. Moreover, there is consensus among clinical sexologists that promotion of autoerotic behavior is beneficial in the treatment of a variety of sexual dysfunctions. In addition, the value of autoeroticism has been found to be an important tool in the promotion of safer sexual behavior ⁴³.

Furthermore, the stigma about sexual pleasure has caused the elimination of any mention to pleasure in many sexuality education programs. This omission affects health care seeking behavior. People with problems or concerns regarding their sexual pleasure seek professional help with much less frequency than would be expected in view of the prevalence of Sexual Health problems ⁴⁴.

The importance of healthy emotional attachment/love cannot be underestimated. There is a long-standing awareness among behavioural scientists of the importance of a healthy and loving environment. In more biologically oriented studies, early life experiences involving touching have been shown to be necessary component of development and critical for maturation of the central nervous system ⁴⁵.

Strategy 1.1: Integrate Sexual Health into public health programs

There is abundant evidence that public health concerns and problems are better approached if actions for prevention and treatment are integrated into broader health programs. Although specific actions implemented in specific programs are required, it is indispensable to have Sexual Health integrated into public health programmes.

Promote legislation that ensures the feasibility of the national Sexual Health strategies.

Develop indicators of Sexual Health to be used in policy and program development and evaluation.

Strategy 1.2: Promote gender equality and equity and eliminate gender-based discrimination

Since the groundbreaking work of theoretical and empirical feminism, more and more evidence has emerged as to the links between gender and health ⁴⁷. Particularly the ICPD and Beijing Conferences have contributed to the idea than unless gender is taken into account, health-related developmental goals are unattainable.

To achieve this strategy, actions are required that cover a very wide spectrum from changes in policies that seem not related to health issues, to awareness building as to the specific health needs of women and men. These actions go beyond the recognition that sexual relations are gender relations. Notwithstanding the debate that places conceptually gender within sexuality or gender and sexuality as part of one system, it is obvious that Sexual Health cannot be approached without due consideration to gender and its power implications.

Advocacy to introduce and change public policies that have an impact on gender disparities such as promoting schooling and formal education for girls

Introduction of a gender perspective in the planning and implementation of Sexual Health services. For example such simple matters as taking into account the differences in time availability for men and women to attend health care facilities.

Ensuring that comprehensive sexuality education always includes gender analysis and particularly stresses the right of men and women to sexual equity and equality.

Encouraging actions that facilitate men to discuss and understand changes in gender roles and “the new masculinity.” This is an important area due to the possible threat that changes in the status of women may pose to male sexuality, particularly in those societies in which the latter is linked to dominance and supremacy.

Awareness-building for all health providers as to their own biases regarding gender.

Strategy 1.3: Promote responsible sexual behavior

Responsible sexual behavior is expressed at individual, interpersonal and community levels. It is characterized by autonomy, honesty, respectfulness, consent, protection, pursuit of pleasure, and wellness. The person exhibiting responsible sexual behavior does not intend to cause harm, and refrains from exploitation, harassment, manipulation, and discrimination. A community promotes responsible sexual behaviors by providing the knowledge, resources and rights individuals need to engage in these practices.

To be sexually healthy, persons must behave in a responsible manner; therefore, responsibility is one of the most important values to be promoted. Focusing on responsible sexual behavior can produce cost-effective results reducing burdens on society in terms of morbidity and improving well being. Components of this strategy are:

Inclusion of responsibility as a value to be promoted in all sexuality education programs.

Implementation of adult education programs, specifically addressing the needs of parents, as they are the most immediate and efficient agents in promoting sexually responsible behavior.

Involvement of mass media in introducing the issue of responsible sexual behavior in their messages, via addressing the issue directly in specific broadcasts or publications, or establishing specific campaigns.

Strategy 1.4: Eliminate fear, prejudice, discrimination, and hatred related to sexuality and sexual minorities (minority groups).

