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Sexual health document series

Defining sexual health Report of a technical consultation on sexual health 28–31 January 2002, Geneva

Defining sexual health Report of a technical consultation on sexual health 28–31 January 2002, Geneva

Geneva, 2006

Defining sexual health: report of a technical consultation on sexual health, 28–31 January 2002, Geneva © World Health Organization 2006 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected] int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication contains the collective views of an international group of experts and does not necessarily represent the decisions or the stated policy of the World Health Organization. Printed in Photo credits: Anita Kolmodin

Contents Acknowledgements

IV

Chapter 1: Introduction

1

Chapter 2: Purpose, objectives and overview of the consultation

2

Chapter 3: Working definitions

4

Chapter 4: Building sexually healthy societies: the public health challenge

6

4.1 Healthy sexual development – a gender issue

6

4.1.1 Discussion 4.2 The public health challenge

8 8

Chapter 5: Vulnerability and risk: influencing factors

10

5.1 Models for addressing vulnerability and risk

10

5.1.1 Discussion 5.2 Regional perspectives on sociocultural factors

11 12

5.2.1 Latin America

12

5.2.2 Sub-Saharan Africa

13

5.2.3 Eastern Mediterranean region

13

5.2.4 Asia

14

5.2.5 Discussion

14

Chapter 6: Meeting people’s needs

15

6.1 Integrating sexual health into existing services

15

6.1.1 Discussion 6.2 Sexuality information: how can the health sector make a difference? 6.2.1 Discussion 6.3 Country case studies on sexuality education 6.3.1 Discussion 6.4 Government response: creating an enabling legal and policy environment 6.4.1 Discussion

16 16 17 18 18 19 19

Chapter 7: Conclusion

21

References

22

Annex 1: Meeting agenda

23

Annex 2: Participants’ list

26

Acknowledgements A Technical Consultation on Sexual Health was convened in Geneva, Switzerland, from 28 to 31 January 2002, as a joint effort between the World Health Organization (WHO) and the World Association of Sexology (WAS). It was organized with the support and tireless efforts of Esther Corona and Eli Coleman (WAS) and Rafael Mazin (Pan American Health Organization). Financial support was received from the Ford Foundation. The success of the Consultation would not have been possible without the efforts of all those who participated in the regional round tables, in the preparation of the background papers, and in the Consultation itself. IV

Chapter 1 ■ Sexual health document series

Introduction Sexual and reproductive health and well-being are

that “enhance[s] personality, communication and love”.

essential if people are to have responsible, safe, and

It went further by stating that “fundamental to this con-

satisfying sexual lives. Sexual health requires a positive

cept are the right to sexual information and the right to

approach to human sexuality and an understanding of

pleasure”.

the complex factors that shape human sexual behaviour. These factors affect whether the expression of sexuality

In response to the changing environment, WHO, in col-

leads to sexual health and well-being or to sexual behav-

laboration with the World Association for Sexology (WAS),

iours that put people at risk or make them vulnerable to

began a collaborative process1 to reflect on the state

sexual and reproductive ill-health. Health programme

of sexual health globally and define the areas where

managers, policy-makers and care providers need to

WHO and its partners could provide guidance to national

understand and promote the potentially positive role

health managers, policy-makers and care providers on

sexuality can play in people’s lives and to build health

how better to address sexual health. As in 1975, the

services that can promote sexually healthy societies.

process began with a review of key terminology and of the evidence, and culminated in the convening of a large

The past three decades have seen dramatic changes in

group of experts from around the world to discuss the

understanding of human sexuality and sexual behaviour.

state of sexual health globally.

The pandemic of human immunodeficiency virus (HIV) has played a major role in this, but it is not the only factor. The toll taken on people’s health by other sexually transmitted infections (STIs), unwanted pregnancies, unsafe abortion, infertility, gender-based violence, sexual dysfunction, and discrimination on the basis of sexual orientation has been amply documented and highlighted in national and international studies. In line with the recognition of the extent of these problems, there have been huge advances in knowledge about sexual function and sexual behaviour, and their relationship to other aspects of health, such as mental health and general health, well-being and maturation. These advances, together with the development of new contraceptive technologies, medications for sexual dysfunction, and more holistic approaches to the provision of family planning and other reproductive health care services, have required health providers, managers and researchers to redefine their approaches to human sexuality. Sexual health was defined as part of reproductive health in the Programme of Action of the International Conference on Population and Development (ICPD) in 1994. Statements about sexual health were drawn from a WHO Technical Report of 1975 (1), which included the concept of sexual health as something “enriching” and

1 The current work on the promotion of sexual health globally was initiated in response to a call by the Pan American Health Organization (PAHO), the WHO Regional Office for Europe, and the World Association for Sexology to update the 1975 report. PAHO, in collaboration with WAS, had initiated the revision process by publishing a report entitled Promoting sexual health (2). To obtain a better understanding of how sexuality and sexual health are viewed in different parts of the world, WHO commissioned 14 national and regional background papers, held four regional meetings or round table discussions and one international preparatory meeting, and established an interdepartmental working group within WHO headquarters as part of a collaborative consensus-building process.

1

Chapter 2 ■ Sexual health document series

Purpose, objectives and overview of the consultation

2

On 28–31 January 2002, a Technical Consultation on

The presentations and discussions were grouped in broad

Sexual Health was convened by the WHO Department of

categories (see Annex 1). On the first day, the presenta-

Reproductive Health and Research, in collaboration with

tions stressed the importance of addressing sexuality and

the Department of Child and Adolescent Health and the

sexual health holistically, and laid out the consequences

prevention team of the Department of HIV/AIDS.

for individuals, families, communities and societies of not addressing sexual health. National and regional

The Consultation was the first activity in an expanding

perspectives on barriers and opportunities for improving

area of work for WHO. Its purpose was to reaffirm sexual

sexual health in different social, cultural and religious set-

health as an important and integral aspect of human

tings identified many of the particular challenges faced

development and maturation throughout the life cycle and

by those working on sexuality in specific contexts. The

to contribute to the development of a long-term strategy

presentations indicated that, despite vast geographical

and research agenda on sexual health for the Organiza-

and cultural differences, the obstacles that health profes-

tion.

sionals need to overcome are similar in all regions; they

The specific objectives of the meeting were to: ■ discuss key concepts including definitions of sexual health and related issues; ■ examine the specific barriers to the promotion of sexual health for adolescents and adults; and ■ propose appropriate, effective strategies for promoting sexual health. The meeting brought together over 60 international and national experts on sexuality and sexual-health-related issues. Participants were from all regions of the world and included: representatives of governments and nongovernmental organizations (NGOs); social scientists; health providers, programme managers and policy-makers working on STI/HIV prevention, reproductive health and family planning; clinical psychologists, psychiatrists and sexologists; sexual health educators; representatives from WHO regional offices; and donors. A paper giving an overview of sexual health as a public health issue was prepared by WAS, and two working papers dealing with, respectively, definitions and health sector strategies for addressing sexual health and development were prepared by WHO. These documents, together with a number of commissioned background papers, informed the discussion and served as a basis for this report.

include the difficulty of talking about sexuality because of its private nature, and the gender aspects of sexual roles, responsibilities and relationships, including the power dynamics associated with them. A working group was formed to draft operational definitions of sex, sexuality, sexual health and sexual rights, and was asked to report back to the Consultation on the final day. On the second day, the presentations and discussion focused on how the health sector has addressed vulnerability and risk related to sexuality and sexual health. The first presentation shared lessons learned from efforts to prevent HIV infection and acquired immunodeficiency syndrome (AIDS) over the past two decades. It was noted that HIV prevention and sexual health activities have extended, and must continue to extend, beyond the health sector to include individuals, families and communities, as well as environmental factors that contribute to vulnerability and risk. The second presentation traced the history of integration of services noting that it took more than thirty years for family planning programmes to begin to address sexuality as part of reproductive health care services. The ICPD Programme of Action called for the integration of services as fundamental to achieving reproductive health. Participants noted the different approaches, emphases and

Purpose, objectives and overview of the consultation

successes of HIV prevention programmes and reproductive health programmes, and the importance of gathering better evidence on the success of various methodologies aimed at changing behaviour. Case studies of best practices from Sweden, South Africa and Thailand were presented. In Sweden, sexual health education has transformed the way people think about sex, sexuality, and reproductive and sexual health, but the road to achieving these successes has been long and sometimes difficult, and the political barriers posed along the way significant. In Thailand, where recent HIV prevention efforts have resulted in lower transmission rates, an early success was achieved by focusing the intervention strategy on commercial sex establishments and their clients. In South Africa, a current sexual rights advocacy campaign is focused on getting decision-makers and politicians to integrate a more comprehensive perspective of sexual health and rights into their work. This involves working with nongovernmental and community-based organizations to address HIV/AIDS, violence against women, and adolescent sexual health in an integrated manner based on a new vision of femininity and masculinity in which the sexual rights of all people are respected. This report presents a summary of the presentations and discussions held over the course of the four-day meeting. It summarizes the critical issues raised, as well as the differences of opinion, approach and direction of actors in different regions in addressing common problems. While one stated objective of the meeting was to define appropriate sexual health strategies, the group concluded that such general recommendations would not be useful, given the very specific national and regional perspectives on how sexuality and thus sexual health can be addressed and promoted by the health sector. The group agreed, however, that despite the differences, all programmes and services aimed at addressing sexuality and promoting sexual health can and must be based on fundamental values and principles grounded in human rights. These guiding principles for work on sexuality and sexual health are described in chapter 6. The meeting concluded with a series of recommendations to WHO on how to take this important area of work forward in the coming years.

