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Sexual health document seriesDefining sexual healthReport of a technicalconsultation on sexual health28–31 January 2002, Geneva

Defining sexual healthReport of a technical consultationon sexual health28–31 January 2002, GenevaGeneva, 2006

Defining sexual health: report of a technical consultation on sexual health, 28–31 January 2002, Geneva World Health Organization 2006All 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: bookorders@who.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: permissions@who.int).The designations employed and the presentation of the material in this publication do not imply the expression of any opinionwhatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or ofits authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate borderlines 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. Theresponsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organizationbe 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 inPhoto credits: Anita Kolmodin

ContentsAcknowledgementsIVChapter 1: Introduction1Chapter 2: Purpose, objectives and overview of the consultation2Chapter 3: Working definitions4Chapter 4: Building sexually healthy societies: the public health challenge64.1 Healthy sexual development – a gender issue64.1.1 Discussion4.2 The public health challenge88Chapter 5: Vulnerability and risk: influencing factors105.1 Models for addressing vulnerability and risk105.1.1 Discussion5.2 Regional perspectives on sociocultural factors11125.2.1 Latin America125.2.2 Sub-Saharan Africa135.2.3 Eastern Mediterranean region135.2.4 Asia145.2.5 Discussion14Chapter 6: Meeting people’s needs156.1 Integrating sexual health into existing services156.1.1 Discussion6.2 Sexuality information: how can the health sector make a difference?6.2.1 Discussion6.3 Country case studies on sexuality education6.3.1 Discussion6.4 Government response: creating an enabling legal and policy environment6.4.1 Discussion16161718181919Chapter 7: Conclusion21References22Annex 1: Meeting agenda23Annex 2: Participants’ list26

AcknowledgementsA 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). Itwas 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 theConsultation would not have been possible without the efforts of all those who participated in the regional roundtables, in the preparation of the background papers, and in the Consultation itself.IV

Chapter 1 Sexual health document seriesIntroductionSexual and reproductive health and well-being arethat “enhance[s] personality, communication and love”.essential if people are to have responsible, safe, andIt went further by stating that “fundamental to this con-satisfying sexual lives. Sexual health requires a positivecept are the right to sexual information and the right toapproach to human sexuality and an understanding ofpleasure”.the complex factors that shape human sexual behaviour.These factors affect whether the expression of sexualityIn 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 tobegan a collaborative process1 to reflect on the statesexual and reproductive ill-health. Health programmeof sexual health globally and define the areas wheremanagers, policy-makers and care providers need toWHO and its partners could provide guidance to nationalunderstand and promote the potentially positive rolehealth managers, policy-makers and care providers onsexuality can play in people’s lives and to build healthhow better to address sexual health. As in 1975, theservices that can promote sexually healthy societies.process began with a review of key terminology and ofthe evidence, and culminated in the convening of a largeThe past three decades have seen dramatic changes ingroup of experts from around the world to discuss theunderstanding 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 sexuallytransmitted infections (STIs), unwanted pregnancies,unsafe abortion, infertility, gender-based violence, sexualdysfunction, and discrimination on the basis of sexualorientation has been amply documented and highlightedin national and international studies. In line with the recognition of the extent of these problems, there have beenhuge advances in knowledge about sexual function andsexual behaviour, and their relationship to other aspectsof health, such as mental health and general health,well-being and maturation. These advances, togetherwith the development of new contraceptive technologies,medications for sexual dysfunction, and more holisticapproaches to the provision of family planning and otherreproductive health care services, have required healthproviders, managers and researchers to redefine theirapproaches to human sexuality.Sexual health was defined as part of reproductive healthin the Programme of Action of the International Conference on Population and Development (ICPD) in 1994.Statements about sexual health were drawn from aWHO Technical Report of 1975 (1), which included theconcept of sexual health as something “enriching” and1 The current work on the promotion of sexual health globallywas initiated in response to a call by the Pan American HealthOrganization (PAHO), the WHO Regional Office for Europe, and theWorld Association for Sexology to update the 1975 report. PAHO,in collaboration with WAS, had initiated the revision process bypublishing a report entitled Promoting sexual health (2). To obtain abetter understanding of how sexuality and sexual health are viewedin different parts of the world, WHO commissioned 14 national andregional background papers, held four regional meetings or roundtable discussions and one international preparatory meeting, andestablished an interdepartmental working group within WHO headquarters as part of a collaborative consensus-building process.1

