Sexual health concerns and problems are present whenever life situations related to sexuality require interventions by individuals and/or society due to their impact on wellness and quality of life. The variety of these concerns and problems is very wide, ranging from conditions that are perceived as “part of life” to those that constitute a threat to well being and even, to life. However, all of them demand attention from all segments of society including the health sector both through prevention and appropriate comprehensive care.
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.
HIV/AIDS Pandemic. Sexual Health concerns and problems impact various areas of human activity at individual and social levels. For example, the global spread of HIV, mainly through unprotected sexual intercourse, has resulted in around 35 million infected people and over 19 million deaths worldwide since the beginning of the epidemic. Communities at large bear the effects of the AIDS pandemic to the extent that there are around 13 million children and young people orphaned as a result of HIV-related death of one or both parents. Furthermore PAHO estimates there are 2.5 million people currently living with HIV in the Region of the Americas.
The HIV/AIDS pandemic has brought to public attention the extreme seriousness of sexually transmitted infections. One million people die each year from reproductive tract infections, including sexually transmitted infections (STIs) other than HIV/AIDS. It has been estimated that 333 million new cases of STIs may occur globally each year.
Violence. The World Development Report (1993) of the World Bank estimated that women aged 15 to 44 years lose a significant amount of Discounted Health Years of Life (DHYLs) due to rape and domestic violence, which may be related to gender inequity, and irresponsible behavior. 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. Rape victims are nine times more likely than non-victims to attempt suicide and to suffer major depression. Furthermore, 50 to 60 percent 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 percent 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 percent of its pregnant clients under 15 were victims of incest 32.
The impact and importance of gender related problems (in particular those related to gender inequality) are widespread, and the importance of addressing the issue and solving the problem has been recognized worldwide 33.
Sexual Dysfunctions. The problem of sexual syndromes has recently been highlighted. The prevalence of sexual dysfunctions has been established for some populations. For example, in the United States, a prevalence rate of 43% for females and 31% for males is reported 34. Sexual dysfunctions have been correlated with lower levels of quality of life 35, and to other health problems: heart disease, hypertension, diabetes, associated medications, and high indexes of anger and depression 36.
Although the above mentioned figures may seem very dramatic, they are only the tip of the iceberg in a field that is just emerging as a public health issue. Any actions to reduce the magnitude and severity of situations affecting Sexual Health require a comprehensive and ample approach that surpasses the curative paradigm of health care.
Sexual health concerns are life situations that require preventive and educational actions by society to ensure its members attain and maintain Sexual Health. Sexual Health problems are the result of conditions, either in an individual, relationship, or a society, that require specific action for their identification, prevention and/or treatment and therefore, eventual resolution. The necessary level of training for professionals also differentiates these two categories. Sexual problems usually need clinically trained professionals for their solution, whereas sexual concerns can be addressed and managed by a variety of professionals often not needing specialized clinical training.
The expert working group recommends that the following sexual concerns and problems be addressed as a means of advancing societies towards Sexual Health (See Box V).
The following list is not exhaustive but rather examples and illustrations of sexual concerns. Each of these concerns allows the appropriate assessment of information, counseling and/or care needs that demand actions from governmental and non-governmental agencies and institutions including the health sector.
5. Sexual Health Concerns
Health concerns related to body integrity and to sexual safety
for health-promoting behaviors for early identification of
sexual problems (e.g., regular check-ups and health screening,
breast and testicular self-exam).
Need for freedom from all forms of sexual coercion such as sexual violence (including sexual abuse and harassment).
Need for freedom from body mutilations (i.e. female genital mutilation).
Need for freedom from contracting or transmitting sexually transmitted infections (including but not limited to HIV/AIDS).
Need for reduction of sexual consequences of physical or mental disabilities.
Need for reduction of impact on sexual life of medical and surgical conditions or treatments.
2. Sexual Health concerns related to eroticism
Need for knowledge about the body, as related to sexual response and pleasure.
Need of recognition of the value of sexual pleasure enjoyed throughout life in safe and responsible manners within a values framework respectful of the rights of others.
Need for promotion of sexual relationships practice in safe and responsible manners.
Need to foster the practice and enjoyment of consensual, non-exploitive, honest, mutually pleasurable sexual relationships
3. Sexual Health concerns related to gender
Need for gender equity.
