促進性健康的行動方案與策略

目標 1:促進性健康,包括消除對性健康的障礙

  策略 1.1:把性健康整合于公共衛生保健規劃

  策略 1.2:促進性別平等和公正及消除基於性別的歧視

  策略 1.3:促進負責任的性行為

  策略 1.4:消除涉及到性和性少數(性少數群體)的恐懼、偏見、歧視和仇恨

  策略 1.5:消除性暴力

目標 2:大規模地為全區域人口提供全面的性教育

  策略 2.1:提供以學校為基地的全面的性教育

  策略 2.2: 把性教育適當地整合於公共教育機構的普通課程

  策略 2.3: 為精神和身體殘障者提供全面的性教育

  策略 2.4: 為特殊群體(例如:囚犯、非法移民、被收容者和無家可歸者)提供他們有權得到的全面的性教育

  策略 2.5: 為其他群體(例如:合法移民、持少數民族語言群體和難民)提供他們有權得到的全面的性教育

  策略 2.6: 整合大眾媒體的力量,讓其做出努力以傳播和促進全面的性教育

目標 3: 對工作在性健康相關領域的專業人員提供教育、培訓和支持

  策略 3.1: 為衛生保健及其相關人員提供性健康教育和培訓

  策略 3.2: 為學校教師提供性健康教育和培訓

  策略 3.3: 促進性科學(性學)成為一個專業/學科

目標 4.: 為全區域人口制定和提供他們有權享用的全面的性衛生保健服務

  策略 4.1: 把性健康事務整合于現有的公共衛生保健計畫

  策略 4.2: 為全區域人口提供他們有權享用的全面的性衛生保健服務

  策略 4.3: 為精神和生理殘障者提供他們有權享用的全面的性衛生保健服務

  策略 4.4: 為特殊群體(例如:囚犯、非法移民、受收容者和無家可歸者)提供他們有權享用的全面的性衛生保健服務

  策略 4.5: 為其他群體(例如:合法移民、少數民族語言群體和難民)提供他們有權享用的全面的性衛生保健服務

目標 5: 促進與贊助性*和性健康領域的研究和評估,傳播由性與性健康所衍生的知識

  策略 5.1: 促進性*研究和性評估。

  策略 5.2: 促進性科學成為一門理論學科。

  策略 5.3: 促進性科學的跨學科 (例如:護理學、社會學、人類學、心理學和流行病學等等)研究。

  策略 5.4: 確保在性科學的研究成果充分地傳播給政策制定者、教育家、健康保健服務提供者,以給他們的工作提供研究基礎。

Actions and Strategies to promote Sexual Health

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

  Strategy 1.1: Integrate Sexual Health into public health programs

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

  Strategy 1.3: Promote responsible sexual behavior

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

  Strategy 1.5: Eliminate sexual violence

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

  Strategy 2.1: Provide school based comprehensive sexuality education.

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

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

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

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

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

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

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

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

  Strategy 3.3: Promote sexology as a profession/discipline.

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

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

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

  Strategy4.3: Provide access to comprehensive Sexual Health services to 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).

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

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

  Strategy 5.1: Promote sexual research and evaluation.

  Strategy 5.2: Promote sexology as a research discipline.

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

  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.

中文翻譯:彭曉輝(中國 武漢 華中師範大學生命科學學院,430079)完成時間:20063

TranslatorXiaohui Peng (Life Science College of CCNU, Wuhan, 430079, China)

   對:吳敏倫(中國 香港 香港大學醫學院)完成時間:20068

促進性健康的行動方案與策略

達到健康是所有社會優先達成的目標。為了達到全面健康的目的,必須促進和維持性健康。通過再一次強調性健康憂慮和性健康問題,美洲區域內的衛生保健的許多方面將會有相當程度的改善。尤其在生殖健康和HIV/AIDS的預防和控制的領域,已經取得了重大的成就。本專家工作小組經過協商認為,如果從更廣泛的途徑對性展開研究,譬如在本報告裏所提議的這種概念化的理論研究,改善健康的基本目標可能會以更有效率的方式達成。

