1
Sexual Health: A public health perspective
H.1: Sexual health: theoretical perspectives
Sex = In everyday speech, the term ‘sex’ is used to refer both to sexual activity (for example,
‘having sex’, ‘sex work’) and to the sum of biological characteristics that defi ne people as
female and male. In this book, we use the term in both these senses and rely on the context
to make clear in which it is being used.
Sexuality = A core human dimension that 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.
Sexuality is a result of the interplay of biological, psychological, socio-economic, cultural,
ethical, and religious/spiritual factors.
Theoretical perspectives of sexuality:
1. Essentialist theories hold that forms of sexual expression are for the most part
fixed, innate and instinctual, that sex is determined chiefly by biological forces, even
though situational and environmental factors may give rise to variation.
a. Natural phenomenon.
b. Freud.
c. Darwin; evolution theory explains sexuality in terms of reproductive strategies.
2. Social constructionist theories regard sexual behaviour as malleable and shaped
extensively by cultural norms and socialization; socially structured. Often mediated
by language as a way of organizing experience and sharing concepts.
a. Product of social and historical forces, social constructionists deny the limits
imposed by biology or psychology, their focus is on cultural and social
influences as the decisive factors in explaining human sexuality. Our sexual
potential and capacities are given meaning only in social relations and
through forms of social organization.
b. John Gagnon and William Simon: so while taking account of social-structural
factors determining sexual expression, the theory also stresses the
significance of individual agency, the idea that an individual is capable of
‘making’ as well as ‘taking’ specific social roles and patterns of behaviour.
c. Choice theory focuses on how individuals choose between different options in
sexual activities or partnerships according to different goals: sexual pleasure,
emotional satisfaction, having children, and enhancing personal reputations.
d. Network theory: people tent do treat their sexual partners in similar ways to
others in their social circle; and they tent to have sex with the type of
individuals they would be likely to have other kinds of relationships with.
e. Foucault forces us to rethink our ideas about sexuality and to question the
inevitability (onvermijdelijkheid) of the sexual categories and assumptions we
have inherited.
, 2
A balance and a bias:
Not one theory explains all our sexual behaviour. If innate biological factors were the sole
determinants of sexuality, then its expression would vary little between one society and
another; yet we see there are marked differences between sexual norms and customs
between different societies. But it also is not only social because we see in families
differences of behaviour. → It is important to recognize individual agency and social
structure when theorizing sexual practices and sexual health outcomes.
The regulation of sexual behaviour:
Societies support and encourage the kinds of sexual behaviour that best underpin their
social arrangements.
- For example raising well-adjusted children is seen in most social settings as being
best achieved within a monogamous union.
- Many non-procreative sexual practices have long been the subject of social
disapproval. (Oral and anal sex, same-sex practices, sexual acitivity before the age
deemed suitable for childbearing, masturbation)
(In the past), religion and legislation were commonly invoked to regulate sexual behaviour:
+ Fiscal benefits for men and women who marry for example.
- A law in 1533 made it illigal for a man and women to have anal sex.
21e eeuw, medicine and psychology are used to underpin social rules relating to sexuality.
Adverse health consequences of sexual behaviour (true or not) are often used to deter
socially disapproved sexual behaviours.
- Anti-abortion campains who claim there is a link between abortion and breast cancer.
Barriers to the improvement of sexual health:
Sexual health is personal and private, often stigmatized and discriminated against that are
barriers for public health.
In what ways might the regulation of sexual behaviour impact on public health efforts to
improve sexual health?
- Those in need may not come forward for help, because of fear of highlighting that
they have been in practices that are socially disapproved.
- Service providers may not be able to help those in need, because of that behaviours
who are socially disapproved happen secretly so it may be hard tot reach them in
terms of public health. And social attitudes toward harm limitation also limit service
provision.
- Practitioners may not want to help those in need.
- Men and women may not be able to help themselves.
- Public health practitioners may not be able to help in ways that they consider to be
effective.