Need for freedom from all forms of discrimination based on gender.
Need for respect and acceptance of gender differences.
4. Sexual Health concerns related to sexual orientation
Need for freedom from discrimination based on sexual orientation.
Need for freedom to express sexual orientation in safe and responsible manners within a values framework respectful of the rights of others.
5. Sexual Health concerns related to emotional attachments
Need for freedom from exploitative, coercive, violent or manipulative relationships.
Need for information regarding choices of family options and lifestyles.
Need of skills, such as decision-making, communication, assertiveness and negotiation, that enhance personal relationships.
Need for respectful and responsible expression of love and intimacy.
Prevention and appropriate care of couple maladjustment and distress.
Appropriate management of separation and divorce.
6. Sexual Health concerns related to reproduction
Need to make informed and responsible choices about reproduction.
Need to make responsible decisions and practices regarding reproductive behavior regardless of age, gender and marital status.
Access to reproductive health care.
Access to safe motherhood
and care for infertility.
Sexual problems are the result of conditions, either in an individual, relationship, or a society, that require specific action for their identification, prevention and/or treatment and therefore, eventual resolution.
In the past, the use of the term “pathology” to denote sexual problems has created considerable controversy. The usual and clear cut meaning of the term pathology in other areas of health care is frequently lost when it is applied to sexual problems and concerns due to the nature of the problems experienced. Therefore the expert working group recommends the use of the term “sexual problem” rather than “pathology” to refer to Sexual Health problems.
Another recommendation is the use of syndrome level classification. Clinical syndromes define a cluster of symptoms and complaints that seriously inhibit the exercise of the individual's sexual rights and alter his/her Sexual Health.
There are a number of advantages of taking a syndromic approach. Syndromes are easy to identify. Awareness of the presence of the problem both in health personnel and the general public is easier to create when problems are known at a syndrome level. A syndrome level classification also is more succinct and can be used for epidemiological considerations. Much of what is currently known about epidemiology of some of these categories is at a syndrome level 37. In categories such as sexually transmitted infections preventive and curative actions can be taken effectively from a public health perspective if a syndromic approach is taken 38.
On the other hand, many sexual problems are caused by a rather complex variety of etiologies. For example, in sexual dysfunctions the need for etiology based diagnosis persists even when the syndrome has been identified 39. A syndrome level classification helps in reminding that the listed categories are syndromes, not etiologically classified clinical entities. For the above reasons the expert working group strongly recommends that a syndromic approach to the classification of Sexual Health problems be undertaken.
Clinical syndromes are rather artificial categories that are created with broad agreement between professionals. There is considerable consensus in many of the clinical syndromes presented in the proposed classification: sexual dysfunctions are a good example of the process of consensus. In other categories such as compulsive sexual behavior syndromes, process of consensus is still in its initial building stages.
Sexual problems, therefore, are presented here as syndromes. Each of these problems allows the appropriate assessment of information, counseling, prevention, early identification, need for further diagnostic evaluation, and course of treatment, rehabilitation and/or care needs that demand actions from governmental and non-governmental agencies and institutions including the health sector. Sexual problems are divided into the following syndrome categories (See Table 7):
Table 7. Sexual Health
1. Clinical Syndromes that Impair Sexual Functioning (Sexual dysfunctions)
Hypoactive sexual desire
Female sexual arousal dysfunction
Male erectile dysfunction
Female orgasm dysfunction
Male orgasm dysfunction
Sexual pain syndromes (including dyspareunia and other pain conditions)
2.Clinical Syndromes Related to Impairment of Emotional Attachment/Love(also known as Paraphilias)
3. Clinical Syndromes Related to Compulsive Sexual Behavior
Compulsive cruising and multiple partners
Compulsive fixation on an unattainable partner
Compulsive love affairs
Compulsive sexual behavior in a relationship.
4. Clinical Syndromes Involving Gender Identity Conflict
Childhood Gender Dysphoria
Adolescent Gender Dysphoria
Adult Gender Dysphoria
Unspecified Gender Identity Syndrome
5. Clinical Syndromes Related to Violence and Victimization
Clinical syndromes following being sexually abused as a child/minor (Including but not limited to post-traumatic stress disorder)
Clinical syndromes following being sexual harassed
Clinical syndromes following being sexual violated or raped
Clinical phobia focused on sexuality (e.g., homophobia, erotophobia)
Clinical syndromes related to engaging in threat or acts of violence focused on sex or sexuality (e.g., raping another person)
Patterns of unsafe sexual behavior placing self and/or others at risk for HIV infection or/and other sexually transmitted infections.