性健康是一個廣義的概念。針對達到和維持性健康所採取的行動方案和策略應該會增進健康狀況,並因此而改善個人與社會的健康狀態。

除了改善健康的廣泛途徑以外,本專家工作小組協商後認為,人權的公認是一個推動社會、政治、法律和文化改變的有效途徑。世界衛生組織已經承認健康是一項基本人權40。必不可少的性健康促進將會改變社會、政治、法律和文化,因此,推薦在人權框架之下來促進性健康。

例如,聯合國開發計畫署(UNDP)制定了一項官方政策,其聲明如下:

人權是基於對人類的尊嚴和價值的尊重,是基於尋求確保免予恐懼和短缺的自由。人權源自道德原則(並通常載於一個國家的憲法與法律框架內),它對於每一個男人、女人和兒童的健康是必不可少的。人權以基本的和不可侵犯的準繩為前提,它們是一項普遍的和不能讓渡的權利41

本專家工作小組向美洲區域各國政府與非政府機構以及包括衛生部門在內的公共機構推薦下列五個目標:

目標 1:促進性健康,包括消除對性健康的障礙

目標 2:大規模地為全區域人口提供全面的性教育

目標 3:為工作在性健康相關領域的專業人員提供教育、培訓和支持

目標 4:為全區域人口制定和提供他們有權使用的全面的性衛生保健服務

         目標 5:促進與贊助性學和性健康領域的研究和評價,並以此為基礎傳播性健康知識

為了實現上述列舉的目標,本專家工作小組也確認了許多促進性健康行動策略。現予分述如下。

目標 1:促進性健康,包括消除對性健康的障礙

性健康將會在社會的所有成員中來促進。本專家工作小組強調必須承認包括精神和生理殘障者在內的所有個體的性權利。

如果兼顧到了性的所有組成方面,促進性健康的努力將會更加有效。因此,欲要把性健康整合于公共衛生保健規劃,則應該給國民提供全方位的性健康 (例如:情感依戀/情欲發展、性別發展和生殖健康等)服務。

性快樂(Erotic pleasure)常常被人否定,其實它是人類積極、有益、促進健康的基本需要。近來的證據已經證明,甚至從生理層面上看,性愛體驗也含有重要意義42

當把性快樂作為自體性行為(常常稱為手淫)來體驗的時候,它甚至受到更嚴厲的指責。可是,在科學研究文獻中,還沒有證據顯示這種行為有有害的效應。而且,臨床性學家一致認為,促進自體性行為有益於治療各種各樣的性功能障礙。另外,有研究者發現了自體性行為的價值,它是促進安全性行為的重要手段43

再之,對性快樂的這種誣衊,已經導致在許多性教育項目中排除了任何快樂的內容。這種不必要的忽略會影響以尋求行為方式為手段的衛生保健作用。有一項有關性健康問題的疾病流行程度研究顯示,對性快樂有迷惑或擔憂的人尋求專家諮詢的頻率比所期望的要低許多44

人們還不能理解情感依戀/情欲在健康中的重要性。長期以來,行為科學家已經獲悉和諧與親愛的生活環境的重要意義。更有從生物學角度所做的研究證明,人生早期所涉及到的觸摸體驗對於個體發育和中樞神經系統的發育成熟是必不可少的45

策略 1.1:把性健康整合于公共衛生保健規劃

有大量的證據顯示,如果把預防和治療行為整合於範圍更廣的公共衛生保健專案裏,就會較順利地解決公共健康憂慮和公共健康問題。儘管需要在特殊專案中採用行動方案,卻需要把性健康整合于公共衛生保健規劃。

為了實現這個方略,我們確定了下列的特殊行動方案:

制定國家特殊的性健康策略和計畫。

促進確保國家性健康策略可行性的立法。

把性健康方法整合于現有的衛生保健專案。

制定用於政策、專案發展和評估的性健康指標。

支持在性健康問題的定義和分類上達成一致的意見。

為性健康問題制定最好的實踐指導方針46

策略 1.2:促進性別平等和公正及消除基於性別的歧視

自從理論學派與經驗學派的女權主義著述破繭而出以後,越來越多的證據顯示在性別和健康之間有著關聯47。特別是在國際人口與發展大會(ICPD)和北京第四屆世界婦女大會上,已經提出了這樣的觀點:除非把性別因素考慮在內,不然,與性健康有關的社會發展目標則難以達到。

為了達到這個策略目標,性健康促進行動方案必須涵蓋從調整各項政策(指那些似乎與衛生保健事務無關的那些政策)到洞悉男女不斷增長的各種特殊的健康需要這樣一個非常廣泛的範圍。這些行動方案超出了性關係就是性別關係這樣的認識範圍。儘管從概念上是把性別(gender)歸於性(sexuality)的範疇,還是把它們作為一個系統內的兩個部分?尚有爭議;顯然,如果沒有充分考慮到性別及其深刻的含意,要想達到性健康是不可能的。

本策略的一些行動方案包括:

提倡引導和改變那些對性別不和諧有影響作用的公共政策,例如促進女孩接受學校和正規的教育。

在計畫和實施性衛生保健服務中引入性別觀念。例如,可以考慮男女分時段地使用衛生保健服務設施這樣的簡單方法。

確保全面的性教育始終要包括性別分析,尤其要特別強調男女在性別公平和性別平等方面的權利。

鼓勵男性討論和理解促進性別角色轉變和新的男性(the new masculinity)的行動方案。由於存在著女性向男性提出要求改變地位的可能趨勢,尤其在男性占統治地位和霸主地位的社會,實施這種鼓勵策略尤為重要。

讓所有健康服務提供者意識到自己存有性別偏見。

策略 1.3:促進負責任的性行為

負責任的性行為是在個體、人際之間和社會的層面來體現的。它在於對性快樂和性健康方面體現出自主、相互關聯、誠實、尊重、允諾、保護和尋求快樂的特點。個人所展示的負責任的性行為並不是在性的方面意欲引起傷害,而是摒棄自私的利用、騷擾、操縱和歧視。社會通過提供知識、資源和公正來促進負責任的性行為,而個人則必須要參與促進負責任的性行為的實踐活動。

為了達到性健康,個人必須以負責任的方式去作為;所以,責任是一項需要促進的最重要的價值觀。強調負責任的性行為能夠為社會在疾病發病率和改善健康狀態方面減輕負擔,產生低成本的效果。本策略的方案是:

在所有的性教育項目中包含責任價值觀的教育內容。

實施成人教育計畫,特別要針對父母的需要實施成人教育計畫,因為他們在促進負責任的性行為中是最直接和最有效的代理人。

將大眾媒體納入在內,讓它們在各種傳播資訊中引介負責任的性行為,尤其在廣播或出版物中直接針對這個話題開展教育活動,或者在媒體上建立專欄和專題節目。

宣導促進負責任的性行為的立法。

策略 1.4:消除涉及到性和性少數(性少數群體)的恐懼、偏見、歧視和仇恨

涉及到性與性少數群體的恐懼、偏見、歧視和仇恨都是性健康的妨礙因素。恐懼源自無知和誤傳。有大量的證據表明當個人的知識增加的時候,他們會養成更健康的行為48

研究已經表明帶有恐懼和負面心理的人有更大的不健康行為舉止的危險。性愛恐怖就是一種對性的快樂成分做出負面情感價值判斷的反應。性愛恐怖者可能在將來更少有性交行為,並且對公開談論性顯示有各種更負面的反應,而且未能在性活動之前獲取避孕藥具49