Chapter 2 Sexual health document seriesPurpose, objectives and overviewof the consultation2On 28–31 January 2002, a Technical Consultation onThe presentations and discussions were grouped in broadSexual Health was convened by the WHO Department ofcategories (see Annex 1). On the first day, the presenta-Reproductive Health and Research, in collaboration withtions stressed the importance of addressing sexuality andthe Department of Child and Adolescent Health and thesexual health holistically, and laid out the consequencesprevention team of the Department of HIV/AIDS.for individuals, families, communities and societies ofnot addressing sexual health. National and regionalThe Consultation was the first activity in an expandingperspectives on barriers and opportunities for improvingarea of work for WHO. Its purpose was to reaffirm sexualsexual health in different social, cultural and religious set-health as an important and integral aspect of humantings identified many of the particular challenges faceddevelopment and maturation throughout the life cycle andby those working on sexuality in specific contexts. Theto contribute to the development of a long-term strategypresentations indicated that, despite vast geographicaland 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; theyThe specific objectives of the meeting were to: discuss key concepts including definitions of sexualhealth and related issues; examine the specific barriers to the promotion ofsexual health for adolescents and adults; and propose appropriate, effective strategies for promotingsexual health.The meeting brought together over 60 international andnational experts on sexuality and sexual-health-relatedissues. Participants were from all regions of the world andincluded: representatives of governments and nongovernmental organizations (NGOs); social scientists; health providers, programme managers and policy-makers workingon STI/HIV prevention, reproductive health and familyplanning; clinical psychologists, psychiatrists and sexologists; sexual health educators; representatives from WHOregional offices; and donors.A paper giving an overview of sexual health as a publichealth issue was prepared by WAS, and two workingpapers dealing with, respectively, definitions and healthsector strategies for addressing sexual health anddevelopment were prepared by WHO. These documents,together with a number of commissioned backgroundpapers, informed the discussion and served as a basis forthis report.include the difficulty of talking about sexuality because ofits private nature, and the gender aspects of sexual roles,responsibilities and relationships, including the powerdynamics associated with them. A working group wasformed to draft operational definitions of sex, sexuality,sexual health and sexual rights, and was asked to reportback to the Consultation on the final day.On the second day, the presentations and discussionfocused on how the health sector has addressed vulnerability and risk related to sexuality and sexual health. Thefirst presentation shared lessons learned from efforts toprevent HIV infection and acquired immunodeficiency syndrome (AIDS) over the past two decades. It was noted thatHIV prevention and sexual health activities have extended,and must continue to extend, beyond the health sector toinclude individuals, families and communities, as well asenvironmental factors that contribute to vulnerability andrisk.The second presentation traced the history of integrationof services noting that it took more than thirty years forfamily planning programmes to begin to address sexuality as part of reproductive health care services. The ICPDProgramme of Action called for the integration of servicesas fundamental to achieving reproductive health. Participants noted the different approaches, emphases and

Purpose, objectives and overview of the consultationsuccesses of HIV prevention programmes and reproductive health programmes, and the importance of gatheringbetter evidence on the success of various methodologiesaimed at changing behaviour.Case studies of best practices from Sweden, South Africaand Thailand were presented. In Sweden, sexual healtheducation has transformed the way people think aboutsex, sexuality, and reproductive and sexual health, butthe road to achieving these successes has been long andsometimes difficult, and the political barriers posed alongthe way significant. In Thailand, where recent HIV prevention efforts have resulted in lower transmission rates, anearly success was achieved by focusing the interventionstrategy on commercial sex establishments and theirclients. In South Africa, a current sexual rights advocacycampaign is focused on getting decision-makers andpoliticians to integrate a more comprehensive perspectiveof sexual health and rights into their work. This involvesworking with nongovernmental and community-basedorganizations to address HIV/AIDS, violence againstwomen, and adolescent sexual health in an integratedmanner 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 anddiscussions held over the course of the four-day meeting.It summarizes the critical issues raised, as well as thedifferences of opinion, approach and direction of actorsin different regions in addressing common problems.While one stated objective of the meeting was to defineappropriate sexual health strategies, the group concludedthat such general recommendations would not be useful,given the very specific national and regional perspectiveson how sexuality and thus sexual health can be addressedand promoted by the health sector. The group agreed,however, that despite the differences, all programmesand services aimed at addressing sexuality and promoting sexual health can and must be based on fundamentalvalues and principles grounded in human rights. Theseguiding principles for work on sexuality and sexual healthare described in chapter 6. The meeting concluded witha series of recommendations to WHO on how to take thisimportant area of work forward in the coming years.3

