Sexual Health – this is an important component of the overall emotional and physical health of any person. Although erectile dysfunction and does not threaten human life, it in no way be regarded as some sort of trivial problem. Admittedly, it is – a widespread violation, based often on the physical cause. Sexual health is a state of physical, mental and social well-being in relation to sexuality. It 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.
WHO has been working in the area of sexual health since at least 1974, when the deliberations of an expert committee resulted in the publication of a technical report entitled “Education and treatment in human sexuality” (WHO, 1975).
In 2000, the Pan American Health Organization (PAHO) and WHO convened a number of expert consultations to review terminology and identify programme options. In the course of these meetings, the working definitions of key terms used here were developed. In a subsequent meeting, organized by PAHO and the World Association for Sexual Health (WAS), a number of sexual health concerns were addressed with respect to body integrity, sexual safety, eroticism, gender, sexual orientation, emotional attachment and reproduction.
Coming up with a definition of sexual health is a difficult task, as each culture, sub-culture, and individual has different standards of sexual health. ASHA believes that sexual health includes far more than avoiding disease or unplanned pregnancy. We also believe that having a sexually transmitted infection or unwanted pregnancy does not prevent someone from being or becoming sexually healthy.
Here is ASHA’s definition of sexual health:
Sexual health is the ability to embrace and enjoy our sexuality throughout our lives. It is an important part of our physical and emotional health. Being sexually healthy means:
- Understanding that sexuality is a natural part of life and involves more than sexual behavior.
- Recognizing and respecting the sexual rights we all share.
- Having access to sexual health information, education, and care.
- Making an effort to prevent unintended pregnancies and STDs and seek care and treatment when needed.
- Being able to experience sexual pleasure, satisfaction, and intimacy when desired.
- Being able to communicate about sexual health with others including sexual partners and healthcare providers.
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.
According to the current working definition, 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.” (WHO, 2006a)
Defining Sexual Health
The phrase “sexual health” encompasses a range of public health and clinical issues related to prevention of sexually transmitted infections. I use the phrase a lot in my own work and its widening currency is a welcome new paradigm in our field. In fact, the concept of sexual health seems to me of fundamental relevance to all aspects of prevention of sexually transmitted infections.
To be honest, though, all of the talk about sexual health doesn’t seem to have influenced the day-to-day particulars of our work. Sex still is primarily seen as a set of risk factors that we counsel against. I am convinced that this perspective on sex and sexuality as “risk” legitimates the stigma associated with sexually transmitted infections and contributes to our society’s poisonous intolerance of sexual diversity. A sexual health perspective incorporates the concept of personal and epidemiologic risks of sex, but recognizes the pervasive importance of sex in our lives.
However, I’ve begun to wonder if I know what sexual health means in the first place. It’s a big concept, and maybe it’s natural that definitions seem idealistic, overwrought, and self-righteous. Consider the well-known working definition of the World Health Organization:
“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.”
There is a lot to agree with in this definition, especially in its recognition of the complex physical, emotional, mental and social attributes of sexual health, and the anchoring of sexual health in universal sexual rights. But, I find this definition to be quaintly admonishing and parental (“…the possibility of having pleasurable and safe sexual experiences…”). More importantly, however, the definition is sexually vague. No matter how many times I’ve read, used, and cited this definition, I can’t derive from it even a rudimentary vision of how sexual health operates in people’s daily lives. I feel the same about the more recently wrought definition of the U.S. Centers for Disease Control & Prevention, particularly because sexual rights and of sexual pleasure are absent from that sexual health definition.
So, maybe I need to get clearer with myself about what sexual health is. And, sexual health should be more than just the negatives: not coerced; not discriminated; not violent. The prevalence of these negatives in many people’s lives tells us how far we are from achieving a just and equitable society. But I think that sexual health ultimately requires much more active involvement from all of us, and it seems quite insufficient to hope that sexual health will arise on its own if coercion, discrimination, and violence are finally conquered.
Sexual health cannot be defined, understood or made operational without a broad consideration of sexuality, which underlies important behaviours and outcomes related to sexual health. The working definition of sexuality is:
a central aspect of being human throughout life 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, legal, historical, religious and spiritual factors.” (WHO, 2006a)
There is a growing consensus that sexual health cannot be achieved and maintained without respect for, and protection of, certain human rights. The working definition of sexual rights given below is a contribution to the continuing dialogue on human rights related to sexual health (1).