同性戀憎惡是對有同性性取向個體的非理性的恐懼。在許多案例裏,這種憎惡是犯罪行為的基礎。有研究報告指出同性戀憎惡與認知抑制有關聯。對男女同性戀者的公然否決、歧視或暴力與各種各樣的健康和發展問題有關聯50,這些否定同性戀者的作為還與以拒絕和孤立的方式對待男女同性戀者51、與發展親密舉止的能力52、與更頻繁地談論性行為53以及與貶低由衛生保健專業人員提供的衛生保健的品質有關聯54。在其他一些對健康所造成的威脅和妨礙的因素中,有學者暗示這種同性戀否定觀會加強對同性戀者負面態度理解的心理社會動力55

本策略的一些特殊行動方案包括:

促進對男性和女性性別認同性象譜的理解;性別認同的性象譜依次包括異性戀的、同性戀的、雙性戀的、雙性的和跨性的組成成分。

在所有的性取向個體之間消除彼此的同性戀憎惡。

策略 1.5:消除性暴力

大量的證據已經證明性暴力的危害效應56。性健康促進和作為人權的性權利將會為減少和消除性暴力發揮作用。顯而易見,性別平等、性別公平、消除性別歧視以及全面的性教育將會降低暴力的發生率。消除性暴力的行動方案包括:

識別各種各樣的性暴力方式。

有效地引導立法以減少性暴力。

促進告發性暴力的社會文化發展。

促進性暴力的受害者尋求健康的行為。

鑒於許多性侵犯者可能從治療中受益(即通過治療矯正性暴力傾向——譯者注),促進他們的衛生保健。

目標 2:大規模地為全區域人口提供全面的性教育

本專家工作小組完全達成了共識:考慮到全面的性教育是一個提供和轉化非正式與正式的涉及人類性學所有方面的知識、態度、技能和價值的終生教育過程,所以,當一個社會在其國民中促進性健康時57,能夠做到的最好投入莫過於全面的性教育。

全面的性教育應該在生命的早期就要著手;應該適合於年齡與發育階段需要;應該對性採取正面的態度來展開58

性教育必須為國民提供性學的知識素養。此外,人們認識到僅有性知識是不夠的;所以,性教育除了讓人獲得性知識以外,也必須讓人獲得生活技能的發展。

策略 2.1:提供以學校為基地的全面的性教育

以學校為基地的全面的性教育是個人終生性健康的基石,所以需要特別地引起關注。在大多數國家裏,學校幾乎是人人在其生命的某個時期與之接觸的專一的公共機構。這為提供性教育創造了絕好的條件;因此,政府需要以法規的方式委託學校開展這項教育。已經有相當多的研究確認了有效的性教育的特色59,60,61。附件III以概要的形式介紹了全面的性教育的這些特色。

策略 2.2: 把性教育適當地整合於公共教育機構的普通課程

除了基於學校的性教育以外,為了達到對全民終生提供全面的性教育的目的,所有的公共教育機構必須扮演好它們的角色。尤其是高等學校能夠以設置成人人類性學課程的方式促進性健康。

策略 2.3: 為精神和身體殘障者提供全面的性教育

精神與生理殘障者與其他人一樣有獲得全面性教育的同等權利。因為精神與生理殘障者可能有特殊的需要和處於特殊的境況,並且可能在做出涉及性的決定的能力上不時會顯得力不從心,所以,這些人群應該優先獲得全面的性教育。

策略 2.4: 為特殊群體(例如:囚犯、非法移民、被收容者和無家可歸者)提供他們有權得到的全面的性教育

歷史上,人們忽視了兩個群體的性教育需要。被收容者(囚犯、住院病人和長期受護理)和那些無身份的人或社會邊緣群體(包括非法移民和無家可歸者)無權使用教育資源。

凡被收容者得到關懷的地方,就是那些從法律責任上對這些人具有道德責任、給他們提供享用教育資源的地方;當要避免重大風險的時候(例如:HIV和其他性傳播疾病),那些地方會幫助這些人提升他/她的性健康水準。至於在那些缺乏享用教育資源的地方,那裏的政府有道德責任為這些人提供盡可能的服務和教育。