Fear, prejudice, discrimination and hatred related to sexuality and sexual minority groups are obstacles to Sexual Health. Fear arises from ignorance and misinformation. There is abundant evidence that individuals develop healthier behavior as their knowledge increases ⁴⁸.

Research has shown that persons with fears and negative attitudes have a greater risk of behaving in unhealthy ways. Erotophobia is a negative affective-evaluative response to the pleasurable components of sexuality. Erotophobic persons are less likely to plan on having sexual intercourse in the future and have been shown to have more negative reactions to talking openly about sexuality, and to fail to acquire contraceptives prior to sexual activity ⁴⁹.

Homophobia is the irrational fear of persons with homosexual orientation. In many cases it is the basis of criminal acts. There are reports that link homophobia to cognitive inhibition. Overt rejection, discrimination, or violence towards gays and lesbians have been linked to a variety of health and development problems ⁵⁰, use of denial and isolation as coping styles ⁵¹, the ability to develop intimacy ⁵², more frequent risk taking sexual behavior ⁵³ and a diminished quality in the health care provided by health professionals ⁵⁴. Among the other characteristics that represent threats or obstacles to health, the concept of homonegativity has been suggested to increase understanding of the psychosocial dynamics of the development of negative attitudes towards homosexual persons ⁵⁵.

Promote the understanding of the spectrum of female and male identities along a range including heterosexual, homosexual, bisexual, bigender, transgender.

Strategy 1.5: Eliminate sexual violence

The deleterious effects of sexual violence have been well documented ⁵⁶. The promotion of Sexual Health and sexual rights as human rights will contribute to the reduction and elimination of sexual violence. Specifically, the promotion of gender equality and equity, and the elimination of gender based discrimination, which have been specifically linked to the generation and maintenance of sexual violence, as well as comprehensive sexuality education, will lower rates of violence. Actions towards the elimination of sexual violence include:

Promotion of health care for sexual aggressors that in many instances could benefit from treatment.

Goal 2.: Provide comprehensive sexuality education to the population at large

There was a clear consensus among the expert working group that comprehensive sexuality education, considered as a life-long process that informally and formally provides and transforms knowledge, attitudes, skills and values related to all aspects of human sexuality ⁵⁷, is one of the best investments a society can make when promoting Sexual Health among its people.

Comprehensive sexuality education should begin early in life, should be age and developmentally appropriate, and should promote a positive attitude towards sexuality ⁵⁸.

Sexuality education must provide people with a knowledge base of human sexuality. In addition, it is recognized that sexual information alone is not adequate. Sexuality education must also include skills development in addition to acquisition of knowledge.

Strategy 2.1: Provide school based comprehensive sexuality education.

Comprehensive school-based sexuality education acts as a building block for Sexual Health across the lifespan of an individual and therefore requires particular attention. School, in most countries, is the single institution that nearly every person comes in contact with at some stage in their life. This is the ideal setting for providing sexuality education; hence governments need to mandate this kind of education in schools. There has been a considerable amount of research that has identified the characteristics of effective sexuality education^{59, 60, 61}. A summary of these characteristics of comprehensive sexuality education is presented in Appendix III.

Strategy 2.2: Integrate sexuality education into the general curriculum of educational institutions as appropriate.

In addition to school based sexuality education, to reach the goal of providing comprehensive sexuality education to the population across the life span, all education institutions must play a role. In particular, tertiary institutions can promote Sexual Health by establishing adult human sexuality curricula.

Strategy 2.3: Provide comprehensive sexuality education to persons with mental and physical disabilities.

Persons with mental and physical disabilities have the same rights to comprehensive sexuality education as other persons. Because persons with mental and physical disabilities may have special needs and circumstances, and may sometimes be at increased vulnerability regarding the ability to make sexual decisions, comprehensive sexuality education should be a priority for these populations.