Chapter 3 Sexual health document seriesWorking definitions4In 1975, a WHO expert group described sexual health asWhile sexual rights were not specifically defined either by“the integration of the somatic, emotional, intellectual andICPD or by the Fourth World Conference on Women in Bei-social aspects of sexual being in ways that are positivelyjing in 1995, or at their five-year follow-up conferences,enriching and that enhance personality, communicationICPD did elaborate on reproductive rights. Reproductiveand love” (1). The report incorporating this forward-look-rights were defined as embracing “certain human rightsing description of sexual health laid the groundwork for athat are already recognized in national laws, interna-comprehensive understanding of human sexuality and itstional human rights documents and other consensusrelationship to health outcomes. However, many terms,documents. These rights rest on the recognition of thesuch as sex, sexuality and sexual rights, were left unde-basic right of all couples and individuals to decide freelyfined, and there has been no subsequent internationaland responsibly the number, spacing and timing of theiragreement on definitions for these terms (3). In English,children and to have the information and means to dothe term “sex” is often used to mean “sexual activity” andso, and the right to attain the highest standard of sexualcan cover a range of behaviours. Other languages andand reproductive health. This includes the right to makecultures use different terms, with slightly different mean-decisions concerning reproduction free of discrimina-ings.tion, coercion and violence, as expressed in human rightsdocuments.” Since human reproduction generally requiresThe ICPD Programme of Action (4) included sexual healthsexual activity, sexual rights are closely linked to repro-as part of reproductive health. Reproductive health wasductive 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 earlybeing and not merely the absence of disease or infirmity,as 1975 at the World Conference of the Internationalin all matters relating to the reproductive system and toWomen’s Year in Mexico City. It was further defined andits functions and processes. Reproductive health there-elaborated in the Beijing Platform for Action (5): “Thefore implies that people are able to have a satisfying andhuman rights of women include their right to have con-safe sex life and that they have the capacity to reproducetrol over and decide freely and responsibly on mattersand the freedom to decide if, when and how often torelated to their sexuality, including sexual and reproduc-do so. Implicit in this last condition are the right of mentive 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 matterseffective, affordable and acceptable methods of familyof sexual relations and reproduction, including full respectplanning of their choice, as well as other methods of theirfor the integrity of the person, require mutual respect,choice for regulation of fertility which are not against theconsent and shared responsibility for sexual behaviourlaw, and the right of access to appropriate health-careand its consequences.”services that will enable women to go safely throughpregnancy and childbirth and provide couples with theBuilding on these definitions, and bearing in mind thebest chance of having a healthy infant.”public health challenges of sexual health, the Consultation proposed the following definitions as a guide forReproductive health care was defined as including carehealth programme managers, policy-makers and othersfor “sexual health, the purpose of which is the enhance-working in the field of human sexuality and sexual andment of life and personal relations, and not merelycounselling and care related to reproduction and sexuallytransmitted diseases”.

Working definitionsreproductive health. The definitions were informed byand amended following the Consultation by a small inter-the background papers, regional discussions and roundnational working group.tables that preceded the Consultation, and were refinedBox 1: Working definitions2 SexSex 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 asmales 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. SexualitySexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexualorientation, 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 thesedimensions, 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 healthSexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merelythe absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexualityand 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 berespected, protected and fulfilled. Sexual rightsSexual rights embrace human rights that are already recognized in national laws, international human rights documentsand 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.2These working definitions were developed through a consultative process with international experts beginning with he Technical Consultationon Sexual Health in January, 2002. They reflect an evolving understanding of the concepts and build on international consensus documents suchas 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 seriesBuilding sexually healthy societies:the public health challenge6The proposed definition of sexual health states that it “isWhen considering adolescent sexual development,a state of physical, emotional, mental and social well-we must recognize the diversity of this populationbeing in relation to sexuality; it is not merely the absenceand the different ways sexual development will beof disease, dysfunction or infirmity.” This definition callsexperienced and interpreted. The diversity includesattention 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 ormental part of being human. “Sexual health” requires “ainvoluntary), motivations for sexual activity (affection,positive and respectful approach to sexuality and sexualstatus, 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 itdiscrimination and violence.” Unfortunately, rather thanmeans to be sexual. Who is, or has a right to be, sex-enriching personal relationships and intimacy, sexuality isual, under what conditions, circumstances and con-too often a cause of distress.text, and for what purpose or motivation? What doesbeing sexual mean in the context of power differen-The two opening presentations focused on the publictials, particularly for young women, and how do powerhealth imperative to build sexually healthy societies. Thedifferentials manifest themselves as we develop asfirst discussed healthy sexual development, with a focussexual beings? Sexual identity and gender identity areon adolescence. The second discussed the scope andintrinsically embedded in notions of power: who hasprevalence of sexual-health-related problems and thepower, for what purpose, and how they are allowed orpublic health imperative to address sexual health in all itsentitled to use that power?dimensions. The presentations are summarized below.To be sexual is far more than a matter of physiologyand sexual activity. Being sexual is very much about4.1 Healthy sexual development – a genderissue (Smita Pamar)who we are, what we feel, what we value, what wethink, and what we desire. It is to understand andexperience what it means to be a man or woman, andWhat is healthy sexual development? This is a questionwhat happens if one does not fit into the generallythat is answered within the context of the individual,accepted idea [or social stereotype] of what thosefamily, community, society, and culture over time. Whatcategories imply. Understanding what it means to beis considered “healthy” varies not only from generationsexual involves how women and men, girls and boysto generation, from society to society, and between meninterpret sexuality, what is considered sexual, and theand women, but also within any one individual: what maymeaning and value ascribed to it. Sexuality includeshave been considered “healthy” at age 15 may not be atdifferent dimensions of relationships, whether they45. The notion of health, just like sexuality, is not staticare sexual or not, the degree of control and agencyand judgement-free. Sexual development occurs over aover 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-worthriences during adolescence, the pivotal period of transi-and self-esteem, pleasure and desire. Being sexual istion to adulthood. Adolescence sets the stage for sexualalso linked to the social, economic, and educationalhealth in later life.opportunities available to males and females, how

