Promoting sexual health and responsible sexual behavior: an introduction.

We are at a unique juncture in history and have a rare opportunity to develop global, national, and community strategies to promote sexual health for the new century. This opportunity has been created by the fact that the world is experiencing a new sexual revolution and a public health imperative. Much like the sexual revolution of the 1960s and 1970s, it is a revolution fueled by incredible scientific advances, as well as dramatic social and economic change (Coleman, 2000; Inglehart, 1997; Reiss, 1990; Reiss, 2001; Reiss & Reiss, 1997). We also face a myriad of sexual health problems, which is creating an enormous burden on societies. These two factors are putting pressure on health ministries to develop comprehensive approaches to sexual health promotion.

The last major attempt at developing global strategies for promoting sexual health was fueled by the previous sexual revolution of the 1960s and 1970s. In 1975, the World Health Organization (WHO) produced a document Education and Treatment in Human Sexuality: The Training of Health Professionals (WHO, 1975). This historic document called upon societies around the world to develop the necessary sexuality education, counseling, and therapy to promote sexual health and to provide the necessary training for health professionals. This document also served as a stimulus for the development of the field of sexology and sexual resources centers throughout the world.

In order to promote sexual health, a basic definition of sexual health was needed and articulated in this document. Although the authors recognized the difficulty of arriving at a universally acceptable definition, the following definition was presented:

"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" (p. 6). The authors further state that fundamental to the concept of sexual health is the right to sexual information and the right to pleasure.

The document went on to cite Mace, Bannerman, and Burton (1974) who described sexual health as containing three basic elements: (a) capacity to enjoy and control sexual and reproductive behavior in accordance with a social and personal ethic; (b) freedom from fear, shame, guilt, false beliefs, and other psychological factors inhibiting sexual response and impairing sexual relationship; and (c) freedom from organic disorders, diseases, and deficiencies that interfere with sexual and reproductive function. In spite of difficulties at arriving at this definition, this definition has endured and has been used throughout this last quarter century.

In 1983, the European Region of the WHO held a technical consultation meeting to further clarify sexual health strategies that could be implemented in Europe and to develop overall objectives of health for all by the year 2000. The report was published in 1986. In this report, there was an attempt to define sexuality, as without that basic definition promoting sexual health would be difficult (Langfeldt & Porter, 1986). At that time, the WHO defined sexuality as follows:

   Sexuality is an integral part of the personality of everyone: man, woman
   and child. It is a basic need and an aspect of being human that cannot be
   separated from other aspects of human life. Sexuality is not synonymous
   with sexual intercourse, it is not about whether we have orgasms or not,
   and it is not the sum total of our erotic lives These may be part of our
   sexuality, but equally they may not. Sexuality is so much more: it is in
   the energy that motivates us to find love, contact, feel warmth, and
   intimacy it is expressed in the way we feel, move, touch and are touched;
   it is about being sensual as well as sexual Sexuality influences thoughts,
   feelings, actions and interactions and thereby our mental and physical
   health. (Langfeldt & Porter, 1986, p 5)

This definition has also been used throughout the past decades and has been important to distinguish the simply biological aspects of sex and the broader concepts which encompass our sexuality.

The European Region of the WHO held another meeting in 1987 (WHO, Regional Office for Europe, 1987). The purpose of this meeting was to clarify the 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 programs and policies, and (d) making recommendations for further steps forward. This meeting was important because it clarified that any definition of sexual health was a heavily value-laden concept. Therefore, sexual health promotion would need to take into account different cultural and regional values and differences.

RESPONDING TO THE CURRENT NEED TO PROMOTE SEXUAL HEALTH AND RESPONSIBLE SEXUAL BEHAVIOR

Unfortunately, except for the European Region of the WHO, none of the other regions immediately followed up on developing strategies for their region. However, since the publication of these WHO documents, we are facing a new public health imperative to develop strategies to promote sexual health and responsible sexual behavior. These previous reports are clearly out of date. Many developments have occurred in our societies in the field of human sexuality and in other related fields of knowledge. These developments have increased our understanding and awareness of the complexity of sexual education, counseling, and treatment. Research has identified approaches and interventions that are effective, and those that are not. The emergence of new problems, notably the HIV/AIDS pandemic, has raised our awareness of current urgent needs for enhanced sexuality education and a much more conceded and comprehensive approach to addressing sexuality problems.