Strategy 2.4: Provide access to comprehensive sexuality education to special populations (e.g., prisoners, illegal immigrants, the institutionalized, homeless).

Historically, the sexuality education needs of two groups have been neglected. Institutionalized persons (prisoners, the hospitalized, and those in long-term “care” situations) and those with no or only marginal access to education (including illegal immigrants and the homeless).

Where institutionalized persons are concerned, those legally responsible for these persons have an ethical responsibility to provide access to education that assists the person to advance his/her Sexual Health while avoiding serious risks (e.g., HIV and other STDs). For those lacking access to educational opportunities, the government has an ethical responsibility to provide appropriate outreach and education.

Strategy 2.5: Provide access to comprehensive sexuality education to other populations (e.g., legal immigrants, minority language groups, refugees).

Like institutionalized persons and persons without access to education, another group of persons-those with greater barriers to accessing education-has been identified at higher risk for Sexual Health concerns. Immigrants (including refugees), those persons who do not speak the dominant language of a country, have a right to comprehensive sexuality education. Where possible, education should be integrated into existing educational programs for these populations.

Strategy 2.6: Integrate mass media into efforts to deliver and promote comprehensive sexuality education.

The importance of the mass media in influencing social norms has been widely recognized. Any effort in promoting health should be accompanied by the involvement of the mass media, using all current and future channels of communication: electronic (radio and television), printed and internet based media. Mass media professionals have a responsibility to their communities and, in the case of Sexual Health, this responsibility should not be avoided.

Examples of the utilization of mass media for promoting reproductive health and the prevention of sexually transmitted infections already exist and the results reported indicate that good benefits to health promotion can be achieved ⁶².

Goal 3. Provide education, training and support to professionals working in Sexual Health related fields.

The goal of providing education and training in Sexual Health for a wide range of specialists, other professionals, and paraprofessionals involved in the promotion of Sexual Health, including physicians, nurses, therapists, HIV/AIDS specialists, family planning staff, as well as educators and community advocates is necessary to effectively promote Sexual Health among the population.

Strategy 3.1: Provide education and training in Sexual Health for health and allied health professionals.

Sexual health education for health professionals should be promoted at least at four different levels:

Basic Sexual Health education for all health professionals included both in their basic training and in continued educational programs. Health professionals include medicine, nursing, clinical psychology, social work and health practitioners and promoters.

Sexual health education for health professionals specializing in reproductive health programs.

Sexual health education for professionals specializing in STIs and HIV/AIDS prevention and control programs.

Sexual health education and training for professionals specializing in sexology, including education for sexuality, clinical sexology (sexual medicine, sexual surgery, sexual counseling and, sexual psychotherapy) and, basic research sexology.

Specific recommendations regarding the training needs for each of these four groups are provided in Appendix IV. These recommendations describe a general interdisciplinary approach to the training of professionals.

Strategy 3.2: Provide education and training in Sexual Health for school teachers.

Schoolteachers must receive, as part of their training, the knowledge and skills to deliver effective sexuality education. Since sexuality education is proposed as a universal and integrated part of education curricula, such training should be viewed as a compulsory part of any teacher-training curriculum.

Strategy 3.3: Promote sexology as a profession/discipline.

Sexology, as a discipline was first proposed in 1907⁶³. In the last fifty years, great strides have been made in the area of sexology. Historically, there have been three main areas in sexology-education, research and clinical service - mainly focusing on the treatment of sexual dysfunctions. Today, new disciplines are aligned with sexology. The Sexual Health needs of the population have expanded our understanding of sexology. The emergence of HIV, among other serious sexually transmitted pandemics, has led to the specialization of behavioral epidemiologists and infectious disease public health professionals in the study of sexual risk behaviors. In turn this has led to large population studies of sexual behavior. From communities at greatest risk for HIV there have emerged community health educators, paraprofessionals specializing in HIV risk reduction counseling and case management for those at risk. In many clinics, nurse-educators play a key role in promoting preventive health care related to physical health (e.g., breast exams), sexual knowledge (e.g., education on Sexual Health risks related to illness), and reproductive counseling. Advances in assisted fertility techniques, and pharmacological innovations in the promotion of sexual functioning have brought specialists from other disciplines together to focus on the Sexual Health needs of patients. Women's and sexual minority health centers have targeted health care to minorities and the underserved, while at the same time, promoting Sexual Health at a community level. An outgrowth of sexual minority movements has been the emergence of lawyers specializing in the rights of minorities, and advocacy groups promoting safe behaviors. Recently, new approaches in the management of the sexual aggressor have expanded the field of clinical sexology to the treatment of sex offenders.

