• Sex refers to the sum of biological characteristics that define the spectrum of humans as females and males.

• Sexuality refers to a core dimension of being human which includes sex, gender, sexual and gender identity, sexual orientation, eroticism, emotional attachment/love, and reproduction. It is experienced or expressed in thoughts, fantasies, desires, beliefs, attitudes, values, activities, practices, roles, relationship. Sexuality is a result of the interplay of biological, psychological, socio-economic, cultural, ethical and religious/spiritual factors. While sexuality can include all of these aspects, not all of these dimensions need to be experienced or expressed. However, in sum, our sexuality is experienced and expressed in all that we are, what we feel, think and do.

• Sexual health is the experience of the ongoing process of physical, psychological, and socio-cultural well being related to sexuality. Sexual health is evidenced in the free and responsible expressions of sexual capabilities that foster harmonious personal and social wellness, enriching individual and social life. It is not merely the absence of dysfunction, disease and/or infirmity. For Sexual Health to be attained and maintained it is necessary that the sexual rights of all people be recognised and upheld.

• Gender is the sum of cultural values, attitudes, roles, practices, and characteristics based on sex. Gender, as it has existed historically, cross-culturally and in contemporary societies, reflects and perpetuates particular power relations between men and women.

• Gender identity defines the degree to which each person identifies as male, female, or some combination. It is the internal framework, constructed over time, which enables an individual to organise a self-concept and to perform socially in regards to his/her perceived sex and gender. Gender identity determines the way individuals experience their gender and contributes to an individual's sense of sameness, uniqueness and belonging.

SLIDE: if gender ID does not match to sex:

• Sex reassignment surgery
• Gender reassignment surgery
• Female-to-male: have to reconstruct urethra
• 1/3 of these surgeries have complications
• Colonic vaginoplasty: using colon to create artificial vagina
• Popularity of operation:
• HK: 1:1.2 in favour of females
• Taiwan: 1:13 in favour of females
• Europe: 4-3:1 in favour of males

• Sexual orientation is the organisation of an individual's eroticism and/or emotional attachment with reference to the sex and gender of the partner involved in sexual activity. Sexual orientation may be manifested on any one or a combination of sexual behaviour, thoughts, fantasies or desire.

SLIDE: sexual orientation

Attracted to

1. Females

2. Males

3. Both

4. None

Before 1970's: homosexuality was a psychiatric disorder

• Sexual identity is the overall sexual self identity which includes how the individual identifies as male, female, masculine, feminine, or some combination and the individual's sexual orientation. It is the internal framework, constructed over time, that allows an individual to organise a self-concept based upon his/her sex, gender, and sexual orientation and to perform socially in regards to his/her perceived sexual capabilities.

SLIDE: Priapism

• Priapus weighing his penis
• Persistent abnormal erection of penis, accompanied by pain and tenderness.

• Eroticism is the human capacity to experience subjective responses that elicit physical phenomena perceived as sexual desire, sexual arousal and orgasm, and usually identified with sexual pleasure. Eroticism is constructed both at individual and societal levels with symbolic and concrete meanings that link it to other human dimensions.

• Emotional attachment is the human capacity to establish bonds with human beings that are built and maintained brought emotions. Emotional attachment is constructed both at individual and societal levels with symbolic and concrete meanings that link it to other human dimensions. Love represents an especially desirable kind of emotional attachment.

• Sexual activity is a behavioural expression of one's sexuality where the erotic component of sexuality is most evident. Sexual activity is characterised by behaviours that seek eroticism and is synonymous to sexual behaviour.

SLIDE: sexual response cycle in men

• Excitement -> Plateau -> Orgasm -> Refractory period -> Resolution

• Sexual practice is a pattern of sexual activity that is exhibited by an individual or a community with enough consistency to be expected as a behaviour.

SLIDE: anal/ butt plug

• Anal sex: 13% woman; 27% men think acceptable
• Not all homosexuals have anal sex (only 1/4 to 1/3)

• Safer sex is a term used to specify sexual practices and sexual behaviours that reduce the risk of contracting and transmitting sexually transmitted infections, especially HIV.

