1.4.1. Sexual health and sexuality

Sexual health is fundamental to the physical and emotional health and well-being of individuals, couples and families, as well as to the social and economic development of communities and countries. The current WHO working definition of “sexual health”, which arose from an international meeting of experts in 2002, captures a broad view:

Sexual health is a state of physical, emotional, mental and social well-being in relation 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. (37: 3)

Sexual health cannot be defined, understood or made operational without a broad consideration of sexuality, which underlies important behaviours and outcomes related to sexual health. The WHO working definition of “sexuality” is:

… a central aspect of being human throughout life [that] encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors. (37: 4)

In the context of sexual health, “well-being” includes the creation of enabling environments which promote and protect the fulfilment of personal goals in relation to sexual health, while acting responsibly towards others. Autonomy relates to the rights of individuals to self-determination in sexual health; rights that need to be recognized by the state and enabled by everyone – from partners and families to global institutions” (71: e378). Autonomy may be promoted and protected in diverse ways, including through laws and policies as well as through building the negotiating skills of individuals or groups (38, 71).

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Sexual health programmes based on the core principles of autonomy, well-being and fulfilment, promotion and protection of human rights should:

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Address violations of human rights related to sexuality and reproduction

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Promote people's ability to engage in safe and satisfying sexual relationships

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Address people's needs or concerns in relation to sexual orientation and gender identity.

In addition, sexual health programmes need to address the prevention and treatment of sequelae and complications of sexual ill-health, namely:

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infections and their sequelae (HIV, STIs, and associated outcomes such as cancers, infertility, etc.) (37)

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Unintended pregnancy (includes family planning, contraceptive counselling and abortion) (37)

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Sexual problems, concerns and difficulties, whether resulting from emotional causes (7, 113) or relationship distress (97), illness such as diabetes, hypertension (51, 113) and cardiovascular disease (79), or negative consequences of particular medications, e.g. example cancer treatment and palliative care (29, 111, 117, 126)

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Infertility

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Violence related to gender inequality, sexual orientation and gender identity

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Harmful and traditional practices related to sexual health (54); e.g. FGM, “widow cleansing” (a requirement for a widow to have sexual relations with a relative of her husband), and a range of vaginal practices that may be associated with negative health outcomes (75)

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Mental health issues related to sexual health including:

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the sexual health needs of people with mental health problems; e.g. higher rates of sexual dysfunction in people with depression (8, 113) or other sexual problems treated with certain antidepressants (105), and the influence of antidepressant drugs on sexual health (8)

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mental health issues associated with sexual health and high rates of stress, stigma and discrimination e.g. higher rates of mental disorders and mental distress among some populations of gay, lesbian, bisexual and transgender persons (14, 101).

Specific populations are highlighted as being particularly in need of sexual health services, including young people of all sexual orientations; people with physical disabilities, mental challenges and chronic illnesses; intersex people; incarcerated populations; transgender populations; and indigenous populations (71).

The ability of people to achieve sexual health and well-being depends, among other things, on their access to comprehensive information about sexuality, their knowledge about the risks they face, and their vulnerability to the adverse consequences of sexual activity. To achieve sexual health, people also need opportunities for social support, access to good-quality sexual health care (i.e. addressing all elements of sexual health according to the WHO working definition, including products and materials), and an environment that affirms and promotes sexual health for all. These include counselling and communication programmes.

1.4.2. Brief sexuality-related communication

“Counselling” refers to “systematic consultations in primary care for addressing emotional, psychological and social issues that influence a person's health and well-being” (19: 4). Counselling is characterized by its continuity; that is, a specific provider builds trust with a client over time (6, 19). While counselling is appropriate for addressing sexual concerns and difficulties, addressing dysfunctions or disorders may require systematic psychological therapy or physiological medical treatment. It is for this reason that this guideline document makes reference to “clients” rather than “patients”. Carl Rogers' concept of “client-centred therapy” clarifies the distinction: while the term “patient” presumes a hierarchy in which the health-care provider knows best, the term “client” is positions the health-care provider as a supporter to help the person concerned to find solutions for him or herself (121).

This guideline document focuses on the opportunistic use of counselling skills, rather than formal – systematic and continuous – counselling. It frames this approach “brief sexuality-related communication (BSC)”. In BSC, the provider – whether a nurse, doctor or health educator – uses counselling skills “opportunistically with much less certainty about the duration of the encounter” (19: 10) to address sexuality and related personal or psychological problems (as defined above) as well as to promote sexual well-being (26, 37). Unlike professional counselling, BSC does not require provider continuity. In addition, these skills are applied during the length of a typical primary health care visit.

BSC takes into account the psychological and social dimensions of sexual health and well-being as well as the biological ones (99). It aims to support clients in reformulating their emotions, thinking and understanding, and subsequently, their behaviour; that is, by developing their capacity for self-regulation, clients are able to exercise their sexuality with autonomy, satisfaction and safety (38, 140, 121). It is rooted in the understanding that there is often a gap between intention and behaviour. BSC can enable clients to bridge this gap by helping them to establish clear goals, as well as to initiate and sustain their motivation and actions towards achieving these (38).

BSC uses an approach in which most of the time during a primary health care visit is spent listening to the client's concerns, in contrast to the health-care provider using most of the time to impart his or her expertise (11, 19). The aim is to help clients identify ways to address their concerns. This is described as a “client-centred” approach (134), which respects clients' ideas, feelings, expectations and values (52), as opposed to the “disease-centred” model in which the provider makes decisions on behalf of the client (25: 69).

There are a range of models that can inform the health-care provider's approach, mainly along the theoretical dimensions of the “information, motivation and behaviour” model (84). In general BSC uses open-ended rather than direct questions (3). Most approaches incorporate the following four components (25: 62):

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Attending: setting up the relationship with the client. While BSC is shaped around the context and needs of the individual client, there are some typical questions that health-care providers can use in a socially appropriate manner to initiate the subject of sexual health, such as, “Do you have any questions or concerns about sexual matters?” (69)

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Responding: asking questions that open the conversation about sexual health and sexuality such as, “Are you satisfied with your sexual life?” (69); “Is your sexual life going as you wish?”; or “How do you feel in your sexual relationships with others?” (139)

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Personalizing: identifying the existence of sexual concerns, difficulties, dysfunctions or disorders and the dynamics of any interplay between these, such as, “What difficulties do you have in using condoms?” (139); “Some people who have had a particular problem (e.g. cancer, hypertension, diabetes or AIDS treatment -whatever the client is facing) tell me that they have had sexual problems; how is it for you?” (105, 141)

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Initiating: providing information and, with the client, identifying steps that need or could be taken (44, 85, 138).

The process concludes by planning a follow-up or providing a referral for other resources and services when needed. In this way the client is supported in exploring, understanding and acting for their sexual health (25).