It is evident that the future of sexology will involve many new and diverse disciplines collaborating at different levels and serving different functions in addressing Sexual Health needs. As an interdisciplinary science, sexology is uniquely placed to bring together the knowledge and expertise of specialists, the diverse agendas of various advocacy groups, the health concerns of communities, and the methodologies and interests of diverse disciplines. For this reason, it is critical that sexology is promoted as a discipline/profession. It is not sufficient for specialists from other disciplines to apply their fields of expertise to the study of Sexual Health. We also need trained Sexual Health specialists who focus exclusively on Sexual Health concerns to address the diverse and specific concerns raised by sex and sexuality.

Goal 4.:Develop and provide access to comprehensive Sexual Health care services to the population.

Unfortunately the current incidence of many sexual problems makes current prevention efforts insufficient. A large number of persons have sexual problems that demand clinical care. It is also unrealistic that prevention will be able to eliminate all sexual problems in the future. The development of comprehensive Sexual Health care is therefore a critical necessity in all societies, as is the provision of access to this care to the population.

Strategy 4.1: Integrate Sexual Health issues into existing public health programs.

Sexual health is a key public health issue. Although specific actions implemented in specific targeted programs (as outlined in the sections above) are required, it is indispensable to have Sexual Health integrated into existing public health programs. For this reason the expert working group recommends as components the following:

Integrate a Sexual Health approach into existing health programs, related directly or indirectly to Sexual Health (e.g., cardiovascular health promotion programs, anti-smoking programs (benefits of not smoking on erectile performance), cancer prevention programs (early detection of CA on mastectomies, cervical cancer screening), health education programs (link between preventive health and sexual performance).

As part of general health assessments, address sexual issues when clients come into contact with public health programs. This can be advanced by review and, where necessary, reform of existing protocols to ensure adequate addressing of Sexual Health concerns. For example, general practitioners, family physicians, and physicians in public health clinics should incorporate Sexual Health screening/history taking into general health assessments.

Strategy 4.2: Provide access to comprehensive Sexual Health services to the population.

Access to comprehensive health care services is essential. Whilst the expert working group fully recognizes the relevance and cost effectiveness of a preventive approach to Sexual Health, there exist an unfortunately large number of persons already suffering from Sexual Health concerns and problems that create an urgent need for care services to ensure effective treatment.

Sexual concerns and many sexual problems can and should be addressed and solved in primary care settings. Unfortunately, lack of training of primary care providers can be an obstacle to this possibility.

Some Sexual Health problems require the intervention of specially trained individuals for their solution. Therefore, special clinics for the treatment of sexual problems are necessary to address the range of severity of sexual problems.

Strategy4.3: Provide access to comprehensive Sexual Health services to persons with mental and physical disabilities.

Sexual health services, wherever possible, should be integrated into existing services for persons with mental and physical disabilities.

Strategy 4.4: Provide access to comprehensive Sexual Health services to special populations (e.g., prisoners, illegal immigrants, the institutionalized, the homeless).

Sexual health services, wherever possible, should be integrated into existing services for special populations (e.g., prisoners, illegal immigrants, the institutionalized, the homeless).