• Responsible sexual behaviour is expressed at individual, interpersonal and community levels. It is characterised by autonomy, mutuality, honesty, respectfulness, consent, protection, pursuit of pleasure, and wellness. The person exhibiting responsible sexual behaviour does not intend to cause harm, and refrains from exploitation, harassment, manipulation and discrimination. A community promotes responsible sexual behaviours by providing the knowledge, resources and right individuals need to engage in these practices.

• 70% of chronic DM have sexual dysfunction
• When talking to Pt's - mirroring their posture
• Surrogate partner: most males with sexual dysfunction are single; with a sexual partner, a man might gain sexual confidence; most are college undergrads
• Orgasmic reconditioning: man is asked to change his variant fantasy to one of conventional sexual behaviour, while masturbating (eg. Paedophiles)
• Sexual counselling: "Don't ask; don't tell" - if you don't ask Pt's, they won't tell you

• Around 35 million infected people and over 19 million deaths world-wide since the beginning of the HIV epidemic
• 13 million children and young people orphaned as a result of HIV-related death of one or both parents
• 2.5 million people currently living with HIV in the Region of the Americas
• One million people die each year from reproductive tract infections, including sexually transmitted infections (STIs) other than HIV/AIDS
• 333 million new cases of STIs may occur globally each year.

• Somewhere in the U.S., a woman is raped every 3 minutes
• Between 1995 and 1996, more than 670,000 women were the victims of rape, attempted rape or sexual assault
• In 1995, local child protective service agencies identified 126,000 children who were victims of either substantiated or indicated sexual abuse; of these, 75% were girls. Nearly 30% of child victims were between the age of 4 and 7
• Approximately one-third of all juvenile victims of sexual abuse cases are children younger than 6 years of age
• According to the Justice Department, one in two rape victims are under age 18; one in six is under age 12
• Approximately one in six boys are sexually abused before age 16
• Women aged 15 to 44 years lose a significant amount of Discount Health Years of life (DHYLs) due to rape and domestic violence
• 50 to 60 percent of the victims experience sexual dysfunction, including fear of sex and problems with arousal
• In Maternity Hospital of Lima, Peru, 90 percent of young mothers aged 12 to 16 had become pregnant because they had been raped
• In Costa Rica, 95 percent of its pregnant clients under 15 were victims of incest
• Between 85 and 115 million women living in the world today have been subjected to female genital mutilation (FGM) and that 2 million girls under go the procedure each year
• At least 60 million girls are "missing" from the population due to son-preference, via either sex-selective abortions or neglect. 2 million girls between 5 and 15 years old are put on the commercial sex market every year. Nearly 600 million women are illiterate compared with about 320 million men

• In United States, a prevalence rate of 43% for females and 31% for males is reported.
• Only 10% and 20% of men and women with sexual dysfunction behaviour sought medical consultation for their sexual problems.
• CUHK: study 2002 ® 50% male 53% female had sexual dysfunction in last 3 months

• Hypoactive sexual desire
• Sexual aversion
• Female sexual arousal dysfunction
• Male erectile dysfunction
• Female orgasm dysfunction
• Male orgasm dysfunction
• Premature ejaculation
• Vaginismus
• Sexual pain syndromes (including dyspareunia and other pain conditions)

• Exhibitionism
• Fetishism
• Frotteurism
• Paedophilia
• Sexual masochism
• Sexual sadism
• Fetishist transvevtism
• Voyeurism
• Unspecified paraphilia

• Compulsive cruising and multiple partners
• Compulsive fixation on an unattainable partner
• Compulsive autoeroticism
• Compulsive love affairs
• Compulsive sexual behaviour in a relationship

• Childhood Gender Dysphoria
• Adolescent Gender Dysphoria
• Adult Gender Dysphoria
• Intersex syndromes
• Unspecified Gender Identity Syndrome

• Clinical syndromes following being sexually abused as a child/minor (Including but not limited to post-traumatic stress disorder)
• Clinical syndromes following being sexual harassed
• Clinical syndromes following being sexually violated or raped
• Clinical phobia focused on sexuality (e.g., homophobia, erotophobia)
• Clinical syndromes related to engaging in threat or acts of violence focused on sex or sexuality (e.g., raping another person)
• Patterns of unsafe sexual behaviour placing self and/or others at risk for HIV infection or/and other sexually transmitted infections.

