Sexual health and its linkages to reproductive health: an operational approach Sexual health and reproductive health are closely linked, but crucial aspects of sexual health can be overlooked when grouped under or together with the domain of reproductive health. In order to create broader awareness of comprehensive sexual health interventions and to ensure that sexual health and reproductive health both receive full attention in programming (including provision of health services) and research, the World Health Organization (WHO) has reviewed its working definition of sexual health to create a framework for an operational approach to sexual health. The framework, which is intended to support policy-makers and programme implementers and to provide a stronger foundation for further research and learning in sexual health, is presented and described in full in this brief.
2 | Sexual health and its linkages to reproductive health: an operational approach
Background: WHO and sexual health The global understanding of sexual health has evolved over time, including in its relationship to reproductive health. WHO’s work in the area of sexual health extends back to at least 1974, when – at a meeting convened by WHO in Geneva – the deliberations of professionals with expertise in human sexuality resulted in a technical report on training for health professionals on education and treatment in human sexuality (1). This report defined sexual health as: “the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love”. Furthermore, the report indicated that attention to pleasure and the right to sexual information were fundamental to this definition. Twenty years later, sexual health was included within the stated definition of reproductive health in the report of the 1994 International Conference on Population and Development (ICPD): “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” (2). Implicit in this definition was the ability of people “to have a satisfying and safe sex life” and the capability and freedom to reproduce if and when desired. Accordingly, the definition of reproductive health care in the ICPD report also included sexual health, the stated purpose of which was “the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases”(2). The decade following the ICPD gave rise to significant advances in the global understanding of human sexuality and behaviour, as well as recognition of the immense global health burden – including extensive mortality and morbidity – associated with a wide range of sexual and reproductive health conditions, including HIV and other sexually transmitted infections (STIs); unwanted pregnancies; unsafe abortions; infertility; maternal and genitourinary conditions; gender-based violence and sexual dysfunction. There was also growing awareness about the impact of stigma, discrimination and poor quality of care on people’s sexual and reproductive health. Accordingly, WHO’s global Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets, endorsed by the World Health Assembly in 2004, named five core aspects of reproductive and sexual health, one of which mentioned sexual health explicitly: “promoting sexual health” (3). In recognition of the need to define sexual health more clearly, WHO convened a group of global experts to take on this task in 2002, and published the resulting working definition for “sexual health”, as well as for the related concepts of “sex”, “sexuality” and “sexual rights” in 2006, with further updates to the latter in 2010 (4, 5). These definitions are presented in Box 1. Additionally, in 2010, a framework for designing sexual health programmes was published (5). The framework identified and contextualized five multisectoral factors that influence sexual health: (i) laws, policies and human rights; (ii) education; (iii) society and culture; (iv) economics; and (v) health systems. More recently, WHO published a report on Sexual health, human rights and the law (2015) to assist governments and policy-makers in improving sexual health by aligning relevant laws and policies with national and international health and human rights obligations (6).
1974
WHO meeting on education and treatment in human sexuality
1994
International Conference on Population and Development (ICPD)
2002
WHO develops sexual health definitions (published in 2006, updated 2010)
2004
WHO’s global reproductive health strategy endorsed by the World Health Assembly
2010
WHO publishes a framework for action on developing sexual health programmes
2015
WHO publishes a report on sexual health, human rights and the law
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The Sustainable Development Goals, adopted by the United Nations General Assembly in September 2015, include a goal for health: ensure healthy lives and promote well-being for all at all ages (SDG 3). In support of this goal, there is a specific target to ensure universal access to sexual and reproductive health-care services by 2030 (target 3.7). In order for countries to reach this SDG target, it is necessary to improve the operational understanding of what constitute sexual health services, as well as clarify the distinctions and links between sexual health and reproductive health. Building on the work done so far on the concept of sexual health, the clarification presented in this framework will support improved operationalization of sexual health in the context of programming and research.
Box 1. WHO working definitions Sexual health 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.
Sex Sex refers to the biological characteristics that define humans as female or male. While these sets of biological characteristics are not mutually exclusive, as there are individuals who possess both, they tend to differentiate humans as males and females. In general use in many languages, the term sex is often used to mean “sexual activity”, but for technical purposes in the context of sexuality and sexual health discussions, the above definition is preferred.