Strategy 4.5: Provide access to comprehensive Sexual Health services to other populations(e.g., legal immigrants, minority language groups, refugees).

Sexual health services, wherever possible, should be integrated into existing services for other populations (e.g., legal immigrants, minority language groups, and refugees).

Goal 5: Promote and sponsor research and evaluation in sexuality and Sexual Health, and the dissemination of the knowledge derived from it.

Research is needed to increase understanding of sex, sexuality, Sexual Health, and sexual behavior and to evaluate the efficacy of prevention strategies, programs, courses and treatments.

Strategy 5.1: Promote sexual research and evaluation.

Both research and evaluation are urgently needed to advance the Sexual Health of individuals and populations. Research is defined here as the systematic study of an area, including the testing of hypotheses, for the purpose of acquiring new knowledge. Evaluation is defined here as the gathering and analyzing of data for the purposes of decision-making, particularly the assessment of Sexual Health program effectiveness.

Strategy 5.2: Promote sexology as a research discipline.

Sexology, in comparison to other areas of health research, has been neglected in terms of funding, respect, and quality of investigation. These dimensions are not independent. It is an absolute imperative that research on sexuality and sexual behavior of the highest quality be undertaken. To achieve this, as a field, sexology needs to develop the competence and capabilities of researchers at every level.

Strategy 5.3: Promote sexological research across disciplines (e.g., nursing, sociology, anthropology, psychology, epidemiology, etc.)

Research on sexuality and Sexual Health is not limited to sexology trained researchers. Promotion of research among other related disciplines is beneficial to the construction of a greater knowledge base and usually permits new and fresh insights of issues related to the complexity of sexuality and Sexual Health. Promotion of this kind of research can improve efforts towards achieving and maintaining Sexual Health.

Strategy 5.4: Ensure that research findings in sexology are adequately disseminated to policymakers, educators, and service providers to provide a research base for their work.

Research alone is not sufficient. Dissemination of findings is a crucial strategy to ensure that those working in Sexual Health benefit from the knowledge base that sound research creates. Dissemination of research findings is particularly necessary in most of Latin America, where there is a need to create and promote a culture of reporting sound research.

40 0 Press Release WHO/93: DIRECTOR-GENERAL SETS OUT WHO STANCE ON HEALTH AND HUMAN RIGHTS. 8 December 1998 available at: http://www.who.int/inf-pr-1998/en/pr98-93.html

41 United Nations Development Programme. Integrating human rights with sustainable human development. UNDP policy document United Nations Development Programme New York, NY January 1998. Available at: http://magnet.undp.org/Docs/policy5.html

42 Komisaruk, B.R. & Whipple, B. Love as sensory stimulation: physiological consequences of its deprivation and expression. Psychoneuroendocrinology 1998 Nov;23(8):927-44.

43 Cfr.. Kaplan, H.S. The New Sex Therapy Brunner Mazel, New York 1974.

44 In the recent report on prevalence of sexual dysfunction when the help-seeking behavior was analyzed it was found that 10% and 20% of the afflicted men and women, respectively, sought medical consultation for their sexual problems. Laumann, E. O., Paik, A. & Rosen, R. C.. Sexual Dysfunction in the United States: Prevalence and Predictors JAMA. 1999;281:537-544.

45 Nicolelis, M.A., De Oliveira, L.M., Lin, R.C. & Chapin, J.K. Active tactile exploration influences the functional maturation of the somatosensory system. J Neurophysiol 1996 May;75(5):2192-6. Fleming, A.S., O'Day, D.H. & Kraemer, G.W. Neurobiology of mother-infant interactions: experience and central nervous system plasticity across development and generations. Neurosci Biobehav Rev. 1999 May;23(5):673-85.