• Sterility
• Infertility
• Unwanted pregnancy
• Abortion complication

• Genital Ulcer ® Non-vesicular; Vesicular
• Oral ulcer ® Non-vesicular; Vesicular
• Rectal ulcer ® Non-vesicular; Vesicular
• Discharge ® Non-vesicular; Vesicular
• Lower abdominal pain in women
• Asymptomatic sexually transmitted infections and infestations (including HIV)
• AIDS (secondary to HIV infection)

Clinical syndromes secondary to disability or infirmity

Clinical syndromes secondary to physical or mental illness

Clinical syndromes secondary to medication or other medical and surgical interventions

Colorectal conditions

Clinical syndromes secondary to other conditions

• HIV infection
• Acquired Immunodeficiency Syndrome secondary to HIV infection
• Herpes simplex virus infections ® Type 1 Herpes simplex virus infection; Type 2 Herpes simplex virus infection
• Human papilloma virus infection
• Cytomegalovirus infection
• Hepatitis B infection
• Other sexually transmitted viral infections

• Syphilis
• Gonococci infections
• Chlamydiasis
• Thricomonal infection
• Gardnerella infection
• Mycoplasma infections
• Other sexually transmitted bacterial infections

• Candidiasis
• Other sexually transmitted yeast infections

• Phthirus pubis crab infestation
• Sarcoptes scabei infestation
• Other sexually transmitted infestations

The following list is not exhaustive but rather examples and illustrations of sexual concerns. Each of these concerns allows the appropriate assessment of information, counselling and/or care needs that demand actions from governmental and non-governmental agencies and institutions including the health sector.

• Need for health-promoting behaviours for early identification of sexual problems (e.g., regular check-ups and health screening, breast and testicular self-exam)
• Need for freedom from all forms of sexual coercion such as sexual violence (including sexual abuse and harassment)
• Need for freedom from body mutilations (i.e. female genital mutilation)
• Need for freedom from contracting or transmitting sexually transmitted infections (including but not limited to HIV/AIDS)
• Need reduction of sexual consequences of physical or mental disabilities
• Need for reduction of impact on sexual life of medical and surgical conditions or treatments

• Need for knowledge about the body, as related to sexual response and pleasure
• Need of recognition of the value of sexual pleasure enjoyed throughout life in safe and responsible manners within a values framework respectful of the rights of others
• Need for promotion of sexual relationships practice in safe and responsible manners
• Need to foster the practice and enjoyment of consensual, non-exploitive, honest, mutually pleasurable sexual relationship

• Need for gender equity
• Need for freedom from all forms of discrimination based on gender
• Need for respect and acceptance of gender differences

• Need for freedom from discrimination based on sexual orientation
• Need for freedom to express sexual orientation in safe and responsible manners within a values framework respectful of the rights of others

• Need for freedom from exploitative, coercive, violent or manipulative relationships
• Need for information regarding choices of family options and lifestyles
• Need of skills, such as decision-making, communication, assertiveness and negotiation, that enhance personal relationships
• Need for respectful and responsible expression of love and intimacy
• Prevention and appropriate care of couple maladjustment and distress
• Appropriate management of separation and divorce

• Need to make informed and responsible choices about reproduction
• Need to make responsible decision and practices regarding reproductive behaviour regardless of age, gender and marital status
• Access to reproductive health care
• Access to safe motherhood
• Prevention and care for infertility

Sexuality is an integral part of the personality of every human being. Its full development depends upon the satisfaction of basic human needs such as the desire for contact, intimacy, emotional expression, pleasure, tenderness and love. Sexuality is constructed through the interaction between the individual and social structures. Full development of sexually is essential for individual, interpersonal, and societal well being. Sexual rights are universal human rights based on the inherent freedom, dignity, and equality of all human beings. Since health is a fundamental human right, so must sexual health be a basic human right. In order to assure that human beings and societies develop healthy sexuality, the following sexual rights must be recognised, promoted, respected, and defended by all societies through all means. Sexual health is the result of an environment that recognises, respects, and exercises these sexual rights:

• The right to sexual freedom. Sexual freedom encompasses the possibility for individuals to express their full sexual potential. However, this excludes all forms of sexual coercion, exploitation and abuse at any time and situations in life
• The rights to sexual autonomy, sexual integrity, and safety of the sexual body. This right involves the ability to make autonomous decisions about one's sexual life within a context of one's own personal and social ethics. It also encompasses control and enjoyment of our own bodies free from torture, mutilation and violence of any sort
• The right to sexual privacy. This involves the right for individual decisions and behaviours about intimacy as long as they do not intrude on the sexual rights of others
• The right to sexual equity. This refers to freedom from all from of discrimination regardless of sex, gender, sexual orientation, age, race, social class, religion, or physical and emotional disability
• The right to sexual pleasure. Sexual pleasure, including autoeroticism, is a source of physical, psychological, intellectual and spiritual well being
• The right to emotional sexual expression. Sexual expression is more than erotic pleasure or sexual acts. Individuals have a right to express their sexuality through communication, touch, emotional expression and love
• The right to sexually associate freely. This means the possibility to marry of not, to divorce, and to establish other types of responsible sexual associations
• The right to make free and responsible reproductive choices. This encompasses the right to decide whether of not to have children, the number and spacing of children, and the right to full access to the means of fertility regulation
• The right to sexual information based upon scientific inquiry. This right implies that sexual information should be generated through the process of unencumbered and yet scientifically ethical inquiry, and disseminated in appropriate ways at all societal levels
• The right to comprehensive sexuality education. This is a lifelong process from birth throughout the lifecycle and should involve all social institutions
• The right to sexual health care. Sexual health care should be available for prevention and treatment of all sexual concerns, problems and disorders.

• World Association for Sexology, 1999
• SEXUALITY IN THE NEW MILLENNIUM
• 14^th World Congress of Sexology, Hong Kong SAR

A sexually healthy adult would

• Appreciate one's own body
• Seek further information about reproduction as needed
• Affirm that human development includes sexual development that may or may not include reproduction or genital sexual experience
• Interact with both genders in respectful and appropriate ways
• Affirm one's own sexual orientation and respect the sexual orientation of others
• Express love and intimacy in appropriate ways
• Develop and maintain meaningful relationships
• Avoid exploitative or manipulative relationships
• Make informed choices about family options and lifestyles
• Exhibit skills that enhance personal relationships
• Identify and live according to one's values
• Take responsibility for one's own behaviour
• Practice effective decision-making
• Communicate effectively with family, peers, and partners
• Enjoy and express one's sexuality throughout life
• Express one's sexuality in ways congruent with one's values
• Discriminate between life-enhancing sexual behaviours and those that are harmful to self and/or others
• Express one's sexuality while respecting the rights of others
• Seek new information to enhance one's sexuality
• Use contraception effectively to avoid unintended pregnancy
• Prevent sexual abuse
• Seek early prenatal care
• Avoid contracting or transmitting a sexually transmitted disease, including HIV
• Practice health-promoting behaviours, such as regular check-ups, breast and testicular self-exam, and early identification of potential problems

• Demonstrate tolerance for people with different sexual values and lifestyles
• Exercise democratic responsibility to influence legislation dealing with sexual issues
• Assess the impact of family, cultural, religious, media, and societal messages on one's thoughts, feelings, values, and behaviours related to sexuality
• Promote the rights of all people to accurate sexuality information
• Avoid behaviours that exhibit prejudice and bigotry

• Reject stereotypes about the sexuality of diverse populations

Societies that prioritise and protect the Sexual Health of their members have the following characteristics:

• Political Commitment. The State recognises that Sexual Health is a fundamental Human Rights and takes the responsibility of promoting Sexual Health.
• Explicit Policies. Social institutions, including governmental agencies, formulate, develop and implement public policies involving clear and precise directions for protecting and promoting Sexual Health as a fundamental human right.
• Legislation. Laws to protect the sexual rights are necessary to promote Sexual Health. Specifically, legislation is necessary that products the vulnerable form exploitation (eg. child prostitution), recognises the rights of all persons to integrity of the body (eg. protection from genital mutilation), protects the rights of sexual minorities to such fundamental human rights as education, health, and employment (e.g., anti-discrimination legislation), and promotes equity across sexual dimensions (e.g., equal opportunity legislation).
• Good Education. A necessary component of a sexually healthy society is universal access to age-appropriate, comprehensive sexually education across the lifespan.
• Sufficient Infrastructure. To ensure persons have access to services, an infrastructure of professionals and paraprofessionals specialising in sexual concerns and problems is necessary. This includes the provision of training programs for professionals to specialise in Sexual Health.
• Research. A society committed to the Sexual Health of its members will support adequate and sound research to address the Sexual Health related clinical, educational and public health concerns. This includes both research on emerging concerns (e.g., new infections), and behavioural surveillance to monitor preventive health concerns (e.g., rates of unsafe sex in high-risk sub-populations, rates of sexual violence, prevalence of sexual dysfunction, etc.).
• Adequate Surveillance. Surveillance is necessary to monitor biomedical and behavioural markers of Sexual Health concerns and problems.
• Culture. A culture of openness to, and prioritisation of, Sexual Health is necessary. Such indicators as the quality of media reporting on Sexual Health concerns, and the degree to which public health message regarding serious threats to Sexual Health can be openly promoted can measure the culture.