Sexuality Sexuality is a central aspect of being human throughout life and 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, ethical, legal, historical, religious and spiritual factors.
Sexual rights The fulfilment of sexual health is tied to the extent to which human rights are respected, protected and fulfilled. Sexual rights embrace certain human rights that are already recognized in international and regional human rights documents and other consensus documents and in national laws. Rights critical to the realization of sexual health include: §§ the rights to life, liberty, autonomy and security of the person §§ the rights to equality and non-discrimination §§ the right to be free from torture or cruel, inhuman or degrading treatment or punishment §§ the right to privacy §§ the rights to the highest attainable standard of health (including sexual health) and social security §§ the right to marry and to found a family and enter into marriage with the free and full consent of the intending spouses, and to equality in and at the dissolution of marriage §§ the right to decide the number and spacing of one’s children §§ the rights to information, as well as education §§ the rights to freedom of opinion and expression, and §§ the right to an effective remedy for violations of fundamental rights. The application of existing human rights to sexuality and sexual health constitute sexual rights. Sexual rights protect all people’s rights to fulfil and express their sexuality and enjoy sexual health, with due regard for the rights of others and within a framework of protection against discrimination. Sources: WHO, 2006 and 2010 (4, 5).
4 | Sexual health and its linkages to reproductive health: an operational approach
The framework: an operational approach to sexual health This framework has been developed by WHO in partnership with a core working group of external experts and practitioners of law, academia, research and clinical work (see Acknowledgements) through a thorough review and consultation process. WHO’s previous and ongoing work in sexual health was reviewed along with recent evidence from the literature, and a first draft of the framework was developed. This was reviewed by the Gender and Rights Advisory Panel (GAP) of the UNDP/UNFPA/UNICEF/WHO/ World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and a revised draft was produced. The core group reviewed the revised draft; the final framework presented here is the result of their deliberations. At the centre of the framework is the ultimate objective of sexual health: the attainment of physical, emotional, mental and social well-being in relation to sexuality. In certain settings and for certain populations, crucial aspects of this objective may be overlooked when sexual health is grouped under or together with the domain of reproductive health. The framework, therefore, aims to operationalize WHO’s comprehensive working definition of sexual health to ensure that it receives full attention in programming and research, alongside reproductive health, for all populations, everywhere. The graphic framework separates out the individual components of the definition, setting them in relation to one another at three levels. 1. The foundation of guiding principles: These are six crucial, cross-cutting principles (shown at the base of the illustration) which must be incorporated into the design of all sexual health (and reproductive health) interventions and which can also serve as evaluation criteria against which these interventions should be assessed. 2. The rosette of sexual health and reproductive health interventions: The two groups of interventions are depicted on contrasting colours of the intertwined ribbons of a rosette – blue for sexual health and orange for reproductive health – to show that they are distinct yet inextricably linked. 3. The climate of social-structural factors: The surrounding shading in the graphic framework represents the existing cultural, socioeconomic, geopolitical and legal environment that forms the context for people’s lives in different settings, and which influences sexual health interventions and outcomes.
Sexual health and its linkages to reproductive health: an operational approach | 5
Framework for operationalizing sexual health and its linkages to reproductive health
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6 | Sexual health and its linkages to reproductive health: an operational approach
1. The foundation of guiding principles These six cross-cutting and interlinked principles – which are all of equal importance – must be incorporated into the design and implementation of all sexual health interventions, and they are also the criteria against which these interventions will be evaluated. These guiding principles, represented at the base of the graphic framework, are intended to provide a strong foundation upon which sexual health can be achieved for all.
Multilevel influences on sexual health A range of factors exert influence on an individual’s sexual health, operating at multiple levels. Informed by an ecological approach, attaining sexual health therefore requires interventions not only at the level of the individual, but also at the levels of family and peers; community (social, organizational); and law, policy and other structural factors, since these ever-widening circles of influence can affect an individual’s sexual health (9). Sexual health and reproductive health intervention areas therefore can and do and, indeed, must encompass multiple levels of programming and research, from interventions for individuals in a clinical setting to social and policy reform.
Holistic approach to sexual health This principle reflects the comprehensive working definition of sexual health (Box 1) which emphasizes that it is more than just the absence of ill health, but also the attainment of a state of physical, emotional, mental and social well-being in relation to sexuality. Sexual health programming (including health services) and research should address not only the prevention of disease and dysfunction, but also the active promotion of positive sexual health and general well-being.
