Sexual health: a public health
perspective
Kaye Wellings, Kirstin Mitchell & Martine Collumbien
Part 1: Conceptual and theoretical aspects of sexual
health
1 Sexual health: theoretical perspectives
Key terms
- Sex: it is used to refer both to sexual activity and to sum of biological characteristics that
define people as female and male.
- Sexuality: includes sex, gender, sexual identity and orientation, eroticism, attachment and
reproduction and is experienced or expressed in thoughts, fantasies, desires, beliefs,
attitudes, values, practices, roles and relationships.
Sexual health: a state of physical, emotional and social well-being in relation to sexuality. It is not
merely (alleen) the absence of disease, dysfunction of infirmity. Sexual health requires a positive and
respectful approach to sexuality and sexual relationships, as well as the possibility of having
pleasurable and safe experiences, free of coercion (dwang), discrimination and violence.
Theoretical perspectives
1 Essentialist theories
Forms of sexual expressions are for the most part fixed, innate and instinctual. Sex is determined by
biological forces, even though situational and environmental factors may give rise to variation.
Sexuality had its origin in biology and psychology: chromosomes, hormones, psychic energy and
unconscious compulsions. Freud (1949, Freud analytic theory) describes sex as a drive (natural drive
for survival of the species) and Havelock Ellis as an impulsion. Paradoxically, Freud’s attitude towards
masturbation, homosexuality and aspects of woman sexuality was one of distaste. He wrote about
‘normal’ and ‘abnormal’.
2 Social constructionist theories
Sexual behaviour is malleable (kneedbaar), amenable (vatbaar) to modification and shaped
extensively by cultural norms and socialization, often mediated by language as a way of organizing
experience and sharing concepts. It is a product of historical and social forces.
The regulation of sexual behaviour
The expression of sexual behaviour is defined, regulated and given meaning by cultural
norms. Some societies are against non-procreative sexual practices (not for reproduction,
such as oral and anal sex, same sex practice and sexual activity before the age deemed
suitable for childbearing), homosexual/bisexual and non-homogamous (multiple partners).
Barriers to the improvement of sexual health
, Homosexual activity varies a lot in countries: some celebrate it in public parades of pride, in
others it carries the dead penalty. Condoms are available to young people in schools in Brazil,
but in Indonesia, possession is a criminal offence. This has consequences for public health:
- Those in need may not come forward for help.
- Service providers may not be able to help those in need.
- Practitioners may not want to help those in need.
- Public health practitioners may not be able to help in ways that they consider to be effective.
Part 2: Sexual health outcomes
2 Sexually transmitted infections (STIs)
Incidence rate: the rate at which new infections occur in a population.
- Numerator: the number of new events occurring in a defined period.
- Denominator: the population at risk of experiencing the event during the chosen period.
Infectivity: the attributes of an individual of pathogen likely to lead to a spread of infection.
Prevalence: the proportion of individuals in a population with an infection of disease at any one time.
Prophylaxis: measures designed to preserve health and prevent the spread of disease.
Susceptibility: the attributes of an individual likely to make them more or less likely to be affected by
infection or disease.
An STI is an infection that has a higher probability of transmission via sexual contact than any other
means. It includes bacterial infections (gonorrhoea, chlamydia, chancroid, syphilis), viral infections
(HIV, human papilloma, herpes simplex virus, hepatitis B), parasites (crabs) and protozoal infections
(trichomoniasis). The pore countries have the most STIs.
R0 = β c D. R0 is the reproductive rate, β the likelihood of transmission between an infected and a
susceptible individual, c the rate of contact between infected and susceptible individuals and D the
length of time a person remains infected. When R 0 > 1, then the infection will continue to spread.
STIs are influenced by:
1. Biomedical factors: characteristics of the infection, prevalence rates in a particular setting,
susceptibility of the non-infected person and the infectivity of the infected person.
2. Behavioural factors:
a. sexual practices: anal, vaginal, etc.
b. partnerships and partner change.
c. risk-reduction strategies: condoms.
d. Male circumcision.
3. Sexual networks and sexual mixing patterns: assortative (sexual contact between individuals
with similar social and behaviour characteristics), disassortative (sexual contact between
individuals with dissimilar characteristics), age mixing.
4. Health service-related factors: willingness to seek health care and to report STI symptoms,
access to services and the quality of health care.
5. Social and political factors: level of resources a setting, attitudes towards prevention and
treatment, social norms and laws relating to STIs.
, Observations figure:
- Population is doubled, the chart numbers are not percentages.
- Increase after WWI and II.
- 1993: effective therapy.
3 Unplanned pregnancy
Key terms:
- Abortion: the termination of pregnancy by the removal or expulsion from the womb of a
foetus or embryo prior to viability. A spontaneous abortion is called ‘miscarriage’.
- Emergency contraception: the use of a drug or device after intercourse to prevent
pregnancy.
- Unmet need: woman who are sexually active but not using contraception and who do not
want a child within 2 years, are considered to have an unmet need for family planning.
- Unsafe abortion: a procedure for terminating an unintended pregnancy carried out by
persons lacking the necessary skill and/or in an environment that does not conform to
minimum medical standards.
It is difficult to measure unplanned pregnancy, because:
1. People don’t always think in dichotomous categories: the difference between planned and
unplanned isn’t black-white, but rather grey.
2. Assumptions of rationality may not be justified: don’t use questions about
planned/unplanned, but use multi-item measures.
3. Perceptions of planning change over time.
Prevalence of abortion: data are less reliable in countries where abortion is restricted, illegal
abortions are not reported/ under-reported.
Birth outcomes: less preparation for parenthood, failure or delay in uptake of prenatal care, higher
risk of maternal morbidity and mortality.
Methods of fertility control:
- Contraceptive sterilization: female or male.
- Hormonal contraception.
- Intrauterine contraceptives: up to 10 years, longer and more painful menstruations.
- Barriers methods: male condom is most commonly. Female condoms offer some protection
against STIs, but not to all.