Summery:
We take a social constructionist approach to sexual health, and so we see sexual
behaviour as essentially modifiable. This has two important consequences. First, the
, 3
fluidity and plasticity of sexuality means that men and women cannot be rigidly pigeonholed
in terms of sexual identity, and so for the most part it makes more sense to think
in terms of sexual behaviours rather than those practising them. This approach also
demands that we take account of social influences on, and regulation of, sexual
behaviour and so recognize that to change behaviour requires efforts not only at
an individual level, but also at the social structural level.
H.2 Sexually transmitted infections
STIs are the most common causes of ill health in the world.
Incidence rate = the rate at which new infections occur in a population. The numerator is
the number of new events occuring in a defined period / the denominator is the population at
risk of experiencing the event during the chosen period (most commonly a year).
Infectivity = the attributes of an individual or pathogen likely to lead to spread of infection.
Prevalence = the proportion of individuals in a population with an infection or disease at any
one time.
Prophylaxis = measures designed to preserve health and prevent the spread of disease:
protective or preventive treatment against infection.
Susceptibility = the attribute(s) of an individual likely to make them more or less likely to be
affected by infection or disease.
STIs:
1. Bacterial infections
a. Gonorrhoea
b. Chalydia
c. Chancroid
d. Syphilis
2. Viral infections
a. HIV
b. Human
c. Papilloma Virus
d. Herpes simplex virus
e. Human cytomegalovirus
f. Hepatitis B
g. Mycoplasma genitalium
3. Parasites
4. Protozoal infections
Sex, sickness and sin:
In attempts to regulate and control sexual behaviour the threat of STIs has long been used
as a deterrent to any sexual activity.
In the past but also nowadays we see that the tendency to distance oneself from people at
risk of STIs continues, and manifests in a reluctance to associate with what are seen as
stereotypical characteristics of infected persons, in terms of illicit sex and moral
transgression. → negative consequences for public health.
, 4
The burden of disease:
STI is a major burden of disease. Prevalence and incidence remain high in most of the
world. STIs have health, social and economic consequences. More consequences in poor
countries.
Sexually transmitted infections also disproportionately affect the health and wellbeing of
women, particularly those in the reproductive age range. In women, STIs can lead to pelvic
inflammatory disease, chronic pelvic pain, ectopic pregnancy, and infertility. In both men and
women, untreated STIs can result in infertility, cancers and, in the case of syphilis,
neurological and heart disease.
Understanding the determinants of STI transmission:
^necessary for STI control. Reproductive rate of an STI says something about the potential
for spread in a population.
● R0 = β × c × D
○ R0 : reproductive rate
○ β : likelihood of transmission between an infected and a susceptible individual
○ c : rate of contact between infected and susceptible individuals
○ D : length of time a person remains infected
● R0 > 1 = the infection will continue to spread and incidence ↑
● R0 < 1 = incidence ↓ and the infection will disappear from the population.
A complex web of biological, behavioural, and social factors influences the likelihood of STI
transmission.
- Biomedical and epidemiological factors.
- Behavioural factors.
- Health service-related factors.
- Social contextual factors.
Biomedical factors
The probability of transmission of an STI is influenced by the organism involved, the part of
the body it enters, and the integrity of the skin or mucosal barrier.
How easily infections can pass from one person to another also depends on their stage.
Infectivity and susceptibility are also influenced by behavioural factors. The integrity of skin
and mucous membranes of the body can be weakened by for example the practice of
douching, causing breaks in the skin, which provide a portal of entry for other infectious
organisms. But behaviour can also protect, like using a condom.
Having an STI can lead to having more other sickness.
Behavioural factors
● Sexual practices; how easily infections can be acquired varies by sexual practice.
● Risk-reduction strategies; condoms.
● Male circumcision (besnijdenis); reduce transmission.
● Partnerships and partner change; different partners increase the risk.
Sexual networks and sexual mixing patterns