Diversity of needs across life course and populations Sexual health exists on a dynamic continuum, with needs that change across the lifespan and which vary depending on a complex mix of individual characteristics, as well as the cultural, socioeconomic, geopolitical and legal environment. Particular combinations of these factors can create vulnerabilities – which can be temporary or lasting – that may increase susceptibility to ill health and/or hinder access to health care. For example, certain sexual health interventions may not be available because they are not culturally acceptable or legally permissible; available sexual health interventions may be difficult to access for a range of reasons; and the sexual health needs of some individuals, populations or age groups may not be recognized or acknowledged. Sexual health programming and research must therefore be inclusive of the diversity of needs among individuals at various points across the life course and in various settings or circumstances.
Linked nature of sexual health and reproductive health Sexual health and reproductive health have unique aspects to them but they are also inherently intertwined, both conceptually and at the point of programme or research implementation. For example, efforts to prevent and control chlamydia (an STI) have important implications for future fertility, as chlamydia is a major cause of infertility. Meanwhile, issues of access to and use of contraception can impact sexual pleasure and enjoyment. The inherent interlinkages between sexual health and reproductive health are represented in the graphic framework both as a guiding principle and also in the interlocked nature of the two ribbons – sexual health and reproductive health – which together form a rosette.
Respect, protection and fulfilment of human rights Well established regional and international human rights principles, norms and standards relating to the right to the highest attainable standard of health apply to sexual health (7). All individuals have the right to exercise control over, and to decide freely and responsibly on, matters related to their sexuality as well as their sexual and reproductive health – and to do so free of coercion, discrimination and violence. There is also widespread acknowledgement that sexual rights are a necessary condition for attaining sexual health (6, 8). Accordingly, programme implementers and researchers are obliged to ensure that sexual health interventions respect, protect and fulfil relevant human rights.
Evidence-based, respectful and positive approach Sexual health and reproductive health interventions must meet standards for quality of care, including being evidence-based and being provided in a respectful and positive manner. Specifically for sexual health interventions, this includes: maintaining an individual’s privacy and confidentiality; presenting information clearly, without coercion and in a manner that fosters informed decision-making; ensuring providers are adequately trained, competent and nonjudgemental in delivering health services; and ensuring that health services utilize and stock adequate quantities of quality supplies (including commodities and equipment) (6).
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2. The rosette of sexual health and reproductive health interventions Neither sexual health nor reproductive health subsumes the other. Rather, the two are inextricably interlinked as represented in the graphic framework by a rosette, which is formed by two contrasting but interwoven ribbons. In this configuration, the eight intervention areas – four each for sexual health (blue ribbon) and reproductive health (orange ribbon) – are of equal weight. More importantly, in a mutually supportive and protective arrangement, each intervention area enhances the impact of the others, and as a result, strengthens the attainment of sexual health as a whole. Across all eight areas depicted within the rosette in the framework, the interventions may take place in a health-care setting provided by the health sector (e.g. delivery care and STI treatment), but some may be provided in other settings, as initiatives of the education, justice, economic and/or social care sectors, for example. As underlined in the previous section, actions in these eight intervention areas must be planned and designed based on the six guiding principles. The four sexual health intervention areas are described below, followed by the four reproductive health intervention areas.
Gender-based violence prevention, support and care (12, 13) Gender-based violence (GBV) can take many forms, including physical, sexual and emotional. GBV has previously been defined as male violence against women, but in recent years, the term has been used to include violence that is based on gender identity or sexual orientation. Health sector interventions to address GBV include: early identification through clinical inquiry; first-line support and response; treatment and care for intimate partner violence and sexual assault (e.g. emergency contraception, presumptive treatment for STIs, post-exposure prophylaxis for HIV, mental health care). Education for girls of secondary school age, economic empowerment of women, work on masculinities and changing social norms, and home visiting programmes to reduce child maltreatment are all important complementary intervention points outside the health sector. Freedom from violence supports safer sexual relationships, reduces the risk of STIs, enables access to contraception and maternal health care, and increases access to needed health care, including sexual health and reproductive health care.