6. Clinical Syndromes Related to Reproduction
7. Clinical Syndromes Related to Sexually Transmitted Infections (An etiological classification is included in Appendix II)
Lower abdominal pain in women
Asymptomatic sexually transmitted infections and infestations (including HIV)
Acquired Immunodeficiency Syndrome (secondary to HIV infection).
8. Clinical Syndromes Related to Other Conditions
Clinical syndromes secondary to disability or infirmity
Clinical syndromes secondary to physical or mental illness
Clinical syndromes secondary to medication or other medical and surgical interventions
Clinical syndromes secondary to other conditions
32 Interactive Population: Violence against Girls and Women:
33 Again, only to illustrate: At least 60 million girls are “missing” from the population due to son-preference, via either sex-selective abortions or neglect. 2 million girls between 5 and 15 years old are put on the commercial sex market every year. Nearly 600 million women are illiterate compared with about 320 million men. Source UNFPA documents:
34 Laumann, E. O., Paik, A. & Rosen, R. C.. Sexual Dysfunction in the United States: Prevalence and Predictors JAMA. 1999;281:537-544.
35 Laumann, E. O., Paik, A. & Rosen, R. C.. Sexual Dysfunction in the United States: Prevalence and Predictors JAMA. 1999;281:537-544 . McCabe MP Intimacy and quality of life among sexually dysfunctional men and women. J Sex Marital Ther, 23(4):276-90, 1997, Winter. Litwin, M.S., Nield, R.J., Litwin, M.S., Nield, R.J., & Dhanani N. Health-related quality of life in men with erectile dysfunction. J Gen Intern Med, 13(3): 159-66 1998 Mar. Fugl-Meyer, A.R., Lodnert, G., Bräholm I.B., & Fulg-Meyer, K.S. On life satisfaction in male erectile dysfunction Int J Impot Res, 9(3):141-8 1997 Sept.
36 Feldman, H.A., Goldstein, I. Hatzichristou, D.G., Krane, R.J. & McKinlay, J.B. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994 Jan;151(1):54-61.
37 For instance, the prevalence of sexual dysfunctions is known at a syndrome level: i.e. Laumann, E. O., Paik, A. & Rosen, R. C.. Sexual Dysfunction in the United States: Prevalence and Predictors JAMA. 1999;281:537-544.
38 “The difficulties related to the timely collection of disease specific data have led to the concept of collecting information about syndromes. This syndromic approach is used successfully by the poliomyelitis eradication program, which collects data on acute flaccid paralysis (AFP) caused by several infectious or non-infectious diseases, but that will trigger an immediate response from the poliomyelitis surveillance system. The same approach could be applied in areas where rapid laboratory diagnosis cannot be obtained (such as at the periphery of many health systems). Although lacking specificity, the syndromic approach offers: a simple and stable case definition; reliability (as it reports what is actually seen); immediate reporting (as there is no laboratory delay); a wider surveillance coverage allowing for the detection of emerging diseases; and, in some cases, the avoidance of disease-associated stigma. This approach is complementary to a disease-specific list of notificable diseases, and is also being considered in the context of the revision of the International Health Regulations”. An integrated approach to Communicable Disease Surveillance Epidemiological Bulletin, Vol. 21 No.1, March 2000: http://www.paho.org/English/SHA/eb_v21n1-vigil.htm
39 The current availability of effective medications to improve erectile functioning illustrates the advantage a syndromic approach to diagnosis. While a male erectile dysfunction syndrome can be effectively symptomatically treated (i.e. improving the erectile function) with medications such as sildenafil, doing so without a proper etiological diagnostic evaluation can obscure the causative factors, and delay the diagnosis of frequent conditions such as diabetes mellitus or hiperlipidemia or, impose a life treatment to a person who might benefit from treatments that can remove the etiologic factors (e.g. performance anxiety). (Cfr. Rubio, E. & Díaz, J. Las Disfunciones Sexuales In: CONAPO (Editor). Antología de la Sexualidad Humana Vol. 3. CONAPO, Mexico 1994.