In response to the need to articulate new strategies, there have been several simultaneous efforts to develop global, regional, and national strategies. On a global level, the International Conference on Population and Development (ICPD) created the Programme for Action (POA) in Cairo. The ICPD POA was adopted by 184 countries. The POA provided governments with guidance to address the sexual and reproductive health of their populations in a comprehensive integrated manner. The importance of this document was the inclusion of sexual health into general reproductive health strategies. The document defined reproductive health as including 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 (Para 7.2; United Nations, 1999). The POA contained two important objectives pertaining to sexual health: "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" (Para. 7.36; United Nations, 1994), and "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" (Para 7.36b; United Nations, 1994).

On a regional level, the Pan American Health Organization (PAHO) Regional Office of the WHO, in collaboration with the World Association for Sexology, held a consultation meeting as a first step to revise the 1975 WHO document on a global scale and to develop new strategies for the promotion of sexually healthy societies. During this meeting, the expert group revisited and put forward new basic definitions of sex, sexuality, and sexual health (PAHO, Regional Office of the WHO, 2000):

1. Sex: "Sex refers to the sum of biological characteristics that define the spectrum of humans as females and males" (p. 6).

2. Sexuality: Sexuality refers to a core dimension of being human, which includes the individual and social capabilities and conditions for eroticism, emotional attachment/love, sex, gender, and reproduction. It is anchored in thoughts, fantasies, desires, beliefs and values and is expressed through identity, attitudes, values, roles, behaviors, and relationships. Sexuality is a result of the interplay of biological, psychological, socioeconomic, cultural, ethical and religious/spiritual factors. (p. 8)

3. Sexual Health: Sexual health is the ongoing process of physical, psychological, and sociocultural well being in relationship to sexuality. Sexual health can be identified through the free and responsible expressions of sexual capabilities that foster harmonious personal and social wellness, enriching life within an ethical framework. It is not merely the absence of dysfunction, disease and/or infirmity. For sexual health to be attained and maintained it is necessary that sexual rights be recognized and exercised. (p. 9)

Among many goals and strategies that were developed, this document adopted the Sexuality Information and Education Council of the United States (SIECUS) List of Life Behaviors of Sexually Healthy Adults (SIECUS, 1998). In addition, it took a bold step and defined the characteristics of a sexually health society (PAHO, Regional Office of the WHO, 2000, p. 13). Thus, it clearly laid out the responsibilities for societies to ensure that the right conditions exist which will promote sexual health and sexually healthy adults. The basic premise was that the promotion of sexual health would be accomplished if efforts were made to include sexual rights as basic and fundamental human rights. Consequently, this document recommended that international organizations, such as the World Health Organization, promote and serve as advocates to achieve consensus on the World Association for Sexology's Declaration of Sexual Rights (World Association for Sexology, 1999).

The document also included specific actions and strategies to promote sexual health. There were five overarching goals and corresponding strategies:

1. Promote sexual health, including the elimination of barriers to sexual health;

2. Provide comprehensive sexuality education to the population at large;

3. Provide education, training, and support to professionals working in sexual health related fields;

4. Develop and provide access to comprehensive sexual health care services;

5. Promote and sponsor research and evaluation in sexuality and sexual health, and the dissemination of the knowledge derived from it.

As a follow-up to the PAHO/WAS consultation, the WHO, again in collaboration with the WAS, recently held an international consultation to finalize a global document to promote sexual health (January, 2002). It is hoped that the document that emanates from this consultation will serve as a stimulus and a template for countries around the world to develop their own strategies given the particular sexual health climate and unique needs.

DEVELOPING NATIONAL AND LOCAL STRATEGIES TO PROMOTE SEXUAL HEALTH

These global and regional recommendations need to be reviewed and articulated at national and local levels. Several countries have already embarked on developing their own national strategies as well as strategies for specific populations (Australian Institute of Health and Welfare, 2000; Commonwealth Department of Health and Family Services of Australia, 1997; United Kingdom Department of Health, 2001). In the case of Australia and the United Kingdom, the strategies to promote sexual health are more specifically tied to HIV prevention. However, most recently, a broader strategy to promote sexual health and responsible sexual behavior was unveiled by the U.S. Surgeon General entitled: The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior (U.S. Surgeon General, 2001). This document clearly outlined the public health challenge and imperative that the United States faces at this time (high rates of HIV infection, sexually transmitted infections, unintended pregnancies, abortion, sexual dysfunction, and sexual violence). The Surgeon General also acknowledged the serious disparities in the populations affected. The economically disadvantaged, racial and ethnic minorities, persons with different sexual identities, disabled persons, and adolescents bear the heaviest burden.

