Eli Coleman
A fundamental change has occurred in public health discourse over the last 20 years with the acknowledgement that sexual health is essential to overall health and wellbeing. This chapter examines this phenomenon and traces the origins of this transformation. It focuses in particular on how changes in understandings of sexuality have brought about a reorientation of clinical and professional practice, and how in particular the field of sexology has become transformed so as to engage with progressively broader health concerns.
The field of sexology – defined as the interdisciplinary and scientific study of sexuality – was founded in Germany in the early part of the twentieth century. Iwan Bloch (1928) is credited with coining the term Sexualwissenschaft (sexology) (Haeberle 1983, n.d.). With his colleague Magnus Hirschfeld, Bloch published the first sexological journal, Zeitschrift für Sexualwissenschaft, in 1908 (Bloch 1928). In 1919, the first Institute for Sexology was founded at Humboldt University in Berlin, and in 1921 the first international sexological congress took place (Haeberle 1983, n.d.).
Sexology was born in a time of rapid social change fuelled by the women’s emancipation movement and the Industrial Revolution. A basic principle of the emerging new field was that in order to understand the complexity of human sexuality, an interdisciplinary perspective was necessary. Medical science, which hitherto was a dominating discourse on sex, was viewed as a limited lens – and one that tended to view things from a pathological viewpoint. It is interesting to note, however, that most early pioneers in sexology were physicians (e.g. Albert Moll, Max Marcuse and Havelock Ellis; Bullough 1994), and the focus was often on understanding sexual variations and disorders (Krafft-Ebing 1908). However, for the most part what distinguished early sexology from medicine was its attempt to understand the normality and healthiness of a wide range of forms of sexual expression. In addition, the pioneers were sexual reformers fighting for sex education, access to care and sexual rights. Science was their tool for advocacy (Bullough 1978, 1994).
After the destruction of the Hirschfeld Institute by the Nazis in 1933, the field of sexology was revitalised in the USA much to the credit of Alfred Kinsey and the publication of his famous studies (Kinsey et al. 1948; Kinsey et al. 1953). The Kinsey Institute for Sex Research was founded in 1947 (The Kinsey Institute, n.d.). Twelve years later, the Society for the Scientific Study of Sex came into being. The interdisciplinary nature of this group is particularly notable, signalling a shift in the composition of the next generation of sexology pioneers. Albert Ellis, a psychologist, served as the society’s first president. It is notable too that the Americans chose the terms ‘sex research’ and ‘sexual science’ over ‘sexology’. This was a deliberate attempt to try to legitimise the scientific study of sexuality in science.
While Kinsey and Ellis were both sexual reformers, Ellis did not limit himself to the study of sexuality or teaching courses but was an avid lecturer and writer in popular forums. He had a major influence on the sexual revolution, publishing popular books such as The Folklore of Sex (1951), The American Sexual Tragedy (1954) and Sex Without Guilt (1958). These books illustrated his liberal sexual attitudes in the context of the very conservative times of the 1940s and 1950s. He testified in court on behalf of issues related to sexual rights and engaged in many other advocacy activities (Reiss and Ellis 2002).
The new era rekindled European sexology and spawned new centres around the world. The International Academy of Sex Research (note the use of the term sex research; www.iasr.org) was founded in 1974 by Richard Green from the State University of New York at Stony Brook. The first meeting was held there in 1975. The Association is still dominated by scientists from the USA, Canada and, less so, western Europe, but it does have a worldwide membership. Annual meetings generally rotate between North America and western Europe.
On an international level, sexology remained more dominated by physicians, as illustrated by the first World Congress of Medical Sexology which was held in Paris in 1974 (note the term medical). This forum resurrected the sexological congresses first organised by Hirschfeld and Moll. The World Association for Sexology (WAS) was founded in 1978 in Rome at the 3rd World Congress of Medical Sexology. The name of the World Congresses was changed to the World Congress of Sexology, which reflected a wider view of sexology. Male physicians and primarily clinicians led this organisation for most of its early history.
In the fertile environment of the budding sexual revolution of the 1960s and 1970s, sex research was revived and gained speed. This second sexual revolution focused on ‘wellness’ and self-actualisation. Publications by Kinsey (Kinsey et al. 1948; Kinsey et al. 1953), Masters and Johnson (1966, 1970), Gagnon and Simon (1973), Bell and Weinberg (1978) and others challenged the notion of what was considered sexually healthy or not. Kinsey in particular examined the nature of human sexual expression without attempting to find the roots of disease and dysfunction. As with the early German sexologists, an interdisciplinary approach was continued in an attempt to understand normal sexuality (Bullough 1978, 1994).