3

Chapter 3 ■ Sexual health document series

Working definitions

4

In 1975, a WHO expert group described sexual health as

While sexual rights were not specifically defined either by

“the integration of the somatic, emotional, intellectual and

ICPD or by the Fourth World Conference on Women in Bei-

social aspects of sexual being in ways that are positively

jing in 1995, or at their five-year follow-up conferences,

enriching and that enhance personality, communication

ICPD did elaborate on reproductive rights. Reproductive

and love” (1). The report incorporating this forward-look-

rights were defined as embracing “certain human rights

ing description of sexual health laid the groundwork for a

that are already recognized in national laws, interna-

comprehensive understanding of human sexuality and its

tional human rights documents and other consensus

relationship to health outcomes. However, many terms,

documents. These rights rest on the recognition of the

such as sex, sexuality and sexual rights, were left unde-

basic right of all couples and individuals to decide freely

fined, and there has been no subsequent international

and responsibly the number, spacing and timing of their

agreement on definitions for these terms (3). In English,

children and to have the information and means to do

the term “sex” is often used to mean “sexual activity” and

so, and the right to attain the highest standard of sexual

can cover a range of behaviours. Other languages and

and reproductive health. This includes the right to make

cultures use different terms, with slightly different mean-

decisions concerning reproduction free of discrimina-

ings.

tion, coercion and violence, as expressed in human rights documents.” Since human reproduction generally requires

The ICPD Programme of Action (4) included sexual health

sexual activity, sexual rights are closely linked to repro-

as part of reproductive health. Reproductive health was

ductive rights.

defined as: Respect for bodily integrity was recognized as a funda“a state of complete physical, mental and social well-

mental element of human dignity and freedom as early

being and not merely the absence of disease or infirmity,

as 1975 at the World Conference of the International

in all matters relating to the reproductive system and to

Women’s Year in Mexico City. It was further defined and

its functions and processes. Reproductive health there-

elaborated in the Beijing Platform for Action (5): “The

fore implies that people are able to have a satisfying and

human rights of women include their right to have con-

safe sex life and that they have the capacity to reproduce

trol over and decide freely and responsibly on matters

and the freedom to decide if, when and how often to

related to their sexuality, including sexual and reproduc-

do so. Implicit in this last condition are the right of men

tive health, free of coercion, discrimination and violence.

and women to be informed and to have access to safe,

Equal relationships between men and women in matters

effective, affordable and acceptable methods of family

of sexual relations and reproduction, including full respect

planning of their choice, as well as other methods of their

for the integrity of the person, require mutual respect,

choice for regulation of fertility which are not against the

consent and shared responsibility for sexual behaviour

law, and the right of access to appropriate health-care

and its consequences.”

services that will enable women to go safely through pregnancy and childbirth and provide couples with the

Building on these definitions, and bearing in mind the

best chance of having a healthy infant.”

public health challenges of sexual health, the Consultation proposed the following definitions as a guide for

Reproductive health care was defined as including care

health programme managers, policy-makers and others

for “sexual health, the purpose of which is the enhance-

working in the field of human sexuality and sexual and

ment of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases”.

Working definitions

reproductive health. The definitions were informed by

and amended following the Consultation by a small inter-

the background papers, regional discussions and round

national working group.

tables that preceded the Consultation, and were refined

Box 1: Working definitions2

■ Sex Sex refers to the biological characteristics that define humans as female or male. While these sets of biological characteristics are not mutually exclusive, as there are individuals who possess both, they tend to differentiate humans as males and females. In general use in many languages, the term sex is often used to mean “sexual activity”, but for technical purposes in the context of sexuality and sexual health discussions, the above definition is preferred.

■ Sexuality Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors.

■ Sexual health Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.

■ Sexual rights Sexual rights embrace human rights that are already recognized in national laws, international human rights documents and other consensus statements. They include the right of all persons, free of coercion, discrimination and violence, to: • the highest attainable standard of sexual health, including access to sexual and reproductive health care services; • seek, receive and impart information related to sexuality; • sexuality education; • respect for bodily integrity; • choose their partner; • decide to be sexually active or not; • consensual sexual relations; • consensual marriage; • decide whether or not, and when, to have children; and • pursue a satisfying, safe and pleasurable sexual life. The responsible exercise of human rights requires that all persons respect the rights of others.

2

These working definitions were developed through a consultative process with international experts beginning with he Technical Consultation on Sexual Health in January, 2002. They reflect an evolving understanding of the concepts and build on international consensus documents such as the ICPD Programme of Action and the Beijing Platform for Action. These working definitions are offered as a contribution to advancing understanding in the field of sexual health. They do not represent an official position of WHO.

5

Chapter 4 ■ Sexual health document series

Building sexually healthy societies: the public health challenge

6

The proposed definition of sexual health states that it “is

When considering adolescent sexual development,

a state of physical, emotional, mental and social well-

we must recognize the diversity of this population

being in relation to sexuality; it is not merely the absence

and the different ways sexual development will be

of disease, dysfunction or infirmity.” This definition calls

experienced and interpreted. The diversity includes

attention to the inter-related nature of the physical, men-

sex, marital status, class and socioeconomic status,

tal and social dimensions of sexuality, and importantly,

place of residence, age, ethnicity, sexual orientation,

the notion of sexual well-being. Sexuality is a funda-

level and manner of sexual experience (voluntary or

mental part of being human. “Sexual health” requires “a

involuntary), motivations for sexual activity (affection,

positive and respectful approach to sexuality and sexual

status, and needs) and health status.

relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion,

Discussing sexual health raises the question of what it

discrimination and violence.” Unfortunately, rather than

means to be sexual. Who is, or has a right to be, sex-

enriching personal relationships and intimacy, sexuality is

ual, under what conditions, circumstances and con-

too often a cause of distress.

text, and for what purpose or motivation? What does being sexual mean in the context of power differen-

The two opening presentations focused on the public

tials, particularly for young women, and how do power

health imperative to build sexually healthy societies. The

differentials manifest themselves as we develop as

first discussed healthy sexual development, with a focus

sexual beings? Sexual identity and gender identity are

on adolescence. The second discussed the scope and

intrinsically embedded in notions of power: who has

prevalence of sexual-health-related problems and the

power, for what purpose, and how they are allowed or

public health imperative to address sexual health in all its

entitled to use that power?

dimensions. The presentations are summarized below. To be sexual is far more than a matter of physiology and sexual activity. Being sexual is very much about

4.1 Healthy sexual development – a gender issue (Smita Pamar)

who we are, what we feel, what we value, what we think, and what we desire. It is to understand and experience what it means to be a man or woman, and

What is healthy sexual development? This is a question

what happens if one does not fit into the generally

that is answered within the context of the individual,

accepted idea [or social stereotype] of what those

family, community, society, and culture over time. What

categories imply. Understanding what it means to be

is considered “healthy” varies not only from generation

sexual involves how women and men, girls and boys

to generation, from society to society, and between men

interpret sexuality, what is considered sexual, and the

and women, but also within any one individual: what may

meaning and value ascribed to it. Sexuality includes

have been considered “healthy” at age 15 may not be at

different dimensions of relationships, whether they

45. The notion of health, just like sexuality, is not static

are sexual or not, the degree of control and agency

and judgement-free. Sexual development occurs over a

over sexuality, whether sexual activities involve vio-

lifetime, but adult health status is closely linked to expe-

lence and coercion, but also a sense of self-worth

riences during adolescence, the pivotal period of transi-

and self-esteem, pleasure and desire. Being sexual is

tion to adulthood. Adolescence sets the stage for sexual

also linked to the social, economic, and educational

health in later life.

opportunities available to males and females, how

Building sexually healthy societies: the public health challenge

that availability influences decisions to be sexually active

through school, community, media, religious institutions

or not, and how information about sexuality and sexual

and health services.

health is interpreted. Social assumptions about gender identity and sexuality Sexual development is often typified as something

often carry the assumption, either implicitly or explicitly

problematic to be contained and controlled, especially

(depending on culture), that women should not want

for girls. This characterization often has more to do with

sexual activity or find it pleasurable, or have sexual

the anxieties, fears, and beliefs of adults than the real-

relations outside of marriage. Sexual activity should be

ity experienced by adolescents. Adolescence is a time

for procreative purposes and motherhood is a marker

of rapid development, discovery, experimentation, and

of social status. On the other hand, men and boys are

exploration about all aspects of life. It is a time of initia-

often socialized to feel entitled to have sexual relations

tion and experimentation (voluntary and involuntary)

and pleasure and that their self-worth is demonstrated

in sexual activity. Yet socially it is often not acceptable

through their sexual prowess and notions of authority

for adolescents to be sexually active. As a result, young

and power. Gender roles often dictate who is supposed

people, especially girls, have to hide their sexuality and

to be passive or aggressive in sexual relationships and

sexual activity and submit to restrictions and control.

what the proper motivations are for seeking sexual activ-

Due to social, cultural and religious restrictions of young

ity: girls often report a need for intimacy, love, and affec-

women, they may have less access to health care ser-

tion; boys often report curiosity, pleasure, and status

vices, and information.

among their peers.

In considerations of healthy adolescent sexual develop-

(iii) Social, cultural, and economic factors also affect

ment three issues emerge: (i) cognitive development and

sexual decision-making by boys and girls, as individuals

the context of decision-making; (ii) gender identity; and

and within society. Young people are often unprepared

(iii) the socioeconomic context of physical development.

for, and lack information about, the physical changes

(i) Cognitive development — acquisition of the ability to

cence. Community values and fears about sexuality in

think and reason abstractly, weigh consequences and

young people tend to limit the availability of the basic

make decisions — occurs during adolescence and is

information and education they need to understand and

influenced by the social (particularly gender-related),

appreciate their changing bodies, leaving the transfer

political, economic, and cultural contexts in which deci-

of knowledge about sex and sexuality to parents, fami-

sions are made. What does it mean to make a decision

lies and professionals. Unfortunately, parents, health

related to one’s sexuality when public knowledge of

workers, and teachers themselves also often lack such

sexual activity is a serious social liability with potential

information, or do not feel comfortable communicating

long-term social sanctions and stigma?

about sexuality. As a result, young people tend to enter

they undergo during puberty and throughout adoles-

(ii) Gender identity development defines for most people what it means to become a man or a woman. It is a process of interpreting and accepting (or not accepting)

into sexual relations without the necessary knowledge or skills to negotiate for their own sexual health and welfare.

what family, community, culture and society, say about

All cultures assign meaning to the onset of puberty. The

the appropriate roles, responsibilities and behaviours of

social meaning of puberty is different for boys and girls.

men and women. Although gender identity is constructed

In many cultures, the onset of puberty for a boy may

over time, in adolescence gender roles (and their dis-

lead to greater freedom, mobility, and opportunities. For

parities, stereotypes, and inequities) are often solidified

girls, in many places, it may mean an end to schooling,

and intensified through observation of adults and peers.

restricted social or physical mobility, and the beginning

This is reinforced in messages received by young people

of married life and childbearing. Traditional practices,

7

Chapter 4



Sexual health document series

rites, ceremonies and celebrations often accompany this

planning research, which still characterizes men as the

transition from childhood to adulthood, some of which,

core group of HIV-infected people. Reproductive health

such as female genital mutilation/cutting, may have last-

activists acknowledged the prevalence of this gender

ing effects on sexual health and well-being.

bias against men, but felt strongly that there continue to be unaddressed gender issues in HIV prevention pro-

Factors such as poverty and educational opportunity also

grammes, and that, in most cases, women are victims,

have a direct impact on an individual’s ability to develop

whether as a result of lack of power to avoid HIV infec-

sexually in a healthy way during adolescence. Economic

tion in relationships or as targets of sexual violence.