Building sexually healthy societies: the public health challengethat availability influences decisions to be sexually activethrough school, community, media, religious institutionsor not, and how information about sexuality and sexualand health services.health is interpreted.Social assumptions about gender identity and sexualitySexual development is often typified as somethingoften carry the assumption, either implicitly or explicitlyproblematic to be contained and controlled, especially(depending on culture), that women should not wantfor girls. This characterization often has more to do withsexual activity or find it pleasurable, or have sexualthe anxieties, fears, and beliefs of adults than the real-relations outside of marriage. Sexual activity should beity experienced by adolescents. Adolescence is a timefor procreative purposes and motherhood is a markerof rapid development, discovery, experimentation, andof social status. On the other hand, men and boys areexploration about all aspects of life. It is a time of initia-often socialized to feel entitled to have sexual relationstion and experimentation (voluntary and involuntary)and pleasure and that their self-worth is demonstratedin sexual activity. Yet socially it is often not acceptablethrough their sexual prowess and notions of authorityfor adolescents to be sexually active. As a result, youngand power. Gender roles often dictate who is supposedpeople, especially girls, have to hide their sexuality andto be passive or aggressive in sexual relationships andsexual activity and submit to restrictions and control.what the proper motivations are for seeking sexual activ-Due to social, cultural and religious restrictions of youngity: 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 statusvices, and information.among their peers.In considerations of healthy adolescent sexual develop-(iii) Social, cultural, and economic factors also affectment three issues emerge: (i) cognitive development andsexual decision-making by boys and girls, as individualsthe context of decision-making; (ii) gender identity; andand 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 tocence. Community values and fears about sexuality inthink and reason abstractly, weigh consequences andyoung people tend to limit the availability of the basicmake decisions — occurs during adolescence and isinformation and education they need to understand andinfluenced by the social (particularly gender-related),appreciate their changing bodies, leaving the transferpolitical, 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 decisionlies and professionals. Unfortunately, parents, healthrelated to one’s sexuality when public knowledge ofworkers, and teachers themselves also often lack suchsexual activity is a serious social liability with potentialinformation, or do not feel comfortable communicatinglong-term social sanctions and stigma?about sexuality. As a result, young people tend to enterthey undergo during puberty and throughout adoles-(ii) Gender identity development defines for most peoplewhat it means to become a man or a woman. It is aprocess of interpreting and accepting (or not accepting)into sexual relations without the necessary knowledgeor skills to negotiate for their own sexual health andwelfare.what family, community, culture and society, say aboutAll cultures assign meaning to the onset of puberty. Thethe appropriate roles, responsibilities and behaviours ofsocial meaning of puberty is different for boys and girls.men and women. Although gender identity is constructedIn many cultures, the onset of puberty for a boy mayover time, in adolescence gender roles (and their dis-lead to greater freedom, mobility, and opportunities. Forparities, stereotypes, and inequities) are often solidifiedgirls, 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 beginningThis is reinforced in messages received by young peopleof married life and childbearing. Traditional practices,7

Chapter 4 Sexual health document seriesrites, ceremonies and celebrations often accompany thisplanning research, which still characterizes men as thetransition from childhood to adulthood, some of which,core group of HIV-infected people. Reproductive healthsuch as female genital mutilation/cutting, may have last-activists acknowledged the prevalence of this gendering effects on sexual health and well-being.bias against men, but felt strongly that there co

Aug 31, 2006 · Defining sexual health Report of a technical consultation on sexual health 28–31 January 2002, Geneva World Health Organiza-S e xual health document se . sexual health and sexual rights, and was asked to report back to the Consultation on the final day