策略 2.5: 為其他群體(例如:合法移民、持少數民族語言群體和難民)提供他們有權得到的全面的性教育

如同被收容者和未受教育者一樣,另一個群體就是那些有較大障礙享用教育資源者。據確認,他們在性健康憂慮方面有更大的風險。那些不會講一國主導語言的移民(包括難民)有得到全面的性教育的權利。在盡可能的地方,應該把對這些群體的教育整合于現有的教育計畫之中。

策略 2.6: 整合大眾媒體的力量,讓其做出努力以傳播和促進全面的性教育

在影響社會規範方面,大眾媒體的重要性業已被廣泛認可。任何促進健康的舉措都應該包含大眾媒體的參與,要利用所有現時的和將來的傳媒管道:電子傳媒(無線電廣播和電視)、紙質傳媒和互聯網傳媒等所有手段。大眾傳媒從業人員負有對其社會的責任,尤其在性健康方面,不應該規避這種責任。

已經有了利用大眾媒體促進生殖健康和預防性傳播疾病的實例,並且據報導的結果表明:媒體對健康促進能夠達到良好的收益62

目標 3: 對工作在性健康相關領域的專業人員提供教育、培訓和支持

為了在國民中有效地促進性健康,有必要為各行各業的專家、其他專業人員和涉及性健康促進的輔助專業人員(包括內科醫生、護士、治療專家、HIV/AIDS防治專家、計劃生育服務人員、教育家和社會活動家)提供性健康教育和培訓。

策略 3.1: 為衛生保健及其相關人員提供性健康教育和培訓

為衛生保健專業人員開展的性健康教育,至少應該在四個不同的層面來展開:

為所有衛生保健專業人員提供既包括基礎訓練也包括繼續教育的基本的性健康教育。衛生保健專業人員包括醫生、護士、臨床心理醫生、社會工作者、衛生保健從業者和性健康宣導者。

為專門從事生殖健康項目推廣的衛生保健專業人員提供性健康教育。

為專門從事性傳播疾病與HIV/AIDS預防和控制專案的專業人員提供性健康教育。

為專門從事包括性教育、臨床性科學(性醫學、性外科學、性諮詢和性心理療法)和基礎理論性學研究的性學專業人員提供性健康教育與培訓。

有關為這四類人員提供的相關培訓需要,在附錄IV作了詳細介紹。附錄IV闡述了培訓各學科專業人員的通常方法。

策略 3.2: 為學校教師提供性健康教育和培訓

作為培訓內容之一,學校教師必須接受有效的傳授性教育知識和技能的培訓。既然性教育作為普遍和整體的教育課程的組成部分被提出,這樣的培訓就應該被看作是任何教師培訓課程的必修課。

策略 3.3: 促進性科學(性學)成為一個專業/學科

性科學(也稱為性學——譯者注)作為一門學科於1907年被首次提出63。在過去的50年裏,性科學學科領域已經有了巨大的進步。從歷史上看,性科學有三個主要領域:教育、研究和臨床治療,其中主要集中在性功能障礙的臨床服務。當今,新學科與性科學發生了融合。人口的性健康需要已經擴展了我們對於性科學的認識。從其他嚴重的性傳播流行性疾病中凸現出的HIV,已經導致了行為流行病學家和傳染病公共衛生專業人員在危險性行為的研究中的專業化發展。繼而,這已經導致了對大規模人口的性行為研究。從HIV威脅最為嚴重的社會裏,湧現出了公共衛生教育家、專門從事降低HIV威脅的諮詢服務和管理受HIV威脅者的輔助人員。在許多診所,護理教師(nurse-educators)在促進預防性的涉及體格檢查(例如:乳房檢查)、性知識傳授(例如:涉及疾病的性健康風險知識教育)和生殖健康諮詢的衛生保健方面起著關鍵的作用。輔助生殖技術的進步和促進性功能的藥物創新從其他學科已經吸引了各類專家共同關注于病人的性健康需要。婦女健康中心和性少數健康中心已經針對性少數群體和受劣質服務者的衛生保健採取了改進措施,同時在社會層面促進性衛生保健服務。在興起的性少數運動中,湧現出一批專門從事維護性少數群體權益的律師和宣導促進安全行為的社團。最近,性侵犯者管理的新方法已經把臨床性科學(性醫學、性外科學、性諮詢和性心理治療——譯者注)擴展到了性侵犯者的治療方面。