necessity often leads young people to leave school to work. Girls are often married early to transfer their eco8

nomic burden to the husband’s family and to fulfil the family’s duty to protect the daughter until marriage when she becomes the responsibility of her husband’s family. Women and girls (and sometimes boys) may use sex to secure financial or other support for themselves and their children or extended family. The meanings and motivation of each sexual act are therefore affected by numerous

4.2 The public health challenge (Eli Coleman) Sexuality is an integral part of human life. From infancy, we are conditioned for what our sexual life will be. Touch, attachment and bonding, together with good guidance, love and caring early in life, prepare children for healthy sexual development and maturation. Natural

potential influences.

sexual curiosity, experimentation and learning before and

Adolescent sexual development does not happen in a

occur in all cultures. Adolescence is a time for learning

vacuum. It is intrinsically linked to economic and social

to love oneself and others and to be responsible in one’s

justice, human rights, and gender equity. Understand-

relationships. During this period, young people develop

ing and promoting healthy sexual development require

intimate bonds and learn to enjoy the pleasures of sexual

understanding and promotion of social justice, in which all

activity. They also learn about the health risks associated

people have a right to their sexuality and to live with dig-

with sexual practices and behaviours, and their vulner-

nity, respect, and self-determination.

ability to these risks – often at first hand. This period

during adolescence are both normal and healthy, and

sets the stage for mature adult sexual relationships. 4.1.1 Discussion The inter-related themes of gender and masculinity dominated the discussion. Some participants expressed a growing concern about the way men and masculinity are overlooked in discussions on gender. In the reproductive health literature, women are often portrayed as victims, men as perpetrators. Some participants emphasized the need to reconceptualize gender to include men, particu-

During the reproductive years, norms of behaviour, sexual activity and practices are solidified. Adults transfer their knowledge, beliefs and assumptions about sexuality and sexual life to their children and with this, patterns of sexual health or ill-health are established. For older people, sexual activity can be pleasurable and fulfilling, but with age come also increased risks of ill-health and its adverse effects on sexuality.

larly since reproduction and sexual violence also involve

Risk of sexual ill-health begins with the onset of unsafe

men, both positively and negatively. Gender issues are not

sexual activity, usually in the adolescent years, and con-

the same across and within regions. There is a need to

tinues as long as the unsafe activity or harmful sexual

start bridging gaps between research and programmes,

practices are engaged in. In all countries, many individu-

in order to better understand what motivates men and

als suffer from the consequences of some form of sexual

women in different countries and regions as well as the

ill-health. The HIV pandemic has shown us that commu-

power differentials between them.

nities, countries and regions are in a sexual health crisis

Participants working in HIV prevention expressed concern about the wide divide between gender research and family

of incredible proportion.

Building sexually healthy societies: the public health challenge

Sexuality-related illnesses range from sexual dysfunc-

and anxieties. Sexual dysfunctions [such as low sexual

tion to sexually transmitted infections. The global AIDS

desire, erectile dysfunction, inability to achieve orgasm,

pandemic has now affected the lives of some 40 million

premature ejaculation, pain during sexual activity (dys-

people. WHO and the Joint United Nations Programme

pareunia) and vaginismus] are relatively common but

on HIV/AIDS (UNAIDS) reported that, in 2001, 5 million

seldom diagnosed or treated. Few figures are available

people were newly infected with HIV, 800 000 of them

for developing countries. However, in the USA, individual

children. This is equivalent to approximately 14 000 new

disorders appear to affect between 8% and 33% of the

HIV infections per day, more than 95% of which were in

adult population (13). Sexual dysfunctions are often

developing countries (6). Recent estimates of the number

associated with other physical and mental disorders,

of curable sexually transmitted infections in adults total

such as diabetes, cardiovascular problems, blood pres-

340 million cases worldwide, with the most dramatic

sure abnormalities, depression and anxiety (14, 15).

rates occurring in south and south-east Asia, sub-Saharan Africa, Latin America and eastern Europe. The preva-

Sexual violence is common and occurs throughout the

lence of syphilis in the Russian Federation, for example,

world. Available data suggest that in some countries one

has increased from almost no reported cases in 1990 to

in five women experiences sexual violence at the hands

260 per 100 000 population in 1996 (7). In developing

of an intimate partner and up to one-third of girls report

countries, STIs and their complications are among the

forced sexual initiation (16). There are many forms of

top five diseases for which adults seek care. The wide-

sexual violence: forced intercourse/rape, sexual coercion,

spread prevalence of STIs and reproductive tract infec-

trafficking, forced prostitution, and sexual harassment. It

tion (RTIs) generally is also a major cause of infertility.

takes place in all settings, but particularly in the home. It has a profound impact on the physical and mental health

The reproductive health consequences of unsafe sexual

of those who experience it, often lasting well beyond the

activity are not limited to STIs. Unintended pregnancy,

assault. It is associated with an increased risk of sexual

early childbirth and unsafe abortion all contribute to

and reproductive health problems, including unwanted

morbidity and mortality. Each year, 15 million women

pregnancy, STI and HIV infection, and mental health

under the age of 20 give birth, accounting for one out of

problems such as depression, anxiety and post-trau-

every five births worldwide (8). Girls aged 15–19 years

matic stress disorder. Sexual abuse of children is associ-

are twice as likely to die in childbirth as women in their

ated with low self-esteem, high-risk sexual behaviours

twenties, and their babies are also at higher risk. In addi-

and drug abuse in later life (17).

tion, young mothers are at increased risk of pregnancyrelated complications linked to cephalopelvic dispropor-

The sexual health of individuals, families and communi-

tion (9, 10). In developing countries, maternal death con-

ties is indeed in crisis. Collective action is needed to

tinues to be one of the most tragic consequences of poor

help individuals and couples to live happy and healthy

sexual and reproductive health and well-being (11). Unin-

sexual lives. In a recent address, the Surgeon-General

tended pregnancy often leads to unsafe abortion, which

of the USA noted that “while sexuality may be difficult

in turn may lead to other health consequences, such as

to discuss for some, and there are certainly many dif-

RTIs, infertility, chronic pelvic pain, pelvic inflammatory

ferent views and beliefs about it, we cannot afford the

disease and death. Of the nearly 20 million women who

consequences of selective silence” (18). Countries must

have an unsafe abortion each year, 5 million are adoles-

begin to adopt national strategies, raise awareness, and

cents. Many adolescents resort to abortion in unsafe or

carry out interventions (prevention and care), evaluation

unhygienic conditions out of fear, shame or guilt about

and research to address the public health crisis related

their socially unacceptable sexual activity (12).

to sexual health. Some countries, such as Australia, the United Kingdom, and the USA, have already done so.

Sexual health problems also include sexual dysfunction, gender identity disorders and a variety of other concerns

Many more need to follow.

9

Chapter 5 ■ Sexual health document series

Vulnerability and risk: influencing factors

10

The sexuality of individuals and couples is largely deter-

a woman who regularly exchanges sex for food for her

mined by family and community values and social mores.

children may see herself as simply “getting by” or as a

It is also influenced by sex, marital status, religion, cul-

“responsible mother”. The researcher, on the other hand,

ture, education, and economic factors. People’s ability to

may describe this woman as a commercial sex worker.

make decisions about their sexual life is influenced by all

Such issues lie at the core of our understanding of sexual

of these factors, often simultaneously. Less recognized,

activity and sexuality and have profound implications for

but equally significant to decision-making, are the mean-

programmes.

ings, motivations and desires that people associate with sexual activity, behaviours and practice.

Early responses to sexuality within the context of HIV/AIDS were also limited by a reticence to address the politi-

During the Consultation a number of presentations

cal aspects. The focus was on sexual behaviour rather

focused on understanding and addressing social and cul-

than the context in which behaviour occurred. This was

tural determinants of sexual behaviour and decision-mak-

evidenced by the focus on sex outside a “regular union”,

ing from various disciplines and regional perspectives.

regardless of whether it was desired or even the norm within a particular culture or setting. Politicians and health

5.1 Models for addressing vulnerability and risk (Peter Aggleton3 ) In reflecting on what has been learned from the field of HIV prevention and sexual health over the past two decades, three issues emerge: the underdeveloped appreciation of sexuality and “the sexual”, reluctance to engage

practitioners alike were quick to collude with the pretence that, all over the world, populations divided neatly into the majority – those who were chaste before marriage and faithful within it – and the minority, who were deviant or promiscuous. This essentially political response led to slow reactions and questioning of contemporary assumptions about sexuality and sexual behaviour.

with the overtly political, and concern with risk rather than

Another feature of the early response to HIV/AIDS was the

with vulnerability.

concern with individual risk. There was an assumption

In the early days of the epidemic, the focus of control activities was on the identification of relevant knowledge, attitudes and reported practices, on partner relations and on the frequency of different forms of sexual intercourse,

that individuals were largely rational decision-makers when it came to sexual activity and health concerns and, with the necessary information, attitudes and skills, would make sensible decisions about their sexual behaviour.

which was largely assumed to be penetrative penile-vagi-

This led to a programme focus on information, education

nal intercourse. There was little or no discussion at that

and communication (IEC) campaigns, social marketing

time about other forms of sexual activity or the motiva-

and life-skills education.

tions or meanings of those activities except in the context of homosexual sexual activity. The focus was rather on

Individual choice, however, is not the only thing that

enumerating a limited range of “sexual risk behaviours”

determines risk. In a key study (19), Hart & Flowers found

in specific target populations, which allowed sexual

that individual risk was affected by interpersonal aspects

behaviour to be classified as risky or safe. At the time, it

of sexual behaviour, formal and informal social structures,

was not well understood or appreciated that, for example,

and organizational aspects of the person’s life. It was also affected by the social context. Programmes, therefore,

3 In the absence of Peter Aggleton, this presentation was read by

Gary Dowsett.

must address these different levels of influence in a systematic manner.

