This new blog series discusses the current policy landscape on sexual and reproductive health (SRH), both in the US and globally, and looks into their implications for public health practice to promote equity in SRH in the US. It begins with a review of the definitions of SRH and discussions around key components of SRH. Posts 2 and 3 focus on the policy landscape and health systems for SRH promotion in the US and globally. Post 4 will discuss the remaining challenges and call for actions by US state and local public health authorities to promote SRH equity.

The recent US health indicators concerning sexual and reproductive health (SRH) are alarming. Maternal mortality has marginally improved over the last 20 years compared to the global trend.¹ Sexually transmitted infections (STIs) rates have rapidly increased, and the congenital syphilis rate in 2022 is 102.5 cases per 100,000 live births, the highest reported rate since 1991.²

However, another important aspect of SRH cannot be underestimated. That is, SRH is also deeply complex and often politicized as it intersects with individuals’ worldviews and encompasses cultural, religious, political, and social perspectives. Moreover, the political landscape is swiftly evolving as the US transitions into the post-Roe era following the 2022 Dobbs decision.

In this dynamic environment, public health activities and interventions play a crucial role. As highlighted by Zaugg et al. (2022), public health departments have the potential to implement a range of activities related to SRH that are tailored to their specific contexts.³ However, to effectively engage in such initiatives, it’s imperative to recalibrate our understanding of SRH and track its evolving conceptual boundaries. This post aims to delve into the definitions of SRH, starting with its seminal articulation at the International Conference on Population and Development (ICPD) in 1994.

ICPD 1994 and Discussions Around Sexual and Reproductive Health

In 1994, SRH was first defined at the International Conference on Population and Development (ICPD) in Cairo: “Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.” ⁴ Thus, this definition expanded the scope of reproductive health to include the notion that “… people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.” ⁴ The ICPD Program of Action called for action for governments to foster accessible reproductive health through the primary health care system to all individuals of appropriate age.⁴ This marked a paradigm shift, reframing family planning and reproductive health as matters of human rights and health care rather than tools for population control.⁵

The ICPD in 1994 did not explicitly define sexual health. In the ICPD Program of Action, sexual health was included as a part of reproductive health care, noted for its aim for the “enhancement of life and personal relations.” ⁴ However, during the 2000s, the idea that sexual health is a component of reproductive health was questioned.6 Discussions focused on the need to separate sexual health from reproductive health care. As sexual activity is necessarily associated with reproduction and is of relevance throughout the lifespan, sexual health may not be a part of reproductive health; rather, it could be broader than reproductive health.

Consequently, efforts emerged in the mid-2000s to articulate a standalone definition of sexual health, reflecting advancements in understanding human sexuality and behavior, global health burden, and growing awareness about discrimination and inequity. Based on these discussions, a working definition of sexual health was proposed by the World Health Organization (WHO). “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.” ⁶ This definition emphasizes human sexuality and sexual rights, which had been lacking in the earlier definitions.

Beyond the WHO’s working definitions, numerous attempts have been made to define sexual health.⁷ Over time, these various definitions incorporate positive concepts of sexual well-being, highlighting the importance of respect and responsibility, freedom from violence and coercion, and the emergence of sexual rights.⁸ 

The Most Recent Comprehensive Definition of Sexual and Reproductive Health

The most recent definition of SRH was proposed in 2018. The Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights proposed a comprehensive definition of sexual and reproductive health and rights SRHR.⁹ They developed comprehensive definitions of relevant concepts and components that incorporate human sexuality, sexual orientation, and sexual and gender identity, aiming to ensure freedom from coercion, stigma, and discrimination, as well as equity in relationships and marriages.

Therefore, in their definition, sexual and reproductive health services encompass not only commonly recognized services such as prevention and treatment of HIV/AIDS but also extend to counseling related to sexuality and the prevention and management of sexually transmitted infections and reproductive cancers. Similarly, reproductive health services include education about the reproductive system, safe abortion, care for infertility, pregnancy, childbirth, and prevention of intimate partner violence.

The definition underscores the importance of sexual rights, affirming individuals’ autonomy in making decisions about their bodies and accessing the services necessary to support those rights.

References:

1. MacDorman MF, Declercq E. The Continuing Challenge of Measuring Maternal Mortality. Obstetrics & Gynecology. 2021:10-1097.
2. Centers for Disease Control and Prevention. Sexually Transmitted Infections Surveillance, 2022.
3. Zaugg C, Berglas NF, Johnson R, Roberts SCM. Reaching Consensus on Politicized Topics: A Convening of Public Health Professionals to Discuss Appropriate Abortion Activities for US Health Departments. Journal of Public Health Management and Practice. 2022;28(4).
4. United Nations. Programme of Action Adopted at the International Conference on Population and Development, Cairo, 5-13 September 1994.; 1995.
5. Aylward E, Halford S. How gains for SRHR in the UN have remained possible in a changing political climate. Sex Reprod Health Matters. 2020;28(1):1741496.
6. World Health Organization. Developing Sexual Health Programmes: A Framework for Action.; 2010.
7. Edwards WM, Coleman E. Defining sexual health: a descriptive overview. Arch Sex Behav. 2004;33:189-195.
8. Starrs AM, Anderson R. Sexual Health and Sexual Rights. The Brown Journal of World Affairs. 2016;22(2):7-23.
9. Starrs AM, Ezeh AC, Barker G, et al. Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. The Lancet. 2018;391(10140):2642-2692.

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