“The fulfilment of sexual health is tied to the extent to which human rights are respected, protected and fulfilled. Sexual rights embrace certain human rights that are already recognized in international and regional human rights documents and other consensus documents and in national laws.
Rights critical to the realization of sexual health include:
- Rights critical to the realization of sexual health include:
- the rights to equality and non-discrimination
- the right to be free from torture or to cruel, inhumane or degrading treatment or punishment
- the right to privacy
- the rights to the highest attainable standard of health (including sexual health) and social security
- the right to marry and to found a family and enter into marriage with the free and full consent of the intending spouses, and to equality in and at the dissolution of marriage
- the right to decide the number and spacing of one’s children
- the rights to information, as well as education
- the rights to freedom of opinion and expression, and
- the right to an effective remedy for violations of fundamental rights.
The responsible exercise of human rights requires that all persons respect the rights of others.
The application of existing human rights to sexuality and sexual health constitute sexual rights. Sexual rights protect all people’s rights to fulfil and express their sexuality and enjoy sexual health, with due regard for the rights of others and within a framework of protection against discrimination.
What are sexually transmitted infections and how are they transmitted?
More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact. Eight of these pathogens are linked to the greatest incidence of sexually transmitted disease. Of these 8 infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are viral infections and are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV). Symptoms or disease due to the incurable viral infections can be reduced or modified through treatment.
STIs are spread predominantly by sexual contact, including vaginal, anal and oral sex. Some STIs can also be spread through non-sexual means such as via blood or blood products. Many STIs—including chlamydia, gonorrhoea, primarily hepatitis B, HIV, and syphilis—can also be transmitted from mother to child during pregnancy and childbirth.
A person can have an STI without having obvious symptoms of disease. Common symptoms of STIs include vaginal discharge, urethral discharge or burning in men, genital ulcers, and abdominal pain.
Scope of the problem
STIs have a profound impact on sexual and reproductive health worldwide.
More than 1 million STIs are acquired every day. Each year, there are estimated 357 million new infections with 1 of 4 STIs: chlamydia (131 million), gonorrhoea (78 million), syphilis (5.6 million) and trichomoniasis (143 million). More than 500 million people are living with genital HSV (herpes) infection. At any point in time, more than 290 million women have an HPV infection, one of the most common STIs.
STIs can have serious consequences beyond the immediate impact of the infection itself.
- STIs like herpes and syphilis can increase the risk of HIV acquisition three-fold or more.
- Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low-birth-weight and prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital deformities. Over 900 000 pregnant women were infected with syphilis resulting in approximately 350 000 adverse birth outcomes including stillbirth in 20122.
- HPV infection causes 528 000 cases of cervical cancer and 266 000 cervical cancer deaths each year.
- STIs such as gonorrhoea and chlamydia are major causes of pelvic inflammatory disease (PID) and infertility in women.
Prevention of STIs
Counselling and behavioural approaches
Counselling and behavioural interventions offer primary prevention against STIs (including HIV), as well as against unintended pregnancies. These include:
- comprehensive sexuality education, STI and HIV pre- and post-test counselling;
- safer sex/risk-reduction counselling, condom promotion;
- interventions targeted at key populations, such as sex workers, men who have sex with men and people who inject drugs; and
- education and counselling tailored to the needs of adolescents.
In addition, counselling can improve people’s ability to recognize the symptoms of STIs and increase the likelihood they will seek care or encourage a sexual partner to do so. Unfortunately, lack of public awareness, lack of training of health workers, and long-standing, widespread stigma around STIs remain barriers to greater and more effective use of these interventions.
When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.
Diagnosis of STIs
Accurate diagnostic tests for STIs are widely used in high-income countries. These are especially useful for the diagnosis of asymptomatic infections. However, in low- and middle-income countries, diagnostic tests are largely unavailable. Where testing is available, it is often expensive and geographically inaccessible; and patients often need to wait a long time (or need to return) to receive results. As a result, follow up can be impeded and care or treatment can be incomplete.
The only inexpensive, rapid tests currently available for STIs are for syphilis and HIV. The syphilis test is already in use in some resource-limited settings. The test is accurate, can provide results in 15 to 20 minutes, and is easy to use with minimal training. Rapid syphilis tests have been shown to increase the number of pregnant women tested for syphilis. However, increased efforts are still needed in most low- and middle-income countries to ensure that all pregnant women receive a syphilis test.
Several rapid tests for other STIs are under development and have the potential to improve STI diagnosis and treatment, especially in resource-limited settings.