Vulnerability and risk: influencing factors

Recently, greater attention has been paid to the distinc-

Philippines and Thailand, syringe and needle exchange

tions between risk and vulnerability (20) and between

programmes in Latin America and Central and East-

risk reduction and vulnerability reduction. In the context

ern Europe, programmes working with diverse groups

of HIV/AIDS, risk is defined as the probability that a per-

of men who have sex with men in countries such as

son will acquire HIV infection. Certain behaviours create,

Bangladesh, India and Morocco, programmes working

enhance and perpetuate such risk. Early responses to the

to empower women educationally and economically in

epidemic focused on reduction of risk-taking behaviours

Côte d’Ivoire and Kenya – all of these might have been

by targeting individuals and groups with specific inter-

considered impossible or unnecessary only two decades

ventions. Individual risk however is also influenced by

ago. The challenge is to bring similar successes and

social and environmental factors. There is now a growing

scale to other activities of sexual health programmes.

recognition of how social inequalities influence risk. Vulnerability is influenced by at least three sets of interacting factors: (i) personal factors; (ii) factors related to the quality and coverage of services and programmes; and (iii) societal factors. In combination, these factors can increase or reduce an individual’s vulnerability to sexual and reproductive ill-health. Personal factors include, for example, knowledge and the capacity to use that knowledge to protect oneself and others from infection. Programme factors include the cultural appropriateness of programmes, accessibility of services, and the capacity of the system to respond to growing needs. Societal factors, such as gender and power imbalances, economic status and social exclusion as a result of, for example, sexual identity, also directly affect an individual’s vulnerability. Programmes that aim to reduce vulnerability are necessary but extremely complex because of the interaction between factors such as gender and poverty, and may be able to reduce only some aspects of vulnerability in some contexts, while enhancing vulnerability in others.

11 5.1.1 Discussion Asha Mohamud, commenting on this presentation, raised the notion of individual and environmental antecedents as protective or risk factors. She noted that factors such as education about protective behaviour, condom knowledge, support from peers, connection to a social network, and positive institutional support are protective. Risk factors include lack of information, skills and power, gender inequalities, poverty and unemployment, negative peer influences, substance abuse and lack of services. Religion can be either a protective or a risk factor, depending on the social and cultural context. Recent work in this area (21) has stressed that “when there are a multitude of antecedents each with a small impact on sexual behaviour as opposed to a few antecedents with a large impact, it is unlikely that a magic bullet will be found to substantially change adolescent behaviour”. In the African context, there are many antecedents that make adolescents vulnerable. In order to address

Programmes that recognize the need for both risk reduc-

their vulnerability, programmes must work to create an

tion and vulnerability reduction in a balanced way are

enabling environment by reducing the effects of those

neither new nor impossible to put into action. Countries

antecedents. This should be done by scaling up sexuality

such as Thailand, Uganda and Zambia have done so

education programmes and paying particular attention

with some success. Recent shifts in programme focus

within those programmes to gender and human rights.

from individual behaviour to the broader context and settings in which sexual practices become meaningful are important. Equally critical are the opportunities for health promotion that vulnerability reduction strategies provide, and the transformative potential they hold for communities and societies as a whole. Changes are taking place that would previously not have been thought possible. Programmes on making sex work safer in Cambodia, the

Participants discussed the need to clarify approaches and language. The model of Hart & Flowers was a response to other vulnerability and risk reduction approaches. This model addresses vulnerability and risk as relatively equal factors influencing behaviour, and thus to be tackled simultaneously. Concern was expressed that this approach took all factors on board without dis-

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Sexual health document series

tinction or prioritization for intervention. Because of cost and time constraints, the approach, though ideal, was not

5.2 Regional perspectives on sociocultural factors

being implemented as intended. The design and staging of adolescent sexual health education programmes, for

How sexual health is and can be addressed within dif-

example, often include plans for second and third steps

ferent countries and regions is largely culturally deter-

but, because of limited funds or commitment, do not

mined. Perspectives on sexual health issues, and on

move beyond the stage of providing information.

the barriers and opportunities for addressing them in different countries and regions, were solicited before and

12

Moving discussion of sexual activity from the personal

during the Consultation. The presentations demonstrated

sphere – where it has been for centuries – to the public

that, despite vast differences in context, tradition and

sphere has to be done with caution. How connections are

approaches, addressing sexuality in almost all regions

made between the individual and institutions is critical

(except perhaps in parts of western Europe), is bound by

to the success of any programme. Sexuality needs to be

gender constructs and religion and reinforced by politics.

demystified before it can be appropriately addressed at

Programmes that seek to reducing vulnerability and

the institutional level. Discussions will therefore need to

risks in sexual behaviour will therefore have to work with

cover sexual activity not related to reproduction, and the

people’s beliefs, values and traditions to support sexual-

problems of dealing with the reality of sexual behaviours

health-seeking behaviour and a more holistic view of

in various national and local contexts. Developing appro-

sexuality throughout the life course.

priate interventions that address the complex web of factors influencing sexual behaviour brings with it challenges. The resources and political will needed may vary. What may begin as a general sexual health education programme in schools, requiring ministerial support, may later require assistance from nongovernmental partners, such as churches, mosques or other traditional associations that have the cultural authority to address issues of sexuality at the family and community levels. By adding this level of complexity we run the risk of losing quality. The group emphasized that teachers charged with delivering basic health information often require significant training. When many different actors are involved in the delivery of messages, the risk of contradictory or incorrect messages may increase, thus exacerbating the very inequities the programme is trying to reduce.

5.2.1 Latin America (Esther Corona) Despite a predominantly common language and historical factors, Latin America is a heterogeneous region, economically and ethnically diverse both within and across countries. Throughout the region, however, common structural and social factors influence sexuality and sexual behaviour. Poverty, the Catholic Church and the media directly affect how sexual and reproductive health is addressed by individuals, families and communities, and at the local and national government levels. Current constructions of sexuality are affected by indigenous culture and traditions, Spanish and Portuguese colonialism, and African traditions brought with the slave trade. Intermarriage and time have inextricably linked

The identification of best practices, as has been done by

these traditions, forming sociocultural barriers to sexual

UNAIDS for HIV interventions, was also discussed. Best

health promotion related to gender issues, individual

practices, some noted, were often rather the best known

perceptions of the body and sexuality, levels of inter-

practices. In order to create complex programmes that

personal violence, and complex belief systems. These

are culturally appropriate, there remains a great need to

constraints are further exacerbated by poverty, illiteracy,

monitor and evaluate projects in developing countries for

rural residence and political strife. As a result, problems

locally successful approaches.

such as unintended pregnancy, sexually transmitted and reproductive tract infections in adolescents, sexual

Vulnerability and risk: influencing factors

violence and gender disparities persist in the region. Key

evident in young people, who appear to be at a distance

to addressing these issues is comprehensive sexuality

from the authorities on issues related to sexuality and

education in schools, as well as for adults and parents

sexual health. Rapid changes in the social environment,

through the media.

as a result of urbanization, migration, displacement and globalization, are affecting expectations and behaviour. Despite these changes, however, traditional discourse

5.2.2 Sub-Saharan Africa (Uwem Esiet) Sexual health in sub-Saharan Africa continues to be dominated by the HIV/AIDS pandemic. The increasingly young population (one in four people in sub-Saharan Africa is between 10 and 19 years of age) is disproportionally affected, accounting for six out of every ten infected persons on the continent. Heterosexual transmission of HIV is aided by the relatively early average age at first intercourse of just 14 years. Factors increasing young people’s vulnerability to infection include poverty, lack of power in sexual relationships, violence, traditional customs such as early marriage and harmful sexual practices, and gender disparities. One result is the transactional nature of sexual relationships, where women or girls exchange sex for money, food, school tuition, or housing. Despite these challenges, opportunities exist to promote sexual health. The high premium placed on children can serve to mobilize political and religious institutions to promote, support and maintain a sexually healthy lifestyle as an imperative for the future well-being of children. Promotion of positive community and family values, especially those that support adolescent health and development (such as participation in sports, music, and drama), can be a constructive way of fostering supportive family and religious values, including the promotion of love, compassion and understanding.

and understanding of sexuality, gender dynamics, and the family remain. In this context, social taboos and fear of stigmatization by family, school, community and/or government and religious authorities continue to limit individual sexual expression, particularly outside marriage. Within marriage, sexuality is considered normal and healthy by religious scriptures, and is promoted as a healthy part of married life. The tension appears when practices, as evidenced by health outcomes such as increased prevalence of sexually transmitted infections, infertility and unsafe abortion, point to “unacceptable” social and sexual behaviour. Individuals in the region have support systems that can serve as positive or negative forces for the promotion of sexual health. These include the family, the community, the legal and political system, and religion itself. How these factors influence the sexual behaviour of individuals and families in the future will depend on how leaders, and in particular those in the health sector, choose to address these critical issues. Participants noted the difficulty in the region in recognizing premarital or extramarital sexual activity and other forms of sexual expression, including men who have sexual relations with men, the denial of which has impeded progress in combating sexually transmitted infections including HIV. In addition, some in the region are beginning to discuss the role and impact of tradi-

5.2.3 Eastern Mediterranean region (Faysal El-Kak)

tional customs, such as segregation of sexes, on sexual practices and behaviour, though there is no significant

In the Eastern Mediterranean region, demographic

evidence yet collected on these topics. The first step

changes are resulting in increasingly young (over 50% in

towards improving sexual health in the region could be

some countries), urban and poor populations. The region

a realistic assessment and discussion of sexual health

is predominantly Arab and Muslim. Politics are aligned

problems and the factors that underlie them. Based on

with religion and, as a result, social and government

such an assessment, sexual health policies could be

institutions tend to reflect traditional religious values and

established that recognize the diversity of sexual prac-

laws. Despite the predominance of traditional religious

tices and behaviours in the region and positively promote

authority in all aspects of private life, there remains a

individual responsibility in sexual relationships for the

divide for some between ideals and practice. This is most

sexual health of the community as a whole.

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5.2.4 Asia (Terence Hull)

5.2.5 Discussion

Sexuality in the Asian region is “defined by differences

Participants felt that an understanding of sexuality is

but dominated by similarities”. Differences in gender

critical to improving sexual health. Finding out how ordi-

roles, socioeconomic status and sexual orientation

nary people define and understand sexuality and sexual

can be observed throughout the region. Despite these,

health, as well as the barriers they perceive to improving

however, in all countries sexual activity is dominated by

their sexual life, may offer an opportunity for providers

heterosexual penetrative intercourse and performance

to work on these issues. In all regions, the subordination

anxiety among both men and women is significant. Prob-

of women and traditional gender roles limit women’s

lems related to sexuality in the region include widespread

and girls’ ability to have safe, equitable and consensual

recourse to commercial sex workers, male dominance in

sexual relations. Traditional practices, many of which

marital sexual relations codified in some religious tradi-

reinforce gender and sexual inequities, are beginning to

tions, and violence motivated by sexual conflicts, includ-

be used to promote change. For instance, sexual health

ing violence against both men and women as a result of

education to promote health and rights is being offered

their sexuality, sexual preferences, or decisions related to

in unconventional arenas such as during initiation rites in

sexual behaviour. In addition, recent evidence has shown

Africa, through sexual health education groups for par-

that harmful sexual practices, such as dry sex using

ents in Asia, in churches and mosques in the Mediterra-

herbs, astringents and diet management, penis inserts

nean region, or through soap operas and other television

intended to increase pleasure or performance, and male

programmes in Europe and Latin America. The women’s

and female genital mutilation/cutting, are more wide-

movement, youth networks and other social movements

spread than had previously been thought. These sexual

are also bringing the issues to the public attention. Allies

behaviours, and the increasing use of anti-impotence

exist in all regions. Participants emphasized that this

drugs and vaginal tightening operations, reflect wide-

highly politically and socially contested area nevertheless

spread performance anxiety among men and women.

produces opportunities to raise and work on the issues.

