Connections and disconnections in public health
Jane Cottingham
At one point during government negotiations on the Programme of Action of the International Conference on Population and Development (ICPD) in Cairo, 1994, someone suggested that the term ‘sexual health’ should be included in the definition of reproductive health. There was a flurry of activity. Representatives of the World Health Organisation (WHO) were asked whether an official definition of sexual health existed and urgent messages were sent back to Geneva for people to comb the archives. They identified one technical report on human sexuality, published in 1975, which provided the following definition:
Sexual health is the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love … The notion of sexual health implies a positive approach to human sexuality, and the purpose of sexual healthcare should be the enhancement of life and personal relationships and not merely counselling and care related to procreation or sexuality transmitted diseases.
(WHO 1975: Section 2.1)
It was the second part of this definition that was slightly amended for inclusion in the eventual ICPD Programme (United Nations 1994). Considering the importance now being attached to sexuality and sexual health, it is striking that, apparently, no further elaboration of the definition of sexual health took place in the 20-year period between the publication of the Technical Report and the ICPD Programme. And despite the fact that the ICPD Programme included sexual health in reproductive health, by far the lion’s share of attention in policies and programmes following ICPD – at least in the developing world – continued to be given to the aspects of reproductive health that had been historically accepted: maternal and child health and family planning. At the level of international development assistance, sexual health as just defined has not been a target of support per se.
Why was this? There are several lines of argument that I will explore here. The first relates to the international political environment that influenced the entire casting of the ICPD Programme of Action. Growing concerns during the 1960s about the population explosion described in best-selling publications such as Paul Ehrlich’s The Population Bomb (1968) and the Club of Rome’s Limits to Growth (Meadows et al. 1972), led to an unprecedented investment during the end of the 1960s and the 1970s in population control through support to family planning programmes (Dixon-Mueller 1987). It was assumed that the substantial distribution of contraceptives to women in developing countries would inevitably have an impact on population growth. Large campaigns were often undertaken to sterilise women in some Latin American countries and both men and women in India, or to bring implantable contraceptives to women in Indonesia through ‘safaris’ in which buses were driven out to the rural areas and women rounded up for the insertions (Isis 1984). That these campaigns were often coercive started to be documented by the emerging international women’s health movement (Hartmann 1987; Garcia-Moreno and Claro 1994), which led to a serious questioning of the impact of ‘international development’ on women’s health and rights. Women’s health advocates argued that women needed ways of regulating their fertility, yes, but this would only become acceptable when they knew they could go through pregnancy and childbirth safely, and have their children survive. Women’s health and lives could not be reduced to stopping pregnancy occurring.
At about the same time, the first global estimates of maternal mortality appeared (AbouZahr and Royston 1991) showing that more than 500,000 women died each year in pregnancy. This hitherto unnamed scandal – women dying, not from a disease but in the act of producing life – was placed high on the international agenda of both the women’s movement and the international development community. Thus, the ICPD Programme was seen as an essential platform for creating a major paradigm shift: from population control to reproductive health. The latter was formulated to be ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes’ (United Nations 1994: paragraph 7.2). The definition goes on to state that reproductive health:
[T]herefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate healthcare services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.
(United Nations 1994: paragraph 7.2)
The following paragraph speaks of reproductive rights, also defined for the first time. It cannot be emphasised enough how essential this shift was for the health and rights of women as it provided for the first time an international mandate to focus on, and invest in, women’s health far beyond their need for contraception and away from seeing them as agents of demographic change. It gave legitimacy to the Safe Motherhood Initiative, launched in 1987, and a basis for action related to the overall improvement of primary healthcare, much of which provided reproductive health-related care. In the light of all this, it was almost inevitable that reproductive elements would take precedence over the ‘satisfying and safe sex life’ part of the definition, something which was much more complex. For the time being, pursuing the health and rights dimensions of reproduction to their full extent would take precedence.
The second line of argument relates to enormous prejudices and taboos related to talking about sexuality in nearly all cultures. Historically, public health has shied away from dealing with sexuality, leaving it rather to the domain of private, clinical medicine where only the problematic aspects of sexuality are of interest. Thus, sexual problems have been broadly labelled ‘sexual dysfunctions’, with an ever growing array of medication and other treatment, usually dispensed through the private sector. There is almost the implication here that problems related to sexuality are not legitimate health problems and should therefore only be dealt with, and paid for, in private as a luxury.