In order to put forth strategies, a basic definition of sexual health was articulated as well as a definition of responsible sexual behavior. The definition of sexual health is consistent with previous definitions of sexual health, yet it emphasizes the importance of individuals to understand and weigh the risks, responsibilities, outcome, and impacts of sexual actions--essentially to act intentionally and responsibly.

   Sexual health is inextricably bound to both physical and mental health.
   Just as physical and mental health problems can contribute to sexual
   dysfunction and disease, those dysfunctions and diseases can contribute to
   physical and mental function, nor is its importance confined to just the
   reproductive years. It includes the ability to understand and weigh the
   risks, responsibilities, outcomes, and impacts of sexual actions and to
   practice abstinence when appropriate. It includes freedom from sexual abuse
   and discrimination and the ability of individuals to integrate their
   sexuality into their lives, derive pleasure from it, and to reproduce if
   they so choose. (U.S. Surgeon General, 2001, p. 1)

Responsible sexual behavior was also defined. Responsible sexual behavior emphasized both individual and community responsibility.

   Sexual responsibility should be understood in its broadest sense. While
   personal responsibility is crucial to any individual's health status,
   communities also have important responsibilities. Individual responsibility
   includes understanding and awareness of one's sexuality and sexual
   development; respect for oneself and one's partner; ensuring that pregnancy
   occurs only when welcomed; and recognition and tolerance of the diversity
   of sexual values within any community. Community responsibility includes
   assurance that its members have access to developmentally and culturally
   appropriate sexuality education, as well as sexual and reproductive health
   care and counseling; the latitude to make appropriate sexual and
   reproductive health choices; respect for diversity; and freedom from
   stigmatization and violence on the basis of gender, race, ethnicity,
   religion, or sexual orientation. (U.S. Surgeon General, 2001, p. 1)

The strategies to promote sexual health and responsible sexual behavior covered three fundamental areas--increasing awareness, implementing and strengthening interventions, and expanding the research base. As a first step, the Surgeon General called for a mature and thoughtful discussion of sexuality to find solutions to our society's myriad of sexual health problems. Research was deemed essential because of the basic assumption that any efforts to promote sexual health and responsible sexual behavior should be based upon the best available science. While the document's recommendations were based upon the extant research, the Surgeon General recognized the need for more basic research in human sexual development, sexual health, and reproductive health, including social and behavioral research on risk and protective factors for sexual health. The Surgeon General also recommended that the research base cover the entire human life span--from children to the elderly. Research should also focus on developing, disseminating, and evaluating educational materials for sexuality education. Research should also be expanded to evaluate community and school- and clinic-based interventions that address sexual health and responsibility.

CONCLUSION

In response to a changing sexual climate and a myriad of sexually related problems, there have been a number of attempts to develop global, regional, and national health strategies to promote sexual health and responsible sexual behavior. There is remarkable consistency throughout these documents. They have all contributed to a clarity in our definitions of sex, sexuality, and sexual health. They call for leadership of the health sector to create better climates for discussion of sexuality, access to information and education about sexuality, prevention strategies to include community-based interventions, access to care for sexually related concerns, and more research in human sexuality and evaluation of programs designed to promote sexual health and responsible sexual behavior. In order to move the research agenda forward, this special issue of The Journal of Sex Research is devoted to reviews of the existing research on topics relevant to the promotion of sexual health and responsible sexual behavior. Since 1975, we have far more evidence of the risk and protective factors of sexual health and have evaluated many interventions. It is hoped that these scientific reviews of the literature will help guide further efforts at articulating strategies for sexual health promotion, both here in the United States and around the world. But, it is clear that more research is needed. Therefore, the second aim of these reviews is to stimulate and point the way toward further research, which will guide our sexual health promotion strategies. As governments and health ministries try to grapple with the complexities of the sexual problems in societies, they will need to turn to the sexual scientists--who have the understanding of human sexuality and the capacity to create more knowledge. We can, in partnership with other sectors of society, promote a sexually healthier world.

REFERENCES

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Address correspondence to Dr. Eli Coleman, 1300 S. 2nd Street, Suite 180, Minneapolis, MN 55454; e-mail: [e-mail].