Not surprisingly, these practices have resulted in a high

Some participants stressed that these opportunities can

prevalence of sexually transmitted and reproductive tract

exist in schools, communities and the formal health sys-

infections.

tem – and we must identify leaders in all of these arenas

Some regional efforts to combat STIs and HIV have proven successful. Organization and regulation of the sex industries in some Asian countries have slowed HIV transmission in certain populations. In addition, in certain circumstances, relatively open discussions about sexual activity and sexuality are possible, allowing researchers and programme managers to identify and target areas for intervention. The region also has the technical capacity in its universities and government research centres to design and monitor such activities. The question remaining is who will lead these efforts: as elsewhere, addressing sexual health requires government leadership, resources and political will.

to assist in our efforts.

Chapter 6 ■ Sexual health document series

Meeting people’s needs In order to address sexual health in existing service

These publications added to the chorus calling for greater

delivery points – whether family planning clinics, STI clin-

attention to sexuality as the most important determinant in

ics, antenatal care clinics or primary health care posts

family planning and sexual and reproductive health. They

– staff need to have knowledge about sexuality, skills to

attempted to demystify sexual activity and sexuality by

deliver appropriately the information, treatment and care

highlighting them. Prior to this, underlying assumptions had

people need, and the willingness and ability to deal with

included the following:

ease with sexuality-related issues. This may seem self-

■ sexuality is a personal matter that people do not want to

evident, but in most contexts and settings, one or more of these dimensions are lacking. In addition, many efforts

discuss;

to address one aspect of sexual health, whether through

■ sexual activity is a voluntary activity between individuals;

programmes to prevent STIs/HIV, to provide family plan-

■ clients prefer family planning methods that do not inter-

ning or to address intimate partner violence, have failed as a result of a lack of a clear strategy based on proper assessment, targeting, and adaptation of the intervention to the needs and interests of the relevant population group. Others have made small gains in a specific setting but, because of their narrow focus, could not be scaled up. Several presentations focused on a number of key strategies found to be critical to the promotion of sexual health and delivery of sexual-health-related services. These included issues related to integration of services, education, information, and the enabling legal and political environment.

fere with coitus; ■ family planning providers are not prepared to respond to clients’ questions and needs concerning sexuality; and addressing sexuality will overburden family planning programmes. Calling into question how family planning services were provided, as well as some of the assumptions about providers’ knowledge and ability to address the issues, opened up a new area of work on linking sexuality and sexual health to reproductive health services. Researchers, managers and providers began to ask questions about how women negotiate their reproductive lives.

6.1 Integrating sexual health into existing services (Judith Helzner)

Investigations into power differentials in sexual relationships

The field of family planning was for years dominated by

connection between gender and power in sexual relation-

two themes or approaches: the expansion of contraceptive

ships was also established . Finally, programme managers

use as a means of slowing population growth, but with-

began to realize that power differentials between men and

out addressing individual needs of clients; and the quest

women can and should be addressed in service programmes

for “respectability” of birth control. More recently, family

(25).

planning providers and managers have acknowledged the connections between these issues. This shift was marked by a focus on determinants of contraceptive use, a holistic approach to reproductive health rather than family planning, and a gender analysis of male–female relations. Changes in thinking after the International Conference on Population and Development in 1994 were reflected in a series of publications (22-24) on the role of sexuality in family planning and reproductive health.

gave rise to work on power distinctions, such as “power to” act versus “power over” someone else. The fundamental

Linkages between sexuality and reproductive health are many. The HIV epidemic has raised awareness about the need to address sexuality in a frank and direct manner. HIV prevention programmes can and must include discussion of sexual practices, partnerships, relationships, power, and condom use if they are to be successful. In family planning, recent discussions of the impact of contraceptive methods on sexual pleasure and relations recognize that this may

15

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Sexual health document series

influence method choice, use and continuation. In addi-

and providers to reach beyond the clinic walls to other

tion, family planning services are often well placed to

associations and workers’ groups, including prostitutes,

discover other needs related to sexual problems or vio-

homosexuals, folk and traditional medical practitioners,

lence (26). During pregnancy, issues related to sexuality

and religious groups. It was stressed that religious groups

need to be addressed, such as the safety and impact of

need to be brought on board if real progress is to be

certain sexual practices and the possibility of a higher

made. In addition, some argued that if a number of sectors

incidence of gender-based violence during pregnancy.

and interests join forces, there is a greater likelihood of getting government support and funds.

The International Planned Parenthood Federation (IPPF)

16

and its partners are working on integrating sexuality

Participants also agreed that providers of existing ser-

and sexual health into family planning and reproductive

vices and programmes should receive training in human

health care programmes. This work includes transform-

sexuality, to help them better address the sexual health

ing national family planning associations (FPAs) into sex-

needs of their clients. The integration of sexuality into

ual health agencies in a number of Caribbean countries,

these services, however, should not require health work-

screening for gender-based violence in clinics in three

ers to do more, but rather to do things differently. The

Latin American countries, integrating sexuality and HIV/

group felt that it was essential to improve the quality of

STI prevention in family planning service delivery in three

services by better addressing sexuality and sexual health

countries, producing “sexwise” radio programmes in 11

for all age groups, including the elderly. As populations in

languages to reach over 60 million listeners, and pilot-

some regions get older, there will be an increasing need to

testing projects for staff, new protocols, and changes in

address the sexual health of the elderly, including issues

structures and partners to better integrate sexuality and

related to sexual function for both men and women. Some

sexual-health-related services into the work of FPAs.

participants raised questions about how the health system

IPPF has created a trainers’ guide to sexual health, in

could better address both sexual dysfunction related to

Spanish and English, with exercises to help improve fac-

mental illness and violence.

tual knowledge, clarify values, and increase the comfort of providers in dealing with sexuality and sexual-healthrelated topics. IPPF, as an independent nongovernmental organization,

6.2 Sexuality information: how can the health sector make a difference? (Pilar Ramos-Jimenez)

has taken the lead in some countries by challenging traditional assumptions about sexuality and sexual health

“Sexuality is a concept that is doubly difficult because

programmes. It emphasizes that governments can take

most persons do not want to talk about their own sexuality

up such programmes once feasibility and acceptance

or they most likely do not know the term…in the Philip-

have been demonstrated. Partnerships are crucial if

pine languages there is no term for sexuality,” wrote a

sexuality is to be successfully integrated into reproduc-

prominent sexuality researcher (27).

tive health care services. 6.1.1 Discussion Participants concurred that sexuality needs to be better integrated into family planning programmes, but emphasized that that was not enough. HIV prevention strategies have addressed these issues in a wide variety of settings and contexts, and many felt that greater effort was needed from reproductive health programme managers

In the Philippines, reference to sexuality in health programmes is limited; there is no equivalent word in the local language. Basic definitions of gender, sex, sexual health and sexual responsibility exist, as do comprehensive STI case management modules – all of which focus on STI and HIV prevention rather than on the wider issues related to sexuality and sexual well-being. This lack of terminology reflects social reticence in addressing sexuality. As a result, few data are collected nationally on sexual health, or sexual practices or behaviour. In research,

Meeting people’s needs

abstract concepts must be operationalized, so that we

seriously by health sector reformers. Preventive health

can measure them or convert them into something

models need to be adapted to sexual health messages,

understandable in the local context. Given the constraints

and clear policies and laws need to be established to

in the language of sexual health and sexuality, and the

support a holistic approach to strategies aimed at chang-

associated absence of data, what can the health system

ing sexual behaviour.

do to better address this difficult and complex issue? The health system should be made more accessible The national health sector must be willing to operational-

through the creation of mechanisms allowing community

ize sexuality programmes that extend beyond STI/HIV

voices to be heard. Emphasis needs to be placed on

prevention and move towards a more holistic and posi-

implementing gender policies and institutionalizing the

tive approach to sexual health and sexuality. This can

collection of disaggregated data. This will help coun-

be done by offering providers at all levels of the health

tries to integrate sexuality and sexual health, not as an

system tools and approaches that will enable them to be

“add-on” but as part of a comprehensive approach to

more compassionate, gender- and culture-sensitive, and

sexual and reproductive health, in which programmes are

respectful of client information related to sexuality. This

equitably distributed and address the needs of the people

will require a new paradigm for interventions, involving

they are intended to serve. To achieve these changes,

partnerships between the health sector, NGOs, research

it is critical to build the capacity of the different players

institutions and communities. Interventions must be

to better understand and address sexuality and sexual

designed with the needs and interests of special groups

health.

in mind (e.g. refugees, sex workers, street children, seafarers, men who have sex with men, transgender, etc.).

Other participants noted that there is a critical absence

Effective collaboration and consultation are needed, as

of evidence and accurate information, especially from

has been demonstrated by HIV control and prevention

developing countries, about vulnerability reduction

programmes. Finally, research methods must be qualita-

programmes. In particular, local practices and customs

tive as well as quantitative, and the health sector must

related to sexuality and sexual health are not well

be willing to use the research findings and make them

researched. Participants felt that capacity-building is

accessible to decision-makers, planners and implement-

needed to improve the quality of sexuality research, since

ers. This will require data collection by health services to

few institutions in developing countries have the mul-

be reconsidered and, if necessary, new types of sexual

tidisciplinary research skills to successfully undertake

heath conditions incorporated, such as incest, rape and

such studies.

domestic violence. Collection of sensitive data will also require training and supervision to ensure records are collected in confidence and stored securely. 6.2.1 Discussion Jane Kwawu shared the concerns expressed about the lack of adequate, relevant and reliable information related to sexuality and sexual health. She noted that in many cases decision-makers do not have sufficient unbiased information. Issues related to preventive health care, such as sexual health status, are given low priority and programmes therefore continue to focus on disease rather than health. She warned that without reliable data and information, sexual health would not be taken

What information does exist needs to be better disseminated. Information can be adapted, made culturally appropriate, and translated for other countries and regions. One way might be to start “implementers’ forums”, where information can be exchanged and tools and resources shared. This could be done through the Internet. Other suggestions included developing dissemination strategies for all related sectors and partners with follow-up mechanisms to determine results. The group raised the fact that information, knowledge and its utilization are different. The health sector needs to be clear about its role with respect to information. For instance, what will the health sector do in situations where information is tightly controlled? What messages will be sent

17

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Sexual health document series

through guidance documents for countries that do not

has taken a different form. The Sexual Rights Cam-

have a word to describe sexuality? The challenge for

paign, launched jointly by NGOs dealing with HIV/AIDS,

health researchers is to find a way to describe and por-

violence against women, and adolescent sexual and

tray these things adequately.

reproductive health, is a multipronged advocacy campaign to get decision-makers and politicians to integrate

18

At the global level, it is important to look at exactly what

sexual health and rights into their work. Underlying the

we are recording and analysing. WHO, for example, has

campaign is the belief that sexuality and sexual health

invested in the DALY (disability adjusted life years) frame-

can and should be associated with safe, positive and

work to measure the relative cost of specific diseases

pleasurable experiences. The NGOs are trying to achieve

to society. However, the published data on DALYs have

this by advocating for a new vision of masculinity and

little relevance or application for sexual health. In this

femininity, in which all women and men can claim their

exercise, sexual dysfunction or disability, in terms of dis-

sexual rights and recognize their sexual responsibilities.

enfranchisement or disempowerment, are not covered. One participant stressed that including sexuality-related morbidities in the DALYs may motivate action within the health sector. A new estimation of DALYs, to include serious sexual health problems, could demonstrate the importance and potential impact of addressing sexual health at national level.