In the mid-1990s, however, when governments were struggling to understand what ICPD meant for their national policies and programmes, and when the HIV pandemic was beginning to make its horror felt to some extent, sexual behaviour became a legitimate topic of inquiry for public health. Yet reviews show that, far from focusing on the ‘safe and satisfying’ dimensions of sexuality, research into sexual behaviour was mainly conducted with a view to understanding (a) how coital frequency within marriage influences contraceptive use and vice versa; (b) how adolescent sexual activity and (lack of) contraceptive use are related to the risks of outof-wedlock pregnancy and childbearing; and (c) how ‘high-risk’ sexual behaviours are related to the spread of sexually transmitted infections including HIV (DixonMueller 1993). In other words, research into sexuality (and sexual health) was only useful insofar as it contributed to an increase in contraceptive use and a decrease in unintended pregnancies and sexually transmitted infections.
During this same period, there were almost no studies to examine the impact of contraception on sexual health, for instance, despite the fact that demographic surveys indicated that one of the main reasons women discontinued methods was for health concerns (Jain and Bruce 1989). In this sense, the population control imperative continued to have an impact, and the taboos could conveniently be left unexamined.
A third consideration – although not a legitimate argument for leaving out sexuality and sexual health from programmes and policies following ICPD – is that of measurement difficulties. In 1997, the first list of reproductive health indicators was developed by WHO and partner agencies (WHO 1997) using a certain number of criteria including scientific robustness, validity and reliability. They included elements for which health systems or national surveys were already gathering data, such as contraceptive prevalence, births attended by skilled health personnel, prevalence of low birth weight, maternal mortality ratio, perinatal mortality rate, availability of comprehensive obstetric care, etc. Of the 15 indicators, not one can be said to deal directly with sexual health and sexuality with the possible exception of reported prevalence in women of female genital mutilation. Others, such as the prevalence of infertility in women or the prevalence of urethritis in men, could be seen to be related to sexual ill health, but could certainly not be used to measure the ‘satisfying and safe sex life’ mentioned in the definition of reproductive health.
Four years later when the list was revised, the two indicators added in order to capture dimensions related to HIV – prevalence of HIV in pregnant women and knowledge of HIV-related prevention practices – did no better in reflecting dimensions related to sexuality and sexual health. On the other hand, it must be said that the concept of sexual health was vague and potentially all encompassing – ‘the enhancement of life and personal relationships’ – presenting an almost impossible challenge for measuring progress. It is only in the last two years that, at the international level, an attempt has been made to elaborate indicators for measuring sexual health (WHO forthcoming), through a process that is described further later.
In the larger international arena, then, the truly reproductive elements of reproductive health were given priority for at least a decade after ICPD. Yet, on a parallel but much lower key track, there was a movement to focus on sexual health within public health, at least in Europe. In 1987 the WHO Regional Office for Europe (EURO) convened a working group of 20 people to examine ‘concepts of sexual health’. The purpose was to clarify the concepts of sexual health by considering a range of population groups, to identify factors contributing to sexual ill health and means of promoting sexual health and to suggest indicators that could be used to evaluate the effectiveness of programmes and policies and measure any general movement towards sexual health.
The report notes that sexuality had been recognised as an important aspect of health and that the European regional family planning programme had included it since 1984. Interestingly, the report notes that due to the range of individual, cultural, religious and social differences and the various patterns of lifestyles, social and gender roles, there could be no single definition of a sexually healthy individual. A definition, it goes on, would be normative, and restrictive and it would also not be feasible. The importance of laws and policies to underpin individuals’ rights related to sexuality is highlighted:
Some positive concept of individual needs, responsibilities and rights in the area of sexuality needs to be established in order that laws that repress human rights can be changed (such as those against homosexuality or abortion) and that policies may be implemented to reduce restrictions on sexual expression and enable services to be established to deal with sexual problems.