In the context of the sexual revolution of the 1960s and 1970s, and the revitalisation and growth of the sexology field worldwide, the World Health Organisation (WHO) held two expert consultations on the training and education of healthcare professionals in 1972 and 1974. Some of the most notable sexologists at the time attended for what was probably the first time that sexual scientists had been called on as experts to address a public health concern. As a result of these consultations, a technical document was published entitled Education and Treatment in Human Sexuality: The Training of Health Professionals (World Health Organisation 1975).
In developing this document, the authors recognised that training was needed to promote sexual health and wellbeing. They also recognised the need to advance knowledge by developing the field of sexology and disseminating knowledge through sexual resource centres around the world. As a first step towards promoting sexual health, the authors recognised the need to define sexual health. Until the WHO consultation, no definition had been constructed. In 1975 the World Health Organisation published the following definition of sexual health:
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.
(WHO 1975)
In the next paragraph, the authors wrote, ‘Fundamental to this concept is the right to sexual information and the right to pleasure’. The document went on to cite Mace et al. (1974), who described sexual health as having three basic elements: (1) the capacity to enjoy and control sexual and reproductive behaviour in accordance with a social and personal ethic; (2) a freedom from fear, shame, guilt, false beliefs and other psychological factors inhibiting sexual response and impairing sexual relationships; and (3) freedom from organic disorders, diseases and deficiencies that interfere with sexual and reproductive functions. The WHO document concluded:
Thus 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 counseling and care related to procreation or sexually transmitted diseases.
(WHO 1975)
While the 1975 document had profound impact on the field of sexology, its influence in the sphere of public health was hardly palpable. It was not until 1986 that WHO took up the issue of sexual health again. In that year and the next, the European Region of WHO held two consultation meetings to clarify concepts of sexual health by (a) focusing on different groups of people within the region; (b) identifying factors contributing to sexual ill health and the means of promoting sexual health; (c) suggesting indicators that could be used to evaluate the effectiveness of programmes and policies by 2000; and (d) making recommendations for further steps forward (Langfeldt and Porter 1986; WHO Regional Office for Europe 1987). While a report was published from the 1986 meeting and a number of background papers were prepared for the 1987 consultation, no official report was ever published of this latter meeting.
In the expert consultation in 1987, participants expressed deep concern about the possibility or utility of defining sexual health. Gunter Schmidt, a German sexologist, was particularly critical of this effort. He said that sexual health implied certain norms for ‘proper’ sex that can be termed ‘healthy’. Attempting to define sexual health risked propagating sexual norms disguised as medical truths (Schmidt 1987).
With the advent of HIV in the 1980s, new technological developments such as the internet, and further developments in the field of human sexuality such as biomedical advances and an understanding of the importance of gender and power analysis, a further sexual revolution began (Coleman 2000). Much like the revolution of the 1960s and 1970s, this revolution was fuelled by scientific advances, as well as by dramatic social and economic change (Coleman 2000; Inglehart 1997; Reiss 1990, 2001; Reiss and Reiss 1997).
The HIV pandemic and the new sexual revolution put pressure on health ministries to develop new approaches to sexual health promotion. The combined burden of HIV, increases in unwanted pregnancies, greater awareness of sexual violence and greater publicity about sexual dysfunctions and disorders, raised awareness of the need for better quality sexuality education and a more concerted approach to addressing sexuality problems. A new public health mandate began to emerge to address these issues (Coleman 1997, 2002, 2007).
In parallel, the term sexual health became incorporated in discourse at a public health level. The programme of action (POA) from the 1999 International Conference on Population and Development (ICPD) provided governments with guidance in addressing the sexual and reproductive health in a comprehensive, integrated manner. The document defined reproductive health as including sexual health, echoing the WHO 1975 definition of sexual health, ‘the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases’ (United Nations 1994: para. 7.2). The POA also contained two important objectives pertaining to sexual health: (1) ‘to promote adequate development of responsible sexuality, permitting relations of equity and mutual respect between the genders and contributing to improving the quality of life of individuals’ (United Nations 1994: para. 7.36) and (2) ‘to ensure that women and men have access to the information, education and services needed to achieve good sexual health and exercise their reproductive rights and responsibilities’ (United Nations 1994: para. 7.36b).