46 Best Practice, the continuous process of learning, feedback, reflection and analysis of what works (or does not work) and why, is the basis from which UNAIDS, its Cosponsors and partners identify, exchange and document important lessons learned. Best Practice has been shared through exchange forums, networks, Best Practice Collection publications, and technical assistance. In 1998, the Best Practice Collection expanded to over 190 original publications and videos, including joint and Cosponsor publications. The collection includes Technical Update, Point of View, Case Study, Key Material and the Summary Booklet. The collection can be accessed at: http://www.unaids.org/bestpractice/collection/index.html

47 Several sources register the fact that women live longer than men, but also that they fall ill more frequently and make use of health care more often than men, even if motherhood related services are excluded. These authors propose hypothesis that can be broadly grouped in four categories: 1.differential risks, which are associated to the ways men and women are socialized; 2. differences due to psychosocial factors, for example, women being more capable (socially) to perceive, evaluate and report illness symptoms, also to better adopt the role of “being ill” and to follow medical treatment.; 3. differences due to a sexist bias on part of physicians who tend to perceive women as more fragile than men, and therefore more prone to fall physically of psychologically ill; 4. possible biological differences. (Cfr. Castro, R. y Bronfman M. Teoría feminista y sociología medica: bases para una discusión. En J.G. Figueroa (ed.) La condición de la mujer en espacio de la salud. México D.F. El Colegio de México. 1998. In Mexico research at the Health Ministry in 1992 revealed that women present more malnutrition and related problems when compared with men (Corona E. & Corona A. La salud en las mujeres en México: Situación actual y algunas propuestas. Presented in the Pre-Conference Seminar of the World Conference on Women. UNIFEM, 1995.

48 Grunseit, A. & Kippax, S., Effects of Sex Education on Young People's Sexual Behaviour. 1993. Unpublished review commissioned by the Global Programme on AIDS, World Health Organization, July, 1993. Moore, K. A. et al. Adolescent Pregnancy Prevention Programs: Interventions and Evaluations, Child Trends, Inc., Washington, DC. Frost, J. J. & Forrest, J. D.. Understanding the Impact of Effective Teenage Pregnancy Prevention Programs. Family Planning Perspectives 1995, 25(5): 188-96; and Kirby, D. et al. School-Based Programs to Reduce Sexual Risk Behaviors: A Review of Effectiveness. Public Health Reports, 1994,109(3), pp. 339-60.

49 William, F. A. A Psychological Approach to Human Sexuality: The Sexual Behavior Sequence. In D. Byrne & K. Kelley (Editors) Alternative Approaches to the Study of Sexual Behavior. 1986. Lawrence Erlbaum Associates, Publishers, Hillsdale, New Jersey.

50 Ferraro, F. & Dukart, R. A Cognitive inhibition in individuals prone to homophobia. J Clin Psychol 1998 Feb;54(2):155-62 .

51 Johnson, M.E., Brems, C. & Alford-Keating, P. Personality correlates of homophobia. J Homosex 1997; 34(1):57-69.

52 Monroe, M., Baker, R.C. & Roll, S. The relationship of homophobia to intimacy in heterosexual men. J Homosex 1997;33(2):23-37.

53 Meyer. I.H. & Dean, L. Patterns of sexual behavior and risk taking among young New York City gay men. AIDS Educ Prev 1995;7(5 Suppl):13-23.

54 Lohrmann, C., Valimaki, M., Suominen, T., Muinonen, U., Dassen, T. & Peate. German nursing students' knowledge of and attitudes to HIV and AIDS: two decades after the first AIDS cases. J Adv Nurs 2000 Mar; 31(3):696-703.

55 Herek, G.M. (1984). Beyond “homophobia”: A social psychological perspective on attitudes toward lesbians and gay men. Journal of Homosexuality, 10 (1/2), 1-21.