6.3.1 Discussion Sexuality education – whether for adolescents, parents, teachers or health workers – generated much discussion and enthusiasm. All participants agreed that, while sexuality education is a key to transforming entrenched belief systems and views of sexuality, programmes often

6.3 Country case studies on sexuality education

face a significant challenge. In the Russian Federation, for example, despite early interest, sexuality education in schools was later denounced by religious and political

Case studies from Thailand (Verapol Chandeying), Swe-

leaders as inflammatory despite the rising incidence of

den (Lillemor Rosenqvist) and South Africa (Khosi Xaba)

STIs and HIV infection.

demonstrated how effective government, private sector and NGO collaboration can be in addressing sexual

Sexuality education must seek to promote health and

health.

well-being, as well as sexual rights. It needs to extend to all sectors, recognizing that not all children go to

In Thailand, where STIs and HIV infection rates reached

school. Different approaches are needed in different

record highs in the late 1980s, programmes targeting sex

settings, and it was noted that a large proportion of

establishments managed to create a 100% condom use

health and education services are delivered through

standard by 2000. This was achieved through coopera-

the religious sector. Others reminded the group that sex

tion between government authorities and the owners

education is not a “magic bullet”. It can empower young

of establishments, followed by increased surveillance,

people, enabling them to make decisions and act, but

supervision, provision of STI services, and changes in

the broader context may restrict their ability to act. The

laws and policies. In Sweden, which has among the

situation and context have a strong influence on sex

lowest rates of unintended pregnancy and abortion in

education, and very often become a barrier, especially in

the world, sexual health education is now provided in

developing countries.

all schools beginning in the elementary years. Although today sexual health education is the norm in Sweden, the

An additional problem mentioned by participants was

road leading to its widespread acceptance has been long

lack of knowledge among providers. Medical doctors

– more than 20 years – and sometimes difficult. In South

are often brought in to provide sexual health education

Africa, where HIV/AIDS affects more than one-quarter

despite their own limitations (lack of knowledge, skills

of the population, promotion of sexual health education

or comfort level). There is an urgent need to ensure that

Meeting people’s needs

medical education curricula include training on sexuality,

a decree prohibiting the participation of health pro-

gender and human rights. This training should also be

fessionals in the practice, female genital mutilation

extended to teachers, allied health workers, police and

was widely condoned by the medical profession.

other members of the justice system, and policy-makers.

The tide began to turn in 1994, in part because of sustained local activism against the practice, and in

Information and education related to sexuality for adoles-

part because of international opinion against it. With

cents is critical to building a sexually healthy future gen-

the support of international organizations, such as

eration. Programmes must therefore move beyond simply

WHO and the International Federation of Gynaecol-

providing information to building skills, so that young

ogy and Obstetrics (FIGO), and in line with the shift

people can use the information they receive. Another

towards comprehensive reproductive health care and

group in need of information is the newly married. While

rights, local activists built a public and religious con-

some information and materials are available, they are

sensus around the condemnation of the practice. The

often not packaged appropriately. Some suggested that

change in policy in Egypt is an example of the coming

the Internet could be used as a method of dissemination

together of different forces and factors to create the

and that the media should be included as partners in pro-

conditions for policy change to occur – a crucial ele-

moting sexual health information.

ment in producing change in practice at the national level.

6.4 Government response: creating an enabling legal and policy environment

■ Colombia – In Colombia, Profamilia established a legal service for women, in an effort to help them secure their reproductive and sexual rights. The ser-

An enabling legal and policy environment is critical to the

vice addresses issues related to sexual orientation

promotion of sexual health. Two case studies were pre-

and discrimination, abortion, prevention of sexually

sented, both led by nongovernmental organizations advo-

transmitted infections, informed consent, emergency

cating for change in laws, policies and practices related

contraception and gender-based violence. In estab-

to sexual health. Amal Abdel Hadi of the New Woman

lishing the legal service, Profamilia is using human

Research Centre in Egypt described the history of regula-

rights and law as instruments for social change,

tion of female genital mutilation in Egypt, while Maria

by promoting partnerships with interested groups

Isabel Plata of Profamilia, a family planning association,

in other sectors, such as the women’s movement,

discussed how the organization established a legal clinic

human rights organizations and community-based

to protect the sexual and reproductive rights of clients in

groups. As a result of their efforts, the Ministry of

Colombia.

Health in Colombia has elaborated guidelines for

■ Egypt – Female genital mutilation is a widespread

sexual and reproductive health services.

practice in Egypt, and 97% of ever-married women aged 15-49 years have undergone the procedure. It is practised by both Muslims and Christians, and the

6.4.1 Discussion

reasons most often given are cultural tradition, reli-

Participants concurred that a legally enabling envi-

gion, and the preservation of virginity. In Egypt, there

ronment is fundamental to advancing sexual rights,

is no penal law against female genital mutilation.

although some noted that there are advantages to work-

Nevertheless, the practice has been hotly debated and

ing in the nongovernmental sector, where political oppo-

contested by women’s rights activists for years.

sition can be seen as a challenge rather than a barrier.

In 1959, a ministerial decree was issued prohibit-

Others noted that if an NGO takes over critical services,

ing the practice by non-medical personnel, such as

the government may then not fulfil its role as provider of

traditional birth attendants and barbers. From that

those services. The example of Profamlia demonstrates

time until 1996, when the Ministry of Health issued

19

Chapter 6



Sexual health document series

that an NGO can be a catalyst for government action, and

Successful interventions came from NGOs, religious groups,

that such fear of government inaction is not necessarily

the private sector, the government sector, professional

justified.

associations, sports and youth clubs, and numerous other agencies. Common features of successful programmes

Group discussions were held on specific national strate-

were discussed using a list of guiding principles provided

gies deemed to be successful, based on established cri-

(30), and a revised list was developed (see Box 2).

teria. These strategies included a range of interventions that involved individuals, families, the community, and a variety of government and non-governmental services.

20 Box 2: Guiding principles for successful programme interventions in sexual health

■ Affirmative approach to sexuality – Using a positive, affirming approach to sexuality, rather than one based on fear, addresses both the pleasure and safety aspects of sexuality and sexual health and recognizes that every human being is sexual throughout the life cycle.

■ Autonomy and self-determination – Women and men must have the right and ability to make their own free and informed choices about all aspects of their lives, including their sexual lives.

■ Responsiveness to changing needs – Sexual health information and services must respond to the changing needs of women and men throughout their life cycle.

■ Comprehensive understanding of sexuality – Issues of sexuality are complex. Interventions must address and integrate emotional, psychological and cultural factors in planning and service delivery. ■ Confidentiality and privacy – Sexuality touches upon intimate aspects of people’s lives. Individuals have the right not to be identified or compelled to share information and the right not to have information about them divulged to someone else.

■ Advocacy for the promotion of sexual health and well-being is essential for change. ■ Cultural diversity – Programmes must consider which cultural practices, traditions, beliefs and values are beneficial and promote sexual health. Factors such as sexual orientation, illness, culture, age or disability must be taken into account in the design of programme interventions and services.

■ Equity – Programmes and services must cater to needs that are specific to each sex, but must not perpetuate stereotypes or double standards about gender and sexuality. Since women have traditionally been less able to access information, services and education, programmes should actively redress gender imbalances through interventions that empower women to protect themselves from sexual ill-health and disease.

■ Address violence, sexual violence and abuse – These are often the conditions under which people, especially women, experience their sexuality or initiation into sexual activity.

■ Non-judgemental services and programmes – Providers and educators must respect the values that others hold, and refrain from judging and imposing their own views upon others.

■ Accessible programmes and services – Programmes and services must be accessible, affordable, confidential, of high quality, and age- and culture-appropriate.

■ Accountability and responsibility – The health system should ensure that sexual health programmes are implemented and services are provided according to the above principles.

Chapter 7 ■ Sexual health document series

Conclusion The Consultation concluded with a series of proposals for future action by WHO: ■ Develop an expanded research agenda on sexuality and convene a meeting to set research priorities. ■ Develop normative guidance documents on sexuality and healthy sexual development and maturation for developing countries. ■ Develop curricula and training tools on human sexuality for physicians and health workers. ■ Evaluate models of service delivery and programmes to establish best practices related to sexual health. ■ Advocate for the collection of data related to sexuality and sexual health in all countries. ■ Evaluate research methods for studying sexuality and sexual behaviour and develop a guidance document on research methods. ■ Build research capacity in sexual behaviour and sexuality in developing countries. ■ Develop a comprehensive guidance document on sexual health to assist countries to develop national strategies and policies on sexual health. Since the Consultation, the Department of Reproductive Health and Research, in cooperation with the Departments of Child and Adolescent Health and the HIV/AIDS Department, has developed a medium-term workplan on sexual health, which takes up several of these recommendations.

21

Sexual health document series

References 1.

Education and treatment in human sexuality: the training of health professionals. Geneva, World Health Organization, 1975 (WHO Technical Report Series No. 572).

2 . Promoting sexual health. Washington, DC, Pan American Health Organization, 2000.

22

16. World report on violence. Geneva, World Health Organization, 2002. 17. The World Health Report 2001. Mental health: new understanding, new hope. Geneva, World Health Organization, 2001.

3.

Langfeldt T, Porter M. Sexuality and family planning: report of a consultation and research findings. Copenhagen, WHO Regional Office for Europe, 1986.