Treatment of STIs
Effective treatment is currently available for several STIs.
- Three bacterial STIs (chlamydia, gonorrhoea and syphilis) and one parasitic STI (trichomoniasis) are generally curable with existing, effective single-dose regimens of antibiotics.
- For herpes and HIV, the most effective medications available are antivirals that can modulate the course of the disease, though they cannot cure the disease.
- For hepatitis B, immune system modulators (interferon) and antiviral medications can help to fight the virus and slow damage to the liver.
Resistance of STIs—in particular gonorrhoea—to antibiotics has increased rapidly in recent years and has reduced treatment options. The emergence of decreased susceptibility of gonorrhoea to the “last line” treatment option (oral and injectable cephalosporins) together with antimicrobial resistance already shown to penicillins, sulphonamides, tetracyclines, quinolones and macrolides make gonorrhoea a multidrug-resistant organism. Antimicrobial resistance for other STIs, though less common, also exists, making prevention and prompt treatment critical.
STI case management
Low- and middle-income countries rely on identifying consistent, easily recognizable signs and symptoms to guide treatment, without the use of laboratory tests. This is called syndromic management. This approach, which often relies on clinical algorithms, allows health workers to diagnose a specific infection on the basis of observed syndromes (e.g., vaginal discharge, urethral discharge, genital ulcers, abdominal pain).
Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic tests. However, this approach misses infections that do not demonstrate any syndromes – the majority of STIs globally.
Vaccines and other biomedical interventions
Safe and highly effective vaccines are available for 2 STIs: hepatitis B and HPV. These vaccines have represented major advances in STI prevention. The vaccine against hepatitis B is included in infant immunization programmes in 93% of countries and has already prevented an estimated 1.3 million deaths from chronic liver disease and cancer.
HPV vaccine is available as part of routine immunization programmes in 65 countries, most of them high- and middle-income. HPV vaccination could prevent the deaths of more than 4 million women over the next decade in low- and middle-income countries, where most cases of cervical cancer occur, if 70% vaccination coverage can be achieved.
Research to develop vaccines against herpes and HIV is advanced, with several vaccine candidates in early clinical development. Research into vaccines for chlamydia, gonorrhoea, syphilis and trichomoniasis is in earlier stages of development.
Other biomedical interventions to prevent some STIs include adult male circumcision and microbicides.
- Male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60% and provides some protection against other STIs, such as herpes and HPV.
- Tenofovir gel, when used as a vaginal microbicide, has had mixed results in terms of the ability to prevent HIV acquisition, but has shown some effectiveness against HSV-2.
Current efforts to contain the spread of STIs are not sufficient
Behaviour change is complex
Despite considerable efforts to identify simple interventions that can reduce risky sexual behaviour, behaviour change remains a complex challenge. Research has demonstrated the need to focus on carefully defined populations, consult extensively with the identified target populations, and involve them in design, implementation and evaluation.
Health services for screening and treatment of STIs remain weak
People seeking screening and treatment for STIs face numerous problems. These include limited resources, stigmatization, poor quality of services, and little or no follow-up of sexual partners.
- In many countries, STI services are provided separately and not available in primary health care, family planning and other routine health services.
- In many settings, services are often unable to provide screening for asymptomatic infections, lacking trained personnel, laboratory capacity and adequate supplies of appropriate medicines.
- Marginalized populations with the highest rates of STIs—such as sex workers, men who have sex with men, people who inject drugs, prison inmates, mobile populations and adolescents—often do not have access to adequate health services.
WHO develops global norms and standards for STI treatment and prevention, strengthens systems for surveillance and monitoring, including those for drug-resistant gonorrhoea, and leads the setting of the global research agenda on STIs.
Our work is currently guided by the “Global health sector strategy on sexually transmitted infections, 2016 -2021, adopted by the World Health Assembly in 2016 and the 2015 United Nations Global Strategy for Women’s, Children’s and Adolescents’ Health, which highlight the need for a comprehensive, integrated package of essential interventions, including information and services for the prevention of HIV and other sexually transmitted infections. The Sixty-ninth World Health Assembly adopted 3 global health sector strategies for the period 2016-2021 on HIV, viral hepatitis and sexually transmitted infections (STIs).
