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

2. 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

3. 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

4. Some key concepts Gender Sexuality
More intimately linked than originally supposed

5. 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)

6. 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

7. 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.

8. 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

9. 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)

10. 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
Challenges in sexual and reproductive health: technical consultation on sexual health, WHO, Geneva
Thereafter ….

11. Some changing definitions

12. 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.)

13. 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.

14. 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

15. 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.

16. 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

17. 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.

18. 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

19. 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

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

21. 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;

22. 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.

23. 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

24. 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

25. 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

26. 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)

27. 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

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

29. 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

30. 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

31. Thank you ……