顯而易見,性科學的將來發展將會涉及許多新的和不同的學科,性科學與這些學科將會針對性健康需要在不同的層面和不同的服務功能上展開合作。作為一門交叉科學,性科學獨特地把專家的知識和技能、各種各樣的宣導性健康團體的不同議題和不同學科的研究方法和興趣融合在了一起。有鑒於此,關鍵或緊要的是要把性科學作為一門學科/專業來推動。來源於其他學科的專家運用其自身的專業領域的技能尚不足以能夠研究性健康。我們還需要訓練有素的專注于性健康憂慮的性健康專家,請他們致力於不同的和特殊的由*和性*所引發的各種性健康憂慮。

更精要地摘要如下,我們需要:

為性教育家和性學專家制定培訓標準。

推動性科學成為一門學科/專業。

向政府宣導對專業人員的性學培訓計畫。

目標 4.: 為全區域人口制定和提供他們有權享用的全面的性衛生保健服務

遺憾的是,現有的許多性健康問題的影響範圍之大使得現有的預防措施捉襟見肘。許許多多的人存在著需要臨床保健的性健康問題。夢想預防措施在將來會能夠消除所有的性健康問題也是不現實的。所以,全面的性衛生保健對所有社會都是一種緊迫的需要,照現在的樣子為全區域人口提供他們有權享用的保健服務。

策略 4.1: 把性健康事務整合于現有的公共衛生保健計畫

性健康是一個關鍵的公共衛生保健問題。雖然特殊行動方案曾經在特殊目標專案中實施(正如在上節所概述的那樣),尚必需把性健康整合于現存的公共衛生保健計畫。鑒於此,本專家工作小組推薦以下策略方案:

把性衛生保健方法整合于衛生保健計畫。衛生保健 [例如:心血管保健促進專案、反吸煙專案(獲益於戒煙後的勃起能力)]與性衛生保健、癌症預防專案(乳房切除術中的早期乳腺癌探測、子宮頸癌常規篩檢)]和健康教育專案(把預防性的保健和性能力聯繫起來)有直接或間接的關係。

當客戶前來接受公共衛生保健服務時,把性健康問題納入常規衛生保健評估範疇。這可以通過(輿論)評論來加以改進,並且在必要時,修改現存的公共衛生保健協議條款,以確保人們足以專注于性健康憂慮。例如:全科醫師(general practitioner)、家庭醫生和公立衛生保健診所醫生應該把性健康常規篩查/性健康既往病史合併到常規衛生保健評估。

策略 4.2: 為全區域人口提供他們有權享用的全面的性衛生保健服務

有權享用全面的衛生保健是人的基本需要。同時,本專家工作小組完全認可性衛生保健預防方法的實用性和成本效率,我們也認為社會持續存在著大量的遭受性健康憂慮和性健康問題煎熬的不幸的人們,這向社會提出了保健服務的急迫需求。提供保健服務將會確保有效治療。