(WHO Regional Office for Europe 1987: 8)
On the question of indicators, however, the report concludes that objective measures of sexual health are impossible (perhaps not surprisingly if no definition can be established), although measures of self-perception of sexual health may be valid. It posits that the only indicators possible must be related to the provision of information and reduction of discrimination, such as the existence of laws, regulations and government policies and government funding to promote public information about sexuality, the existence of educational programmes in schools that reflect the individuality and variability of human sexuality, and the existence of training programmes for educational, social and health professionals that also reflect this. Indeed, the greatest emphasis was given to the training of health professionals, particularly those dispensing family planning services, as they were considered likely to be one of the first sources of help for people with sexual problems.
The report is clear and concise, concluding with very specific recommendations relating to preventive as well as therapeutic services, the inclusion of sexuality in professional training courses and the need for community and policy action as well as research to shore up these efforts. Over 20 years later, the report remains utterly pertinent. Yet it appears that little action was taken as a result of this meeting, almost certainly as a result of it being a ‘working group’ report as opposed to a policy document brought to member states for their approval.
More than a decade later, in 2000, the Pan American Health Organization (PAHO, which also serves as the WHO Regional Office for the Americas) and the World Association for Sexology (WAS), convened a regional consultation to examine how to promote sexual health including the role of the health sector in the achievement and maintenance of sexual health. While the basic reflections around sexual health are very similar to those in the EURO document, the report emanating from the PAHO/WAS consultation is elaborated from an advocacy and policy standpoint, fuelled, among other things, by the HIV pandemic, which had barely been named at the time of the EURO meeting.
The recommendations here are more detailed and are presented in the form of goals, strategies and actions to promote sexual health. They include proposals to integrate sexual health into public health programmes, promote responsible sexual behaviour, provide comprehensive sexuality education to the population at large, provide education, training and support to professionals working in sexual healthrelated fields, provide access to comprehensive sexual healthcare services to the population and promote and sponsor research on sexuality and sexual health. This report can probably boast being the first international (albeit regional) policy document focusing exclusively on sexual health. It is being used widely throughout the region to promote sexual health.
Two more recent events have contributed towards greater articulation of the ‘sexual’ part of ‘reproductive health’. First was an international consultation on sexual health organised in 2002 by WHO at the international level, in conjunction with WAS (WHO 2006). Its purpose was to discuss concepts and definitions, examine barriers to the promotion of sexual health and propose effective and appropriate strategies for such promotion. Unlike the EURO group in 1987, this consultation took up the challenge of defining sexual health and, in line with the PAHO 2000 report, described three other interrelated terms: sex, sexuality and sexual rights. These were deemed essential to the understanding of sexual health.
It is significant that, even in the Technical Report of 1975, the recognition of rights is seen as essential: ‘Fundamental to this concept are the right to sexual information and the right to pleasure’ (WHO 1975: Section 2.1). The 1987 EURO document also affirmed ‘the rights and needs of individuals to be free from sexual exploitation and oppression by others’ (WHO 1987: 19). The PAHO report states that ‘since protection of health is a basic human right, it follows that sexual health involves sexual rights’ (PAHO 2000: 10). The WHO report of the 2002 meeting anchors the definition of sexual rights in human rights documents, including UN human rights treaties such as the Convention on the Elimination of All Forms of Discrimination against Women and international consensus documents such as the Beijing Platform for Action of the Fourth World Conference on Women (United Nations 1995). The latter speaks, inter alia, of women’s human rights as including 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.
The working definition of sexual health from the 2002 meeting makes clear that ‘for sexual health to be attained and maintained, the sexual rights of all persons must be protected, respected and fulfilled’ (WHO 2006: 5) Rape, FGM and persecution on the basis of sexual orientation or sexual practices not only lead to sexual ill health, but are also violations of the right to bodily integrity and to non-discrimination. Thus rights and health are taken to be inextricably linked, in the same way as reproductive rights were defined in the ICPD Programme, even though sexual rights per se were not (see also the chapter in this volume by Carmen Barroso). It was striking that both the PAHO and the WHO meeting reports gave specific focus to different sexualities, thus moving well beyond sexuality as some kind of subset of reproduction.