Sexual health (blue ribbon) Comprehensive education and information (10, 11) Comprehensive education and information involves the provision of accurate, age-appropriate and up-to-date information on physical, psychological and social aspects of sexuality and reproduction, as well as sexual and reproductive health and ill health. Accurate information can address gaps in knowledge, dispel misconceptions and build comprehensive understanding, as well as foster empowering skills, positive attitudes and values, and healthy behaviours. This is rightly a critical part of all intervention areas in the rosette. All interventions should ensure that individuals have the knowledge and skills necessary to make well informed choices about sexuality and reproduction and to follow up on their choices. Within the health sector, information can be made available in the context of preventive or curative care consultation, or in non-clinical settings in the context of health education outreach. Within the education sector, age-appropriate comprehensive sexuality education (CSE) curricula guidance and standardized content are available for preschool through university levels, and can be provided in school as well as in out-of-school settings.
Prevention and control of HIV and other sexually transmissible infections (14–18) Sexually transmitted infections (STIs) are caused by pathogens – such as bacteria and viruses – that can be transmitted through sexual contact (oral, anal, vaginal) as well as through other mechanisms, such as motherto-child transmission or vectors. Also included in this intervention area are reproductive tract infections (RTIs) such as bacterial vaginosis and candidiasis, which can be associated with sexual activity although they are not sexually transmitted. Common STIs include chlamydia, gonorrhoea, syphilis, trichomoniasis, herpes simplex virus (HSV), human papillomavirus (HPV), HIV and some types of viral hepatitis. More recently, outbreakassociated viral infections, such as Zika and Ebola, which are primarily transmitted through vectors or physical contact, have been identified as also sexually transmissible. Many STIs can occur without noticeable symptoms. Left untreated, STIs can have short- and long-term psychological, social and financial effects on individuals, in addition to effects on overall health, fertility and sexuality. STIs can be prevented through delaying sexual debut, non-penetrative sex, use of condoms, vaccination to prevent HPV and hepatitis B, circumcision for HIV prevention, and pre- and postexposure prophylaxis. STIs can be controlled through
8 | Sexual health and its linkages to reproductive health: an operational approach
early identification and treatment, appropriate case management, improving health care-seeking behaviour, partner notification, and preventing and managing complications (e.g. pelvic inflammatory disease).
Contraception counselling and provision (3, 22–25) Contraception is the intentional prevention of pregnancy by artificial or natural means. A range of modern contraceptive methods, commodities and services should be accessible, acceptable, available and affordable, and they should be provided without coercion by skilled providers in settings that meet standards for quality of care (26). Contraception is one of the most cost-effective health-care interventions, preventing unintended pregnancies and abortions (as well as related complications of unsafe abortions) while also contributing to reducing maternal and neonatal mortality, and enhancing newborn and child health. Prevention of unintended pregnancy through contraception also opens up more educational opportunities for girls, thereby improving their socioeconomic status and overall well-being.
Sexual function and psychosexual counselling (11, 19) Sexual function represents the complex interaction of various physiological, psychological, physical and interpersonal factors. Poor sexual function or sexual dysfunctions are syndromes that comprise a cluster of ways in which adults may have difficulty experiencing personally satisfying sexual activities. Identifying and addressing sexual concerns and difficulties, as well as offering treatment for sexual dysfunctions and disorders, are critical components of sexual health care. Psychosexual counselling provides patients with both support and specific information or advice relating to their sexual concerns; this can facilitate a return to satisfying sexual activity. Such treatment focuses on the need to make adjustments in sexual practices or to enhance methods of coping with a sexual event or disorder. Pharmacotherapies may also be part of the treatment.
Fertility care (27) Failure to become pregnant after 12 months of regular, unprotected sexual intercourse is defined as infertility. In addition to the psychosocial impact on individuals of not being able to have children, the effects of infertility can be far-reaching. Inability to have children might result in marital discord, it might be grounds for divorce, or lead to ostracism from the family or community. GBV is more likely among individuals and couples suffering from unwanted childlessness or involuntary infertility. Interventions for fertility care range from improved fertility awareness to advanced medical technologies, including assisted reproductive technologies, such as in-vitro fertilization (IVF). Offering fertility care also provides an important opportunity to engage men, who are generally less willing to access health services or discuss issues related to sexual and reproductive health.