56 The statistics mentioned in the importance of Sexual Health problems section illustrate: In 1993, the World Development Report of the World Bank estimated that “women ages 15 to 44 lose more Discounted Health Years of Life (DHYLs) to rape and domestic violence than to breast cancer, cervical cancer, obstructed labor, heart disease, AIDS, respiratory infections, motor vehicle accidents or war.” Studies show that rape survivors have high rates of persistent post-traumatic stress disorder and make up the largest single group diagnosed with the disorder. And rape victims are nine times likelier than non-victims to attempt suicide and to suffer major depression. Furthermore, 50 to 60 per cent of the victims experience sexual dysfunction, including fear of sex and problems with arousal. A study based on the records of the Maternity Hospital of Lima, Peru, revealed that 90 per cent of young mothers aged 12 to 16 had become pregnant because they had been raped. In Costa Rica, an organization working with adolescent mothers reported that 95 per cent of its pregnant clients under 15 were victims of incest. Interactive Population: Violence against Girls and Women: http://www.unfpa.org/modules/intercenter/violence/gender2f.htm

57 Corona, E. Resquicios en las Puertas: La Educación Sexual en México en el Siglo XX in: CONAPO (Editor). Antología de la Sexualidad Humana Vol. 3. CONAPO, México 1994.

58 Coleman, E. (1998). Promoting Sexual Health: The Challenges of the Present and Future. In J J. Borras Valls & Conchillo, M. P. (Ed.). Sexuality and Human Rights. Valencia, Spain.

59 Cerrutti, S.1993 Salud y Sexualidad desde una Perspectiva de Género. Global Reproductive Health Forum: http://www.hsph.harvard.edu/grhf/_Spanish/course/sesion1/saludsexual.html

60 Grunseit, A. & Kippax, S., Effects of Sex Education on Young People's Sexual Behaviour. 1993. Unpublished review commissioned by the Global Programme on AIDS, World Health Organization, July, 1993. Moore, K. A. et al. Adolescent Pregnancy Prevention Programs: Interventions and Evaluations, Child Trends, Inc., Washington, DC. Frost, J. J. & Forrest, J. D.. Understanding the Impact of Effective Teenage Pregnancy Prevention Programs. Family Planning Perspectives 1995, 25(5): 188-96; and Kirby, D. et al. School-Based Programs to Reduce Sexual Risk Behaviors: A Review of Effectiveness. Public Health Reports, 1994,109(3), pp. 339-60.

61 Franklin, C. Grant, D., Corcoran, J., O'Dell Miller, P. and Bultman, C. (1997). Effectiveness of prevention programs for adolescent pregnancy: A meta analysis. Journal of Marriage and the Family, 59, 551-567

62 See for instance Israel, R.C & Nagano, R. Promoting Reproductive Health for Young Adults through Social Marketing and Mass Media: A Review of Trends and Practices. Education Development Center, Inc. (EDC) 55 Chapel Street, Newton, MA 02158 available at: http://www.pathfind.org/RPPS-Papers/Social%20Marketing.html

63 In 1907 Iwan Bloch published his first truly sexological work under the title Das Sexualleben unserer Zeit (The Sexual Life of Our Time) and stated in its foreword: “The author of the present work . . . is. . . convinced that the purely medical consideration of the sexual life . . . is yet incapable of doing full justice to the many-sided relationships between the sexual and all the other provinces of human life. To do justice to the whole importance of love in the life of the individual and in that of society, and in relation to the evolution of human civilization, this particular branch of inquiry must be treated in its proper subordination as a part of the general science of mankind, which is constituted by a union of all other sciences of general biology, anthropology and ethnology, philosophy and psychology, the history of literature, and the entire history of civilization . . . Hitherto there has existed no single comprehensive treatise on the whole of the sexual life . . . .The time is indeed fully ripe for an attempt to sift. . . the enormous mass of available material, and to present the result from a centralized standpoint”. Bloch, I. The Sexual Life of Our Time. Translated by Eden Paul, New York: Allied Book Company 1908.

中文翻译：彭晓辉(中国 武汉 华中师范大学生命科学学院，430079)完成时间：2006年3月