The second event was the adoption by the World Health Assembly in May 2004 of the WHO Global Reproductive Health Strategy. Despite its title, which was deliberately crafted to be aligned with the ICPD Programme of Action, the Strategy uses the term ‘sexual and reproductive health’ throughout the main text. More significantly, it describes five core aspects of sexual and reproductive health, the fifth of which is promoting sexual health (WHO 2004). This represents a major move forward not only because it articulates much more clearly than the ICPD Programme the importance of sexual health along with all the other aspects – maternal and newborn health, family planning, eliminating unsafe abortion and combating sexually transmitted infections – but it has also necessitated the development of clear indicators for its measurement. These include indicators intended to capture, for instance, to what extent young people’s first sexual experience is protected, consensual and without regret, as well as the more classic prevalence of female genital mutilation (WHO 2007, forthcoming).
Health sector indicators include the availability of service delivery standards and protocols in promoting sexual health, the proportion of the population who has ever received counselling on sexual health/sexuality and the availability of psychosexual services. Because the Strategy’s key actions include creating supportive legislative and regulatory frameworks, indicators for sexual health also include a series of legal/policy indicators such as whether there is a law prohibiting discrimination including that based on sexual orientation, whether there is a law prohibiting sexual violence (including marital rape) and whether comprehensive sexuality education is mandatory. Information on these indicators may not necessarily be easy to collect, but their very existence in official WHO documents designed for use at national level will mean that serious monitoring of sexual health can begin, at least in some countries.
What conclusions can be drawn from these connections and disconnections between sexual health and reproductive health, sexuality and reproduction? The first is that the political environment plays a critical role in which issues are taken up and which are left aside. At ICPD, the women’s health advocacy movement had considerable lobbying power, and at the time their main concern was to ensure that the concepts of reproductive health and gender equality were accepted. As with all strategies, choices usually have to be made, and the importance of the reproductive part meant that it had to take precedence over the sexual health part. One year later, at the Fourth World Conference on Women in Beijing, there was a powerful attempt to include ‘sexual rights’ in the Platform, but the opposition was too strong and despite the additional reference to women’s human rights including their right to decide in matters relating to their sexuality, the ICPD language relating to reproductive health remained the dominant mandate, at least in the international health community.
The second conclusion also relates to strategy. Technical meetings such as the one in 1975 resulting in the WHO Technical Report and that in 1987 in EURO are all well and good. They bring important data and analysis to the table. They can raise and examine issues not previously dealt with. But recommendations from such meetings are likely to remain on desks or in cupboards if they are not backed up or complemented by a process to elaborate and implement policy. At the international level in public health, it is clear that the World Health Assembly carries great weight. The adoption of the Reproductive Health Strategy was done through a resolution which calls for a report on progress every two years. This means that all of the ‘core aspects’ – including promoting sexual health – can be highlighted and debated at high ministerial level on a regular basis. This is an essential piece in the continuing fight for recognition of sexuality and sexual health issues at national level.
At the same time, such initiatives within the United Nations mechanisms are unlikely to be successful unless accompanied by other initiatives at different levels, particularly by civil society. Throughout the period reviewed here, there has been a growing movement in civil society to have sexual health, sexuality and sexual rights named and recognised both nationally and internationally. It is almost certain that the HIV pandemic stimulated the huge activism for such recognition, and that the PAHO and WHO meetings were able to take place because of this. It is noteworthy, too, that the mid-2000s saw the development and publication of two international, NGO documents: the Yogyakarta Principles (2007) signed by over 20 key activists in the field of human rights, and the IPPF Sexual Rights Charter (2008) now being used across the Federation’s members which cover the globe.
Finally, for policies to be taken up and implemented there must be measures of progress and accountability. It is a frequently cited truism that if things are not counted they will not be addressed. The development and use of indicators in the domains of sexuality and sexual health is absolutely critical to keeping sexuality, health and rights on the public health agenda for the foreseeable future.
AbouZahr, C. and Royston, E. (1991) Maternal Mortality: A Global Factbook, Geneva: WHO; abstract available at: www.popline.org/docs/1031/074640.html (accessed 24 January 2009).