18. The Surgeon General’s call to action to promote sexual health and responsible sexual behaviour. Washington, DC, National Institutes of Health, 2001.

4.

Report of the International Conference on Population and Development, Document A/Conf. 171/13, New York, United Nations, 1994, paragraph 7.2.

19. Hart G, Flowers P. Recent developments in the sociology of HIV risk behaviour. Risk, decision and policy, 1996, 1: 153165.

5.

United Nations. Report of the Fourth World Conference on Women, Document A/Conf. 177/20, New York, United Nations, 1995, paragraph 96.

20. Expanding the global response to HIV/AIDS through focused action. Geneva, Joint United Nations Programme on HIV/AIDS, 1998 (Best Practice Collection).

6.

AIDS epidemic update, December 2001. Geneva, World Health Organization and Joint United Nations Programme on HIV/AIDS, 2001.

21. Kirby D et al. (2002) The impact of schools and school programs on adolescent sexual behaviour. The Journal of Sex Research 39 (1): 27-33.

7.

Global prevalence and incidence of selected curable sexually transmitted infections: overview and estimates. Geneva, World Health Organization, 2000.

22. Dixon-Mueller R. The sexuality connection in reproductive health. Studies in Family Planning, 1993, 24: 269-82.

8.

Meeting the needs of young adults. Baltimore, MD, Johns Hopkins School of Public Health, Population Information Program, Report Series J, No. 41, 1995.

9.

Into a new world: young women’s sexual and reproductive lives. New York, Alan Guttmacher Institute, 1998.

10. Senderowitz J. Adolescent health: reassessing the passage to adulthood. Washington, DC, World Bank, 1995 (Discussion Paper). 11. Maternal mortality estimates. Geneva, World Health Organization, 2004. 12. Unsafe abortion: global and regional estimates of incidence and mortality due to unsafe abortion with a listing of available country data. Geneva, World Health Organization, 1998. 13. Laumann EO, Paik A, Posen RC. Sexual dysfunction in the United States: prevalence and predictors. Journal of the American Medical Association, 1999, 281: 237-544. 14. Sipski M, Alexander C. Sexual function in people with chronic illness: a health professional’s guide. Gaithersburg, MD, Aspen Press, 1997. 15. Sadock VA. Normal human sexuality and dysfunction. In: Sadock BJ, Sadock VA, eds., Comprehensive textbook of psychiatry, 7th ed. Philadelphia, PA, Lippincott Williams and Wilkins, 2000: 1577-1607.

23. Zeidenstein S, Moore K. Learning about sexuality: a practical beginning. New York, The Population Council, 1996. 24. Moore K, Helzner J. What’s sex got to do with it? New York, IPPF/Western Hemisphere Region and the Population Council, 1997. 25. Blanc A. Power in sexual relationships. New York, The Population Council, 2001. 26. Becker J, Leitman E. Introducing sexuality within family planning: the experience of three HIV/STD prevention projects from Latin America and the Caribbean. Quality/Calidad/Qualité no. 8. New York, Population Council, 1997. 27. Common ground – sexuality: principles for working on sexuality. New Delhi, Tarshi and Siecus, 2001.

Annex 1 ■ Sexual health document series

Meeting agenda World Health Organization

Challenges in Sexual and Reproductive Health:

Department of Reproductive Health and Research in

Technical Consultation on Sexual Health

collaboration with the Department of Child and Adolescent

28-31 January 2002, Geneva, Switzerland

Health and Development and the Department of HIV/AIDS Agenda Monday, 28 January Defining Sexual Health 9:00 – 10:30

Chair: Dr Purnima Mane Vice-Chair: Dr Rosemary Coates

Opening of the Meeting Introduction, purpose of the meeting Plenary presentations Sexual Health: The Public Health Challenge Healthy Sexual Development

Dr Tomris Türmen Ms Adriane Martin Hilber Dr Adepeju Olukoya Dr Eli Coleman Ms Smita Pamar

Discussion 11:00 – 12:30

Panel Discussion Regional Perspectives on Sociocultural Factors related to Sexual Health

Africa (Dr Uwem Esiet); Asia (Dr Terence Hull); Eastern Mediterranean (Dr Faizal el Kak); Eastern Europe (Dr Ondrej Trojan); Latin America (Dr Esther Corona)

Discussion Introduction to the group work on definitions

Ms Jane Cottingham

14:00 – 15:30

Working groups (Session A) Three working groups will discuss draft operational definitions of sex, sexuality (including sexual maturation and development), sexual health and reproductive and sexual rights

(Facilitators: Ms Marge Berer, Dr Assia Brandrup-Lukanow, Dr Pat Nayar)

16:00 – 17:30

Plenary session Report back from working groups

18:00 – 19:00

Reception

23

Annex 1



Sexual health document series

Tuesday, 29 January Strategies for Addressing Sexual Health 9:00 – 10:30

Chair: Dr Purnima Mane Vice-Chair: Dr Rosemary Coates

Plenary session Sexuality and Sexual Development: Vulnerability and Risk

Dr Peter Aggleton Discussant: Dr Asha Mohamud

Discussion 24

11:00 – 12:30

Panel discussion Integrating Sexual Health into Existing Health Services Country Case Studies: Sweden South Africa Thailand

Ms Judith Helzner

Ms Lillemor Rosenqvist Ms Khosi Xaba Dr Verapol Chandeying

Discussion

Introduction to group work on health sector strategies 14:00 – 15:30

Working groups (Session B) Four working groups will discuss health sector strategies for addressing family and community issues and information needs Working Group 1 Working Group 2 Working Group 3 Working Group 4

16:30 – 17:30

Ms Adriane Martin Hilber

Adolescents Men Women High-risk Groups

Plenary session Report back from working groups

(Facilitator: Ms Radhika Chandramani) (Facilitator: Dr Rafael Mazin) (Facilitator: Ms Khosi Xaba) (Facilitator: Dr Gary Dowsett)

Meeting Agenda

Wednesday, 30 January Strategies for Addressing Sexual Health (cont.) 9:00 -10:30

11:00 – 12:30

Chair: Dr Purnima Mane Vice-Chair: Dr Rosemary Coates

Plenary session Sexual Health Information – How can the Health Sector Make a Difference?

Panel discussion Enabling Environment for Addressing Sexual Health Colombia Egypt

Dr Pilar Ramos-Jimenez Discussant: Dr Jane Kwawu

25 Ms Isabel Plata Dr Amel Abdel Hadi

Discussion

14:00 – 15:30

16:30 – 17:30

Working Groups (Session C) Four working groups will discuss strategies for integrating sexual health into existing health services Working Group 1 Adolescents Working Group 2 Men Working Group 3 Women Working Group 4 High-risk Groups

(Facilitator: Ms Radhika Chandramani) (Facilitator: Dr Rafael Mazin) (Facilitator: Ms Khosi Xaba) (Facilitator: Dr Gary Dowsett)

Plenary session Report back from working groups

Thursday, 31 January Recommendations

Chair: Dr Purnima Mane Vice-Chair: Dr Rosemary Coates

9:00 – 10:30

Plenary session Revisiting definitions

11:00 – 12:45

Plenary session Conclusions and recommendations

12:45 – 13:00

Closing Remarks

Dr Paul Van Look

Annex 2 ■ Sexual health document series

Participants’ list World Health Organization

Challenges in Sexual and Reproductive Health:Technical

Department of Reproductive Health and Research in col-

Consultation on Sexual Health

laboration with the Department of Child and Adolescent

28–31 January 2002, Geneva, Switzerland

Health and Development and the Department of HIV/AIDS Participants’ list 26

Dr Peter Aggleton Institute of Education, Thomas Coram Research Unit University of London 27-28 Woburn Square London WC1HOAA, United Kingdom Tel: + 44 (207) 612 6957 Fax: + 44 (20) 7612 6927 E-mail: [email protected] Dr Ayse Akin Hacettepe University, Medical School Department of Public Health 06-100 Sihhiye Ankara, Turkey Tel: + 90 -(312) 324 39 75 Fax: + 90- (312) 483 3364 E-mail: [email protected] Dr Regina Barbosa Rua Piracuama, 386/35 Sumare, 05017-040 Sao Paulo S.P., Brazil Tel: + 55 (11) 36723215 Fax: + 55 (11) 36723215 E-mail: [email protected] Ms Marge Berer Reproductive Health Matters 444 Highgate Studios, 53-79 Highgate Road London NW5 1TL, United Kingdom Tel: +44-20-7267-6567 Fax: +44-20-7267-2551 E-mail: [email protected] Dr Dorothy Blake Gremlin Hill, San San Drapers P.A. Portland, Jamaica Tel: +1 876 993 7208 E-mail: [email protected] Dr Meiwitta Budiharsana Reproductive Health, Gender and Women’s Rights Ford Foundation P.O. Box 2030 Jakarta 10020, Indonesia Tel: +62 (21) 252 4073 Fax: +62 (21) 252 4078 E-mail: [email protected]

Dr Mariela Castro Espin Centro National de Educacion Sexual La Habana, Cuba Tel: (537) 55 2528 Fax: (537) 30 2295 E-mail: [email protected] Dr Verapol Chandeying Dept. of OB-GYN, Faculty of Medicine Prince of Songkla University Hat Yai 90110, Thailand Tel: +66 (74) 429 617 Fax: +66 (74) 446 361 E-mail: [email protected] psu.ac.th Dr Radhika Chandiramani TARSHI (Talking About Reproductive and Sexual Health Issues) 49 Golf Links, 2nd Floor New Delhi 110 003, India Tel: +91 (11) 4610711 , 465 Fax: +91 (11) 4610711 , 465 E-mail: [email protected] Dr Rosemary Coates Curtin University of Technology Division of Health Sciences Sexual Health Research and Education Unit Selby Street Shenton Park, Western Australia 6008 Tel: +61 (8) 9266 3644 Fax: +61 (8) 9266 3699 E-mail: [email protected] Dr Eli Coleman Dept. of Family Practice & Community Health Program in Human Sexuality University of Minnesota Medical School 1300 South Second Street, Suite 180 Minneapolis, MN 55454, U.S.A. Tel: +1 (612) 625-1500 Fax: +1 (612) 626 8311 E-mail: [email protected]