性健康憂慮和許多性健康問題能夠和應該由初級衛生保健系統予以處理和解決。遺憾的是,缺乏對初級衛生保健提供者的培訓可能是實現這一目標的障礙。

要解決某些性健康問題,則需要特殊的訓練有素的人員來介入。所以,必須建立治療性健康問題的特殊診所,以專門處理一系列嚴重的性健康問題。

策略 4.3: 為精神和生理殘障者提供他們有權享用的全面的性衛生保健服務

只要有可能,性衛生保健服務都應該整合于現有的為精神和生理殘障者的服務體系中去。

策略 4.4: 為特殊群體(例如:囚犯、非法移民、受收容者和無家可歸者)提供他們有權享用的全面的性衛生保健服務

只要有可能,性衛生保健服務都應該整合于現有的為特殊群體(例如:囚犯、非法移民、被收容者和無家可歸者)的服務體系中去。

策略 4.5: 為其他群體(例如:合法移民、少數民族語言群體和難民)提供他們有權享用的全面的性衛生保健服務

只要有可能,性衛生保健服務都應該整合于現有的為其他群體(例如:合法移民、少數民族語言群體和難民)的服務體系中去。

目標 5: 促進與贊助性*和性健康領域的研究和評估,傳播由性與性健康所衍生的知識

為了增強對*、性*、性健康和性行為的理解,需要開展性研究;為了評估性衛生保健預防策略、衛生保健計畫、性教育課程和性治療的功效,也需要開展性研究。

策略 5.1: 促進性*研究和性評估。

為了提升個體與群體的性健康水準,緊迫的問題是既需要性研究也需要性評估。所謂性研究在此被定義為:為了獲得新知識,對包括假設檢驗在內的性的整個領域的系統研究。所謂性評估在此被定義為:為了決策和詳盡地評價性健康計畫的效力目的,所進行的資料收集和分析。

策略 5.2: 促進性科學成為一門理論學科。

與其他健康研究領域比較,性科學在資金、關注度和研究成果的品質方面是被忽略的。這些被忽略的方面並不是孤立的。研究人類的性及人類所從事的最高品質的性行為絕對是緊迫的任務。欲達此目標,作為一個科學領域,性科學需要研究者在每一個研究層面發展知識技能和具備研究潛能。

策略 5.3: 促進性科學的跨學科 (例如:護理學、社會學、人類學、心理學和流行病學等等)研究。

對性和性健康的研究並不限於性科學專業內訓練有素的研究者。促進其他相關學科的研究會有益於擴建知識基礎,並且通常有可能對涉及性和性健康的複雜事物會有新的視野。促進此類研究能夠對達到和維持性健康做出新的貢獻。

策略 5.4: 確保在性科學的研究成果充分地傳播給政策制定者、教育家、健康保健服務提供者,以給他們的工作提供研究基礎。

光有研究尚且不夠。為了確保從事于性健康的各類人員受益于通過可靠的研究所建立起來的這個知識基礎,傳播研究成果則是至關緊要的策略。尤其需要在拉丁美洲大多數地區傳播研究成果,需要在那裏營造和促進研究成果傳播的文化氛圍。

 

Actions and Strategies to promote Sexual Health

  • Goal 1.: Promote Sexual Health including the elimination of barriers to Sexual Health
  • Goal 2.: Provide comprehensive sexuality education to the population at large
  • Goal 3.: Provide education, training and support to professionals working in Sexual Health related fields
  • Goal 4.: Develop and provide access to comprehensive Sexual Health care services to the population
  • Goal 5.: Promote and sponsor research and evaluation in sexuality and Sexual Health, and the dissemination of the knowledge derived from it

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 inalienable 41.

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.

The following specific actions for this strategy were identified:

Develop specific national Sexual Health strategies and plans.

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

Integrate a Sexual Health approach into existing health programs.

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

Promote consensus in the definition and classification of sexual problems.

Develop best practice guidelines for sexual problems 46.

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.

Some of the components of this strategy include:

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.

Introducing legislation to promote sexually responsible behavior.

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.

Some of the components and specific actions of this strategy include:

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

Decrease homophobia both among individuals of all sexual orientations.

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:

Recognition of sexual violence in its various forms.

Introduction of effective legislation to reduce sexual violence.

Promotion of a culture of reporting sexual violence.

Promotion of health seeking behavior for victims of sexual violence.

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 education59, 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.

More specifically, there is a need to:

Establish training standards for sexual educators, sexuality specialists.

Advocate to governments for sexuality training programs for professionals.

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.

 

釋  NOTES


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.