Dixon-Mueller, R. (1987) ‘U.S. International Population Policy and “the Woman Question” ’, New York University Journal of International Law and Politics, 20 (1): 143–67.
Dixon-Mueller, R. (1993) ‘The Sexuality Connection in Reproductive Health’, Studies in Family Planning, 24 (3): 269–82.
Ehrlich, P. (1968) The Population Bomb, New York: Ballatine Books.
Garcia-Moreno, C. and Claro, A. (1994) ‘Challenges from the Women’s Health Movement: Women’s Rights versus Population Control’, in Sen, G., Germain, A. and Chen, L. C. (eds) Population Policies Reconsidered: Health, Empowerment and Rights, Boston, MA: Harvard University Press.
Hartmann, B. (1987) Reproductive Rights and Wrongs: The Global Politics of Population Control and Contraceptive Choice, New York: Harper & Row.
IPPF (2008) ‘Sexual Rights: An IPPF Declaration’; available at: www.apf.pt/cms/files/conteudos/file/SexualRightsIPPFdeclaration.pdf?PHPSESSID=5ca72b06632f81193b7049afa4f4eeaf (accessed 30 January 2009).
Isis (1984) Women and Development: A Guide for Organization and Action, Geneva: Isis Women’s International and Information Service.
Jain, A. and Bruce, J. (1989) ‘Quality: The Key to Success’, People, 16 (4): 6–8.
Meadows, D. H. et al. (1972) The Limits to Growth: A Report for the Club of Rome’s Project on the Predicament of Mankind, New York: Universe Books.
PAHO (2000) ‘Promotion of Sexual Health: Recommendations for Action’, Proceedings of a Regional Consultation convened by the Pan American Health Organization and the World Health Organisation in Collaboration with the World Association for Sexology, Guatemala: PAHO; available at www.paho.org/english/hcp/hca/promotionsexualhealth.pdf (accessed 20 February 2009).
United Nations (1994) Programme of Action of the International Conference on Population and Development, New York: United Nations; available at www.un.org/popin/icpd/conference/offeng/poa.html (accessed 24 January 2009).
United Nations (1995) Platform for Action of the Fourth World Conference on Women, Beijing, 1995, New York: United Nations; available at www.un.org/womenwatch/daw/beijing/platform/index.html (accessed 25 January 2009).
WHO (1975) Education and Treatment in Human Sexuality: The Training of Health Professionals, Geneva: World Health Organisation (WHO Technical Report Series No. 572); available at: www2.hu-berlin.de/sexology/GESUND/ARCHIV/WHOR.HTM#N3 (accessed 24 January 2009).
WHO (1997) Reproductive Health Indicators for Global Monitoring, Report of an Interagency Technical Consultation, First Meeting, April 1997, Geneva: World Health Organisation; available at www.who.int/reproductive-health/publications/HRP_97_27/index.html (accessed 24 January 2009).
WHO (2001) Reproductive Health Indicators for Global Monitoring, Report of an Interagency Technical Consultation, Second Meeting, July 2000, Geneva: World Health Organisation; available at www.who.int/reproductive-health/publications/rhr_01_19/index.htm (accessed 24 January 2009).
WHO (2004) Reproductive Health: A Global Strategy, Geneva: World Health Organisation; available at www.who.int/reproductive-health/publications/strategy.pdf (accessed 24 January 2009).
WHO (2006) Defining Sexual Health, Report of a Meeting, January 2002. Geneva: World Health Organisation; available at www.who.int/reproductive-health/publications/sexualhealth/index.html (accessed 24 January 2009).
WHO (2007) National Level Monitoring of the Achievement of Universal Access to Reproductive Health. Conceptual and Practical Considerations and Related Indicators, Geneva: World Health Organisation; available at www.who.int/reproductive-health/publications/universalaccess/index.html (accessed 24 January 2009).
WHO (forthcoming) Measuring Sexual Health: Conceptual Considerations and Related Indicators, Geneva: World Health Organisation.
WHO Regional Office for Europe (1987) Concepts of Sexual Health, Report of a Meeting in Copenhagen, May 1987, Copenhagen: World Health Organisation.
Yogyakarta Principles (2007) available at www.yogyakartaprinciples.org (accessed 30 January 2009).