Participants’ list

Ms Esther Corona-Vargas Latin American Federation of Sexology & Sex Education Societies (FLASSES) Asociación Mexicana de Educación Sexual (AMES) Av. De las Torres 27-B-301, Col Valle Escondido Tepepan, D.F., Mexico Tel: + 52 525 653 66 42 Fax: + 52 (55) 15 61 03 E-mail: [email protected] [email protected] Ms Sarah Costa Ford Foundation 320 East 43rd Street New York, NY 10017, U.S.A. Tel: +1 (212) 573-5000 Fax: +1 (212) 351-3677 E-mail: [email protected] Dr Adbessamad Dialmy Faculty of Arts and Human Sicences, Dept. of Sociology B.P. 50 Fes, Morocco Tel: + 212 (55) 60-05-63 Fax: +212 (55) 60-05-63 E-mail: [email protected] Dr Gary Dowsett Australian Research Centre in Sex, Health & Society Faculty of Health Sciences, La Trobe University 1st floor, 215 Franklin Street Melbourne VIC 3000, Australia Tel: +61 (3) 9285 5382 Fax: +61 (3) 9285 5229 E-mail: [email protected] Dr Amal Abd El Hadi New Woman Research Center (NWRC) 90D Ahmed Orabi Street Mohendseen, Giza, Egypt Tel: +20 202 304 8085 Fax: +20 202 304 8085 E-mail: [email protected] Dr Faysal El-Kak American University of Beirut, Faculty of Health Sciences POBOX:110236 Beirut, Lebanon Tel: + 961 (3) 867 498 Fax: + 961 (3) 744 470 E-mail: [email protected] Dr Uwem Esiet Action Health Incorporated P.O. Box 803 Yaba Lagos, Nigeria Tel: +234 (01) -7743745 Fax: +234 (01) 863 198 E-mail: [email protected]

Ms Kathryn Faulkner International Planned Parenthood Federation (IPPF) Regent’s College, Inner Circle, Regent’s Park London NW1 4NS, United Kingdom Tel: +44 (0)20 7487 7900 Fax: +44 (0)20 7487 7950 E-mail: [email protected] Dr Jean-Yves Frappier Hôpital Ste-Justine 3175 Chemin Ste-Catherine Montréal, Canada H3T 1C5 Tel: +1 (514) 345 4722 Fax: +1 (514) 345 4778 E-mail: [email protected] Dr Marc Ganem World Association of Sexology 32, Avenue Carnot 75017 Paris, France Tel: +33 1 45 74 52 15 Fax: +33 09 71 69 E-mail: [email protected] Ms Françoise Girard International Women’s Health Coalition, (IWHC) 24 East 21 Street New York, N.Y. 10010, U.S.A. Tel: +1 (212) 979-8500 Fax: +1 (212) 979-9009 E-mail: [email protected] Ms Judith Helzner International Planned Parenthood Federation (IPPF) New York, NY 10005-3902, U.S.A. Tel: (212) 214 0233 Fax: (212) 248 4221 E-mail: [email protected] Dr Terence Hull Demography Program, RSSS The Australian National University Canberra, ACT 0200, Australia Tel: +61 (2) 6125 0527 Fax: +61 (2) 6125 3031 E-mail: [email protected] Dr Hind Khattab The Egyptian Society For Population Studies and Reproductive Health, (ESPSRH) 3 Orabi street Maadi Cairo, Egypt Tel: + 20 202 358 68 53 Fax: + 20 202 380 79 47 E-mail: [email protected] Dr Prakash Kothari ndian ASECT 203A Sukhsagar N.S. Patkar Marg Mumbai 400 007, India Tel: +91 (22) 361 2027 Fax: +91 (22) 204 8488 E-mail: [email protected]

27

Annex 2



Sexual health document series

Dr Igor Kon Institute of Ethnology and Anthropology, Russian Academy of Sciences Vavilova Str., 48-372 117333 Moscow, Russian Federation Tel: +7 (095) 137-5576 E-mail: [email protected]

28

Dr Jane Kwawu International Planned Parenthood Federation (IPPF) Africa Region P.O. Box 30234 Nairobi, Kenya Tel: + 254 (2) 720280 /1/2 Fax: + 254 (2) 726596 E-mail: [email protected] Dr Ana Luisa Liguori John D. and Catherine T. MacArthur Foundation The Program on Global Security and Sustainability Vito Alessio Robles 39-103 Ex-hacienda de Guadalupe Chimalistac, Mexico, DF 01050 Tel: +52 525 661 29 11 Fax: +52 525 661 72 92 E-mail: [email protected]

Ms Smita Pamar SIECUS 130 West 42nd Street, Suite 350 New York, NY 10036, USA Tel: (212) 819 9770 Ext. 308 Fax: (212) 819 9776 E-mail: [email protected] Ms Maria-Isabel Plata PROFAMILIA Calle 34 No 15-52 Bogota, DC, Colombia Tel: +57 (1) 338-3160 Fax: +57 (1) 287-5530 Email: [email protected] Dr Pilar Ramos-Jimenez De La Salle University 3 Saint Marcelino Street San Jose Subdivision Alabang Muntinlupa Metro Manila, Philippines Tel: +63 (2) 524-5349 Fax: +63 (2) 524 5351 E-mail: [email protected]

Dr Purnima Mane Population Council One Dag Hammarskjold Plaza New York, NY 10017, U.S.A. Tel: + 1 (339) 0686 Fax: + 1 (755) 6052 E-mail: [email protected]

Dr Hanne Risor Foreningen Sex & Samfund Danish Family Planning Association Skindergade 28, 1. og 2. sal 1159 Copenhagen K, Denmark Tel: +45 (33) 93 10 10 Fax: +45 (33) 93 10 09 E-mail: [email protected]

Dr Eleanor Maticka-Tyndale University of Windsor, Dept. of Sociology and Anthropology Windsor, Ontario N9B 3PE, Canada Tel: +1 (519) 253-3000 ext 2200 Fax: +1 (519) 971-3621 E-mail: [email protected]

Ms Lillemor Rosenqvist Swedish Association for Sexology Box 65, 297 01 Degeberga, Sweden Tel: +46 (44) 35 10 85 Fax: +46 (44) 35 10 85 E-mail: [email protected]

Dr Asha Mohamud PATH-AYA-Uganda Plot 62 Kiira Road (Opp. The Uganda Museum) P.O. Box 10370 Kampala, Uganda Tel: + 256 202 822-0033 Fax: + 256 202 457-1466 E-mail: [email protected]

Dr Simon Rosser University of Minnesota, Program in Human Sexuality Dept. of Family Practice and Community Health Medical School 1300 South Second Street, Suite 180 Minneapolis MN 55454, USA Tel: +1 (612) 625-1500 Fax: +1 (612) 626-8311 E-mail: [email protected]

Dr Emil Ng Department of Psychiatry University of Hong Kong Queen Mary Hospital Pokulam Road Hong Kong SAR Tel: + 852 (852) -28554488 Fax: +852 (852) -28551345 E-mail: [email protected]

Dr Eusebio Rubio-Aurioles World Association of Sexology Tezoquipa 26 Colonia La Joya Tlalpan D.F. Mexico 14000,Mexico Tel: + 52 (5) 604-2652 60 Fax: + 52 (5) 513 1065 E-mail: [email protected]

Participants’ list

Dr Rashidah Shuib School of Medical Sciences University of Sains Malaysia 16150 Kubang Kerian Kelantan, Malaysia Tel: +609-765-1700 est. 2713 Fax: +609-765-3370 Email: [email protected] Dr Ondrej Trojen Sexological Institute (Affiliated with 3rd Medical School Charles University) Lannova 2 115 60 Prague 1, Czech Republic Tel: +420 608 452453 Fax: +420 2 41432344 E-mail: [email protected] Dr Beverly Whipple Rutgers University 31 NW Lakeside Drive Medford, NJ 08055, U.S.A. Tel: +1 (609) 953 1937 E-mail: [email protected] Ms Khosi Xaba Ipas-South Africa P.O. Box 1079 Auckland Park 2006 Johannesburg, South Africa Tel: 27-11-482 2569 Fax: 27 11 482 4718 E-mail: [email protected]

UN Agencies Dr Ibrahima Diallo UNICEF Charge de programme adolescent/adolescent officer UNICEF WCARO (BRAOC) 04 B.P. 443 Abidjan, Ivory Coast Tel: +225 (20) 21 31 31 Fax: +225 (20) 22 76 07 E-mail: [email protected] Dr Malika Ladjali Education for Sustainable Development UNESCO 7 Place de Fontenoy 75700 Paris 07 SP, France Tel: +(33 1) 4568 0124 Fax: +(33 1) 4568 5635 E-mail: [email protected] Dr Laura Laski UNFPA Reproductive health Branch, Technical Support Division The News Building 220 East 42nd Street New York, NY 10017,U.S.A. Tel: +1 (212) 297-5224 Fax: +1 (212) 297-5145 E-mail: [email protected]

Secretariat WHO Regional Offices Dr Antoine Serufilira, AFRO E-mail: serufi[email protected] Dr Patricia Hoes, AMRO/PAHO E-mail: [email protected] Dr Rafael Mazin, AMRO/PAHO E-mail: [email protected] Dr Ghada Hafez, EMRO E-mail: [email protected] Dr Assia Brandrup-Lukanow, EURO E-mail: [email protected] Dr P. Nayar, SEARO E-mail: [email protected]

WHO Headquarters Dr Tomris Türmen, EXD/FCH Dr Paul Van Look, Director, RHR Dr Hans Troedsson, Director, CAH Dr Andrew Ball, FCH/HIV Tel: +41 22 791 4792 E-mail: [email protected] Ms Magdelena Cerda, VIP/PVL Tel: +41 22 791 2867/ 3480 E-mail: [email protected] Ms Manuela Colombini, FCH/RHR Tel: +41 22 791 4281 E-mail: [email protected] Ms Jane Cottingham, FCH/RHR Tel: +41 22 791 4213 E-mail: [email protected] Ms Amel Fahmy, FCH/RHR Tel: +41 22 791 3328 E-mail: [email protected] Ms Jane Ferguson, FCH/CAH Tel: +41 22 791 3369 E-mail: [email protected] Dr Shireen Jejeebhoy, FCH/RHR Tel: +41 22 791 3348 E-mail: [email protected]

29

Annex 2



Sexual health document series

Ms Adriane Martin Hilber, FCH/RHR Tel: +41 22 791 3607 E-mail: [email protected] Ms Annette Mwansa, MSD/MDP Tel: +41 22 791 4314 E-mail: [email protected] Dr Adepeju Olukoya, FCH/CAH Tel: +41 22 791 3306 E-mail: [email protected]

30

Dr Gundo Weiler, FCH/HIV Tel: +41 22 791 1226 E-mail [email protected] Ms Nena Musngi (Secretary) FCH/CAH Tel: +41 22 791 4789 E-mail: [email protected] Ms Jenny Perrin (Secretary), FCH/RHR Tel: +41 22 791 33 38 E-mail: [email protected]

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Sexual health document series Defining sexual health Report of a technical consultation on sexual health 28–31 January 2002, Geneva Defining sexual...

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