• The following specific actions for this strategy were identified:
• Develop specific national Sexual Health strategies and plans.
• Promote legislation that ensures the feasibility of the national Sexual Health strategies.
• Integrate a Sexual Health approach into existing health programs.
• Develop indicators of Sexual Health to be used in policy program development and evaluation.
• Promote consensus in the definition and classification of sexual problems.
• Develop best practice guidelines for sexual problems.

• Some of the components of this strategy include:
• Advocacy to introduce and change public policies that have impact on gender disparities such as promoting schooling and formal education for girls
• Introduction of a gender perspective in the planning and implementation of Sexual Health services. For example such simple matters as taking into account the differences in time availability for men and women to attend health care facilities.
• Ensuring that comprehensive sexuality education always includes gender analysis and particularly stresses the right of men and women to sexual equity and equality.
• Encouraging actions that facilitate men to discuss and understand changes in gender roles and "the new masculinity". This is an important area due to the possible threat that changes in the status of women may pose to male sexuality, particularly in those societies in which the latter is linked to dominance and supremacy.
• Awareness building for all health provides as to their own biases regarding gender.

Components of this strategy are:

• Inclusion of responsibility as a value to be promoted in all sexuality education programs.
• Implementation of adult education programs, specifically addressing the needs of parents, as they are the most immediate and efficient agents in promoting sexually responsible behaviour.
• Involvement of mass media in introducing the issue of responsible sexual behaviour in their messages, via addressing the issue directly in specific broadcasts or publications, or establishing specific campaigns.
• Introducing legislation to promote sexually responsible behaviour.

Some of the components and specific actions of this strategy include:

• Promote the understanding of the spectrum of female and male identities along a range including heterosexual, homosexual, bisexual, bigender, transgender.
• Decrease homophobia both among individuals of all sexual orientations.
• Strategy 1.5 Eliminate sexual violence.
• Action towards the elimination of sexual violence include:
• Recognition of sexual violence in its various forms
• Introduction of effective legislation to reduce sexual violence
• Promotion of a culture of reporting sexual violence
• Promotion of health seeking behaviour for victims of sexual violence.
• Promotion of health care for sexual aggression that in many instances could benefit from treatment

Sexual health education for health professionals should be promoted at least at four different levels:

• Basic Sexual Health education for all health professionals included both in their basic training and in continued educational programs. Health professionals include medicine, nursing, clinical psychology, social work and health practitioners and promoters.
• Sexual health education for health professionals in reproductive health programs.
• Sexual health education for professionals specialising in STIs and HIV/AIDS prevention and control programs.
• Sexual health education and training for professional specialising in Sexology, including education for sexuality, clinical Sexology (sexual medicine, sexual surgery, sexual counselling and, sexual psychotherapy) and basic research Sexology.

More specifically, there is a need to:

• Establish training standards for sexual educators, sexuality specialists
• Promote Sexology as a discipline / profession
• Advocate to governments for sexuality training for professionals

Recommends as components the following:

• Integrate a Sexual Health approach into existing health programs, related directly or indirectly to Sexual Health (e.g., cardiovascular health promotion programs, anti-smoking programs (benefits of not smoking on erectile performance), cancer prevention programs (early detection of CA on mastectomies, cervical cancer screening), health education programs (link between preventive health and sexual performance).
• As part of general health assessments, address sexual issues when clients come into contact with public health programs. This can be advanced by review and, where necessary, reform of existing protocols to ensure adequate addressing of Sexual Health concerns. For example, general practitioners, family physicians, and physicians in public health clinics should incorporate Sexual Health screening / history taking into general health assessments.