Sexual health: a post-2015 palimpsest in global health?

When the UN Secretary-General submitted his September, 2013, report1UNReport of the Secretary-General. A life of dignity for all: accelerating progress towards the Millennium Development Goals and advancing the United Nations development agenda beyond 2015. 68th session of the General Assembly. http: //www. un. org/ga/search/viewdoc. asp? symbol=A/68/202Date: 2013Google Scholar to a meeting of the UN General Assembly on the post-2015 development agenda, sexual and reproductive health issues were recognised as key elements of sustainable development. The report called for women and girls to have access to “the full range of health services, including in the area of sexual and reproductive health and reproductive rights”. 1UNReport of the Secretary-General. A life of dignity for all: accelerating progress towards the Millennium Development Goals and advancing the United Nations development agenda beyond 2015. 68th session of the General Assembly. http: //www. un. org/ga/search/viewdoc. asp? symbol=A/68/202Date: 2013Google Scholar This call is notable for several reasons; not only for the willingness of the Secretary-General to consider sexual and reproductive health as an important element for sustainable societies and the future global health agenda but also, unfortunately, for what it omits. Specifically, within the Secretary-General's proposed health goal, with its aim “to realise women's reproductive health and rights”, 1UNReport of the Secretary-General. A life of dignity for all: accelerating progress towards the Millennium Development Goals and advancing the United Nations development agenda beyond 2015. 68th session of the General Assembly. http: //www. un. org/ga/search/viewdoc. asp? symbol=A/68/202Date: 2013Google Scholar no mention of human sexuality and concomitant rights in relation to sexual health is present, and, importantly, the report only calls for services to be available for half the population. This exclusion is a missed opportunity, not only because it omits men and boys in health programmes, but also because it does not recognise the fundamental role that sexual health and attendant rights in relation to sexuality has in determination of health outcomes. One reason for this exclusion might be that understanding of the meaning of sexual health and its associated principles, policies, and programmes is not widespread. WHO published its first definition of sexual health in 1975 and emphasised that the “notion of sexual health implies a positive approach to human sexuality, and the purpose of sexual health care should be the enhancement of life and personal relationships”. 2WHOEducation and treatment in human sexuality: the training of health professionals. World Health Organ Tech Rep Ser. 1975; 572: 5-33PubMed Google Scholar This definition served the international community for the next 25 years and was incorporated into various international treaties and covenants, most importantly the Programme of Action of the International Conference on Population and Development (ICPD) in 1994, which allied sexual health with “the new comprehensive concept of reproductive health”. 3UNInternational conference on population and development. Programme of action, section 1. 8. http: //www. un. org/popin/icpd/conference/offeng/poa. htmlDate: 1994Google Scholar Since the beginning of the 21st century, however, sexual health has faced an uphill battle to retain recognition of its role in human fulfilment and wellbeing. A review of development assistance to sexual and reproductive health in 74 so-called Countdown countries (ie, countries tracking progress towards Millennium Development Goals 4 and 5) reported that sexual health projects received the lowest proportion of funding of any of the sexual and reproductive health interventions. 4Hsu J Berman P Mills A Reproductive health priorities: evidence from a resource tracking analysis of official development assistance in 2009 and 2010. Lancet. 2013; 381: 1772-1782Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar WHO revised its definition of sexual health in 2002 to be a state of physical, emotional, mental, and social wellbeing in relation to sexuality, underpinned by human rights in relation to sexuality. 5WHODefining sexual health. Report of a technical consultation on sexual health, 28–31 January 2002, Geneva. http: //www. who. int/reproductivehealth/topics/genderᵣights/definingₛexualₕealth. pdfDate: 2006Google Scholar These rights include, among other things, the right to health care, the right to information and education around sexuality, the right to choose sexual partners, and the right to consensual sexual relations, including consensual marriage. The 2002 definition has not been formally ratified by the World Health Assembly, and thus is a working definition of sexual health. A consultation, led by WHO, to develop a conceptual framework for sexual health incorporated the views of stakeholders from every region of the world. All agreed that at the centre of a definition of sexual health lies the notion of human sexuality underpinned by concepts of autonomy; wellbeing; and the fulfilment, promotion, and protection of human rights (figure). Yet, respondents also recognised that the central notion of sexuality is what is often missing from most of the discourse and from sexual and reproductive health, policies, and programmes. 6Toskin I Hawkes S Garcia Moreno C Caceres C Zohrabyan L Sexual health: conceptual framework and recommendations for indicators. Sex Transm Infect. 2013; 89: A7-A8Crossref Google Scholar Autonomy, in this context, relates to the rights of individuals to self-determination in sexual health; rights that need to be recognised by the state and enabled by everyone—from partners and families to global institutions. The framework also recognises that concepts such as pleasure, intimacy, social values in relation to sexuality, and the diverse range of human gender identities and roles are often overlooked in programmes and policies. Instead, these policies tend to have a narrow focus on the negative outcomes of human sexuality and sexual behaviour—eg, on disease, infection, adverse outcomes of reproduction, and gender-based violence. Inclusion of a broad conceptualisation of sexual health will not only promote, protect, and fulfil rights but also might improve health outcomes. An emerging evidence base suggests that comprehensive programmes, which place sexuality centre-stage in sexual and reproductive health, might be more effective than those that are simply driven by a concern with disease-focused outcomes. HIV programmes in Kenya that include sexuality counselling have noted an increase in clients' self-esteem, contraceptive use, and uptake of services for sexually transmitted infections. 7Ouma AJ van der Kwaak A Promoting sexual health for young people in Kenya: family health options Kenya sexuality counselling approach. The Royal Tropical Institute (KIT), Amsterdam2009Google Scholar In Brazil, sexual and reproductive health clients were willing to pay out-of-pocket for sexuality counselling to be incorporated into services. 8Chacham AS Hilber AM Promising practices of sexuality counselling: the experience in Brazil (Coletivo Feminista de Sexualidade e Saúde). The Royal Tropical Institute (KIT), Amsterdam2009Google Scholar Sexual health inclusion in the post-2015 discourse provides a unique opportunity to pursue policies and programmes that respond to the fulfilment of a core aspect of human nature. However, sexual health should not be seen as merely a palimpsest for the achievement of reproductive health goals for girls and women. Sexual health has been clearly defined and its principles agreed on as important for everyone regardless of sex, gender, sexual orientation, age, or economic position. Sexual health, with its emphasis on human rights and autonomy, deserves to be understood and addressed globally, and, hopefully, addressing sexual health will result not only in improved sexual health outcomes but also in better reproductive and other health outcomes than presently exist. I declare no competing interests.