Sexual health issues
Defining sexual health
Key conceptual elements
- Developing sexual health programmes – A framework for action
Sexual health is a broad area that encompasses many inter-related challenges and problems. Key among the issues and concerns are human rights related to sexual health, sexual pleasure, eroticism (see below), and sexual satisfaction, diseases (HIV/AIDS, STIs, RTIs), violence, female genital mutilation, sexual dysfunction, and mental health related to sexual health.
List of sexual health concerns and problems
During a meeting held in Antigua, Guatemala in May 2000, an expert group convened by the Pan American Health Organization and WHO in collaboration with the World Association for Sexology (WAS) compiled an overview of sexual concerns and problems that should be addressed in order to advance sexual health (PAHO/WHO 2000). Sexual health concerns are life situations that can be addressed through education about sexuality and society-wide actions in order to promote the sexual health of individuals. The health sector has a role to play in assessment, and in providing counselling and care.
Sexual health concerns
- Sexual health concerns related to body integrity and to sexual safety
- Need for health-promoting behaviours for early identification of sexual problems (e.g. regular check-ups and health screening, breast and testicular self-scans).
- Need for freedom from all forms of sexual coercion and sexual violence (including rape, sexual abuse and harassment).
- Need for freedom from body mutilations (e.g. female genital mutilation).
- Need for freedom from contracting or transmitting STIs (including HIV).
- Need for reduction of sexual consequences of physical or mental disabilities.
- Need for reduction of impact on sexual life of medical and surgical conditions or treatments.
- Sexual health concerns related to eroticism
- Need for knowledge about the body, as related to sexual response and pleasure.
- Need for recognition of the value of sexual pleasure enjoyed throughout life in safe and responsible manners within a values framework that is respectful of the rights of others.
- Need for promotion of sexual relationships practised in safe and responsible manners.
- Need to foster the practice and enjoyment of consensual, non-exploitative, honest, mutually pleasurable relationships.
- Sexual health concerns related to gender
- Need for gender equality.
- Need for freedom from all forms of discrimination based on gender.
- Need for respect and acceptance of gender differences.
- Sexual health concerns related to sexual orientation
- Need for freedom from discrimination based on sexual orientation.
- Need for freedom to express sexual orientation in safe and responsible manners within a values framework that is respectful of the rights of others.
- Sexual health concerns related to emotional attachment
- Need for freedom from exploitative, coercive, violent or manipulative relationships.
- Need for information regarding choices or family options and lifestyles.
- Need for skills, such as decision-making, communication, assertiveness and negotiation, that enhance personal relationships.
- Need for respectful and responsible expression of love and divorce.
- Sexual health concerns related to reproduction
- Need to make informed and responsible choices about reproduction.
- Need to make responsible decisions and practices regarding reproductive behaviour regardless of age, sex and marital status.
- Access to reproductive health care.
- Access to safe motherhood.
- Prevention of and care for infertility.
Sexual health problems
- Sexual health problems are the result of conditions, either in an individual, a relationship or a society, that require specific action for their identification, prevention and treatment.
- The expert working group of PAHO/WHO proposed a syndromic approach to classification that makes problems easier to identify by both health workers and the general public, and easier to report for epidemiological considerations.
- All of these sexual health problems can be identified by primary health workers. Some can be addressed by trained health workers at a primary level, but for others referral to a specialist is necessary.
- Clinical syndromes that impair sexual functioning (sexual dysfunction) such as sexual aversion, dysfunctional sexual arousal and vaginismus in females, and erectile dysfunction and premature ejaculation in males.
- Clinical syndromes related to impairment of emotional attachment or love (paraphilias) such as exhibitionism, paedophilia, sadism and voyeurism.
- Clinical syndromes related to compulsive sexual behaviour such as compulsive sexual behaviour in a relationship.
- Clinical syndromes involving gender identity conflict such as adolescent gender dysphoria.
- Clinical syndromes related to violence and victimization such as clinical syndromes after being sexually abused as a child (including post-traumatic stress disorder); clinical syndromes after being sexually harassed; clinical syndromes after being violated or raped; clinical phobia focused on sexuality; patterns of unsafe sexual behaviour placing self and/or others at risk for HIV infection or/and other STIs.
- Clinical syndromes related to reproduction such as sterility, infertility, unwanted pregnancy, abortion complications.
- Clinical syndromes related to sexually transmitted infections such as genital ulcers, urethral, vaginal or rectal discharge, lower abdominal pain in women, asymptomatic STIs.
- Clinical syndromes related to other conditions such as clinical syndromes secondary to disability or infirmity, secondary to mental or physical illness, secondary to medication.
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- Talking about sex
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