This global effort as well as the general crisis of HIV stimulated the development of sexual health national strategies in Australia (Australian Institute of Health and Welfare 2000; England (Department of Health 2001); and the USA (US Surgeon General 2001). In Australia and England, strategies to promote sexual health were clearly tied to HIV prevention and the prevention of teenage pregnancy. In the USA, the Surgeon General took a somewhat broader sexual health approach.
With the passage of time, however, it became evident that the WHO 1975 definition needed to be revisited. The Pan American Health Organization (PAHO) responded by holding a regional consultation in 2000 in Antigua, Guatemala, in collaboration with the World Association for Sexology. For the first time, WAS was consulted to provide expert input, help organise the meeting and invite experts in the field. A regional strategy for sexual health promotion was developed. A new definition of sexual health was crafted (see PAHO 2000) that was crisper and more comprehensive than the original 1975 definition. This reaffirmed the concept of wellbeing and the absence of disease, dysfunction and infirmity. It also recognised that sexual rights were an essential condition for the attainment of sexual health. WAS’s involvement was critical in this respect. In 1999 it had issued a Declaration of Sexual Rights asserting that sexual health was contingent on society’s efforts to protect, promote and preserve the sexual rights of every citizen (World Association for Sexology 1999) (see Box 15.1).
Box 15.1 WAS Declaration of Sexual Rights
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 the 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.
Sexual rights are universal human rights based on the inherent freedom, dignity and equality of all human beings. Since health is a fundamental human right, so must sexual health be a basic human right. In order to assure that human beings and societies develop healthy sexuality, the following sexual rights must be recognised, promoted, respected and defended by all societies through all means. Sexual health is the result of an environment that recognises, respects and exercises these sexual rights.
1 The right to sexual freedom. Sexual freedom encompasses the possibility for individuals to express their full sexual potential. However, this excludes all forms of sexual coercion, exploitation and abuse at any time and situations in life.
2 The right to sexual autonomy, sexual integrity and safety of the sexual body. This right involves the ability to make autonomous decisions about one’s sexual life within a context of one’s own personal and social ethics. It also encompasses control and enjoyment of our own bodies free from torture, mutilation and violence of any sort.
3 The right to sexual privacy. This involves the right for individual decisions and behaviors about intimacy as long as they do not intrude on the sexual rights of others.
4 The right to sexual equity. This refers to freedom from all forms of discrimination regardless of sex, gender, sexual orientation, age, race, social class, religion or physical and emotional disability.
5 The right to sexual pleasure. Sexual pleasure, including autoeroticism, is a source of physical, psychological, intellectual and spiritual well being.
6 The right to emotional sexual expression. Sexual expression is more than erotic pleasure or sexual acts. Individuals have a right to express their sexuality through communication, touch, emotional expression and love.
7 The right to sexually associate freely. This means the possibility to marry or not, to divorce and to establish other types of responsible sexual associations.
8 The right to make free and responsible reproductive choices. This encompasses the right to decide whether or not to have children, the number and spacing of children and the right to full access to the means of fertility regulation.
9 The right to sexual information based upon scientific inquiry. This right implies that sexual information should be generated through the process of unencumbered and yet scientifically ethical inquiry, and disseminated in appropriate ways at all societal levels.
10 The right to comprehensive sexuality education. This is a lifelong process from birth throughout the lifecycle and should involve all social institutions.
11 The right to sexual healthcare. Sexual healthcare should be available for prevention and treatment of all sexual concerns, problems and disorders.
Sexual rights are fundamental and universal human rights.
Declaration of the 13th World Congress of Sexology, 1997, Valencia, Spain. Revised and approved by the General Assembly of the World Association for Sexology (WAS) on 26 August 1999, during the 14th World Congress of Sexology, Hong Kong, People’s Republic of China.
Through pressure by the World Association for Sexology, the PAHO document and the worldwide demand for a public health response to growing sexual health problems, WHO was challenged to revisit its own 1975 definition. Recognising the public health imperative to develop strategies to promote sexual health on a global scale, WHO together with WAS planned an expert consultation in 2002, in Geneva. A range of experts were called on to grapple with the daunting task of finding common ground from all the diverse regions, ideologies and values (WHO 2002a). To everyone’s surprise, there was remarkable consensus. A working group was commissioned to finalise a new definition of sexual health (and included new definitions of sex, sexuality and sexual rights (WHO 2002b)) (see Box 15.2).
Box 15.2 Sexual health
Sexual health is a state of physical, emotional, mental and social well-being related 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.
