Sex, sexuality and sexual health Peter Aggleton School of Education and Social Work University of Sussex

Some starting points Fundamental issues How we talk about an issue reveals much about how we ‘understand’ it Concepts we use in the field of sexuality and sexual health ‘position’ both the speaker and that which is spoken about Precision and consensus are vital in the use of terms and terminology Where valid debate exists it must be acknowledged

In recent times Globally move to move from vertical programming to horizontal ‘integration’ move from AIDS ‘exceptionalism’ to HIV mainstreaming shift from a focus on individual risk to concern for social vulnerability growing interest in structural ‘drivers’ of the epidemic desire to identify structural programmes/interventions with beneficial effects

Some key concepts Gender Sexuality More intimately linked than originally supposed

Gender Refers to societal and cultural norms about ‘appropriate’ male/female behaviour, characteristics and roles Is intimately linked to power (gender systems), oppression, resistance and inequalities Is mutable, contextual and contested ‘Positions’ individuals and groups in relation to each other and within the social structure Articulates with other sets of power relations (e.g. of class/economic status, age, ethnicity, etc)

Sexuality – a ‘more than’ explanation Sexuality encompasses more than sexual behavior. The many aspects of sexuality include not only the physical but the mental and spiritual as well. Sexuality is a core component of the personality and a fundamental part of human life. It carries potential to create new life, can foster intimacy and bonding as well as shared pleasure in our relationships. Human sexuality serves many functions in addition to reproduction, and implies psychological as well as physiological/biological responses Adapted from US Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior, 2001

Sexuality – a psychological explanation Sexuality is an integral part of the personality of every human being. Its full development depends upon the satisfaction of basic human needs such as desire for contact, intimacy, emotional expression, pleasure, tenderness and love. Sexuality is constructed through the interaction between the individual and social structures. Full development of sexuality is essential for individual, interpersonal and societal well being World Association for Sexology (1999) Declaration of Sexual Rights. Adopted August 1999.

Sexuality – a more eclectic definition Sexuality is a central aspect of being human exists throughout the lifespan encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships is influenced by the interaction between biological, psychological, social, economic, political, cultural, ethical, legal, historical and religious and spiritual factors. WHO ongoing consultation process

Sexual Health Negative definitions Avoidance of unintended pregnancy Avoidance of sexually transmitted infections Absence of sexual dysfunctions Positive definitions (the above plus) Equitable relationships Sexual fulfilment Sexual rights (and responsibilities)

The development of global consensus some landmarks 1974 – Education and Treatment in Human Sexuality: The training of health professionals, WHO Copenhagen 2000 – Promotion of Sexual Health, PAHO, WHO and Waorld Association of Sexology, Antigua Guatemala 2002 -- Challenges in sexual and reproductive health: technical consultation on sexual health, WHO, Geneva Thereafter ….

Some changing definitions

Sexual Health – an early definition Sexual health is the integration of the somatic, emotional intellectual, and social aspects of sexual well-being in ways that are positively enriching and that enhance personality, communication and love. (World Health Organization (1975) Education and Treatment in Human Sexuality: The training of health professionals. Technical Report Series 572, 1975.)

Sexual Health – a more recent definition Sexual health is a state of complete physical, mental and social well being related to sexuality. It is not merely the absence of dysfunction, disease or infirmity. Sexual health is evidenced in the free and responsible expression of sexuality that enhances life and personal relations. For sexual health to be attained and maintained a socio-cultural milieu conducive to well being related to sexuality must be fostered and the sexual rights of all persons must be recognised and upheld. PAHO (2000) Promoting Sexual Health. Washington DC, PAHO.

Sexual Health – a ‘bit of everything’ definition …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. WHO post-2002 working definition

Where are we now? Sexual health is fundamental to the physical and emotional health and well-being of individuals, couples and families, and to the social and economic development of communities and countries. Sexual health, when viewed affirmatively, encompasses the rights of all persons to have the knowledge and opportunity to pursue a safe and threat free sexual life.

Key conceptual elements of sexual health is about well-being, not merely the absence of disease involves respect, safety and freedom from discrimination and violence depends on the fulfilment of human rights is relevant throughout the lifespan, not only in the reproductive years, but also to younger girls and boys and older women and men is expressed through diverse sexualities and forms of sexual expression is influenced by gender norms, roles, expectations and power dynamics

The foundation for sexual rights – WHO working definition The human rights of individuals include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination, and violence.

Sexual Rights – WHO working definition Sexual rights 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 pursue a satisfying, safe and pleasurable sexual life

Promoting sexual health a programmatic approach Actions to improve sexual health should take place across a variety of contexts In order to ensure that people attain the highest possible level of sexual health, we need to promote healthy sexuality throughout the lifespan offer sexual health services that are appropriate, affordable, accessible and of good quality provide services to all without discrimination on the basis of race, ethnicity, age, lifestyle, income, marital status, sexual orientation or gender expression

Promoting sexual health a programmatic approach Promoting sexual health requires us to tackle Individual risk Social vulnerability Simultaneously

Risk Risk is the probability that a person will acquire infection and/or disease. Certain individual behaviours (such as unsafe sex) increase such risk. Risk is also influenced by multiple factors, including aspects of individuals’ physical and psychological development, sexual history, history of abuse, ability to negotiate, awareness of sexuality-related issues, access to support, and membership of social networks;

Vulnerability Vulnerability forms the backdrop to risk-taking, and arises from the broader social, political and environmental factors that provide the context in which people act, and influence the kinds of risks they take. These contextual factors include political economy, inequalities and exclusions relating to gender, ethnicity and sexuality, and legislative context. The existence or absence of health and education programmes, and their accessibility, capacity, content and delivery, also influence sexual health.

Promoting sexual health a programmatic approach Sexual health programme activities need to take place across a variety of programme areas Laws, policies and human rights Education Society and culture Economics Health systems

Laws, policies and human rights International conventions (e.g. CRC) and consensus statements (e.g. ICPD, Beijing) can provide a supportive environment for sexual health Laws and legal frameworks can obstruct (laws which criminalize sex outside of marriage or set a different age of consent) facilitate (e.g. laws outlawing sexual discrimination) the attainment of sexual health goals Laws and policies can help reduce stigma and discrimination

Education Sexual health education can provide information and skills to reduce risk Correlation between educational level and sexual health outcomes Better knowledge High levels of health seeking Good quality comprehensive sexuality education reduces unintended pregnancies, delays sexual debut and promotes condom use

Society and culture Family and community are double edged Enhance vulnerability (denial of information, gender based violence, incest, abuse) Promote sexual health (accurate information, respect, acceptance, signposting of services) Religious and cultural values are double edged Enhance vulnerability (denial of full range of accurate information, violence, ‘corrective’ rape) Promote sexual health (promoting service access, tackling gender-based violence)

Economics Poor, marginalized communities have poorer sexual health outcomes Poor sexual health can contribute to poverty (by limited earning potential and necessitating spending on health care) Poverty intimately connected to participation in sex work and transactional sex In many contexts, participation in sex work and transactional sex associated with poorer health outcomes

Last but not least Because promoting sexual health involves a lot more than the health sector alone

Health Services should Be available to all regardless of age, sex, sexuality, marital status Be provided in confidential, private and non-discriminatory way Include identification and referral for victims of sexual and other forms of violence Include voluntary counselling and testing for HIV Offer access to safe abortion to the full extent of the law, together with post-abortion care including provision of contraceptive information, counselling and methods Diagnosis and referral for sexual dysfunction Diagnosis and treatment for RTIs, reproductive cancers and associated infertility

Conceptual shifts From hospital to community From vertical to horizontal programming From individual behaviour change to a focus on networks and broader context From a focus on reproductive age to a lifespan perspective From a focus on women to a concern for gender From a needs-based approach to a concern for rights From sexual ill-health to sexual well-being and pleasure

Thank you ……