Working Definition, World Health Organisation, 2002. www.who.int/reproductive-health/topics/gender-rights/defining-sexual-health.pdf
By way of follow up to the 2002 expert consultation, WHO established a new thematic work programme within one of its departments. Although sexual health had been implicitly understood to be part of the reproductive health agenda, the emergence of HIV-, sexual- and gender-based violence, and the extent of sexual dysfunction (to name but a few of the developments over the past two decades), highlighted the need to focus more explicitly on sexuality and the promotion of sexual health. WHO developed a conceptual framework to guide this work, although this document remains as yet unpublished.
Meantime, WAS changed its name to the World Association for Sexual Health (WAS) (retaining the acronym) in 2005. This change was a significant departure and illustrates this chapter’s theme, the transition from sexology to sexual health. As WAS articulated its mission, there was a realisation that it was not only through the promotion of sexology, but also of sexuality education, clinical work and advocacy efforts that the association could be influential. By changing its name, WAS recognised that sexual health had come of age. The World Congress of Sexology changed its name as well and became the eighteenth World Congress for Sexual Health.
With its newly refined vision and mission, WAS launched an effort to make a declaration for the promotion of sexual health. It saw an opportunity to advance the sexual health agenda with the advent of the UN Millennium Development Goals (MDGs). A series of round tables at the World Congress in Montreal in July of 2005 developed the Montreal Declaration: Sexual Health for the Millennium. Ultimately, WAS revised and published Sexual Health for the Millennium: A Declaration and Technical Document (WAS 2008). WAS saw sexual health as central to the attainment of wellness and wellbeing, and the achievement of sustainable development and the implementation of the MDGs. Individuals and communities who experience sexual wellbeing are better positioned to contribute to the eradication of individual and societal poverty. By nurturing individual and social responsibility and equitable social interaction, the promotion of sexual health can and will foster the quality of life and the realisation of peace (WAS 2008).
In 2006 ministers of health from 48 African countries (later affirmed by the African heads of states) declared that the MDGs could not be achieved without more work on sexual and reproductive health and rights. In a historic declaration, they asserted that sexual health – beyond a venereological approach – was needed to combat poverty and promote human development. This included access to good quality sexual and reproductive health services, information and education related to sexuality, the protection of bodily integrity and the guarantee of sexual rights such as choice of sexual and marriage partners, childbearing and, ultimately, the right to pursue a satisfying, safe and pleasurable sexual life (African Union Commission 2006).
Two years later, in 2008, the Swedish International Development Cooperation Agency published a remarkable concept paper entitled Sexuality: A Missing Dimension in Development (Sida 2008). Taking up the issue of the MDGs, Sida affirmed the centrality and importance of promoting sexual health and rights in attaining these goals. The concept paper acknowledged that much work hitherto had focused on the problematic and negative aspects of sexuality and/or gender equality. The concept paper endorsed many of the sexual health principles outlined in the Maputo Plan of Action alongside a rights-based approach to sexual health. Sida committed itself to take a leading role internationally in the area of sexuality, and to supporting empowering approaches to sexuality in general and sexuality education in particular.
In the same year the International Planned Parenthood Federation (IPPF) published a declaration affirming sexual rights as a component of basic human rights (IPPF 2008). This was a significant development for this organisation. Putting the ‘s’ into sexual and reproductive rights had hitherto been difficult for many organisations working in the field of reproductive health. The IPPF Declaration recognised that many expressions of sexuality are non-reproductive and that sexual rights cannot be subsumed under reproductive rights and reproductive health.
Yet another recent historic achievement was the recent declaration ‘preventing through education’ drafted and signed by ministers of health and education from Latin American and the Caribbean on the eve of the World AIDS Conference in Mexico City, 1 August 2008 (Ministers of Health and Education in Latin American and the Caribbean 2008). This declaration affirmed sexual rights as a basic human right, and the critical importance of comprehensive sexuality education as a strategic means of stemming the HIV pandemic. It was significant that this was a joint declaration made by ministers of health and education. While the discourse of sexual health had dominated the health sector, the issue of sexuality education is more current in education. There was recognition of the need for cooperative intersectoral strategies. Never before had regional policymakers embraced the concept of sexual health so completely.
From a slow beginning, there has been steady progress towards the development of a strategic and comprehensive approach to the promotion of sexual health. What began with the pioneering work of sexologists in the early part of the twentieth century, and a WHO technical document in 1975 has led to an increasing number of commitments, declarations, technical documents and concept papers. The term ‘sexual health’ is now widely used at a global level and is likely to have far reaching effects. Critically, something fundamental has shifted, and a new era has begun. Sexual health is now part of public policy discourse and is recognised as a key strategy to promoting health and wellbeing.
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