Reproductive health (orange ribbon) Antenatal, intrapartum and postnatal care (20, 21) Pregnancy, childbirth and the first six weeks after childbirth are critical times for maternal and newborn survival. Good quality antenatal, intrapartum and postnatal care are vital to reducing adverse outcomes of pregnancy, labour and delivery, and to optimizing the well-being of women and their infants. Interventions during this period may include: overall promotion of a healthy lifestyle and nutrition; risk identification, and prevention and management of pregnancy-related or pre-existing conditions; management of labour and childbirth; provision of respectful, dignified care, and effective communication between women and caregivers; care and support for GBV victims during and after pregnancy; postpartum contraception; diagnosis and treatment of STIs; and provision of mental health care. These maternal health services provide a platform for other important health-care functions beyond pregnancy and childbirth, such as: health promotion (e.g. tobacco and alcohol cessation), screening and diagnosis (e.g. diabetes, HIV, malaria, syphilis, tuberculosis), and disease prevention (e.g. vaccination).
Safe abortion care (28–31) Where legal services are readily accessible and available, abortions are generally safe. Where access and availability of legal services are highly restricted, abortions tend to be unsafe and can be a significant cause of maternal mortality and morbidity. Safe abortion care includes: provision of information; counselling; provision of medical and/or surgical abortion; recognition and management of complications from unsafe abortion; provision of postabortion contraception, when desired; and having in place referral systems for all required higher-level care.
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3. The climate of social-structural factors Four interrelated, often overlapping dimensions collectively determine the cultural, socioeconomic, geopolitical and legal environment in which sexual health and reproductive health are experienced by individuals and in which the relevant interventions are implemented. Consequently, these factors – the realities of the settings in which we live – also have an influence on the effectiveness and impact of health interventions. The four dimensions encompassing all of these contextual factors are represented in the graphic framework by the shading surrounding the rosette of interventions. This current climate or existing context should be considered when designing and implementing sexual health (and reproductive health) interventions in order to optimize effectiveness. It should be noted that progress in each of these dimensions is also necessary to support lasting improvements in sexual health. reflected in intimate and/or interpersonal relationships as well as at the family, household, community, societal, institutional and political levels. These inequalities influence who has power and control, including in decision-making surrounding sexual relations. They also form the foundation of norms related to sexuality (e.g. acceptable expressions of sexuality), and can hinder access to services and resources.
Human rights (6) Sexual health cannot be achieved or maintained without respect for, and protection of, human rights. National laws, international human rights documents and other consensus statements recognize human rights related to the enjoyment of sexual health and expression of sexuality, which are sometimes referred to simply as “sexual rights” (see Box 1). Recognition and enforcement of these rights (or lack thereof) affects the extent to which all persons can control and decide freely on matters related to their sexuality; are free from violence, coercion or intimidation in their sexual lives; have access to sexual and reproductive health information, education and services; and are protected from discrimination based on their sexuality. Human rights also inform the legal and policy environment of sexual health, sexuality and related interventions, and this environment modifies the impact of other social-structural factors on sexual health (e.g. social norms, gender inequalities).
Cultural and social norms around sexuality (32, 33) Social norms are shared expectations or informal rules among a group of people (known as a “reference group”) as to how people should behave. Norms manifest as: (i) a reflection of values or ideologies about sexuality (e.g. men have the right to control women’s bodies, or a woman’s place is in the home); (ii) behaviours that are considered acceptable or unacceptable (e.g. heterosexual relationships are acceptable, same-sex ones are not); and (iii) patterns of behaviour that are perceived as “normal” (e.g. having unprotected sex, multiple concurrent sexual relationships or transactional sex; sexual abuse and sexual harassment; child, early and forced marriage; female genital mutilation). Health-care providers often espouse the same norms, and may reinforce or further perpetuate these in their interactions with clients. Therefore, existing cultural and social norms relating to sexuality may affect access to and quality of sexual health interventions.
Laws, policies, regulations and strategies (6) Laws, policies, regulations and strategies set institutional and other parameters for the design and implementation of sexual health-related programmes, interventions and research. Thus, in any given country or context, they play an important role in either fostering or undermining sexual health, and in promoting and protecting or violating people’s human rights related to sexual health. These include national laws and policies governing the provision of health services, as well as criminal, civil, administrative and other laws that are applied to sexuality-related matters and which thus impact sexual health. The legal and regulatory framework can also serve to establish guarantees for access to justice mechanisms for people whose human rights are violated, and can support transparent monitoring and review processes to record and improve sexual health outcomes across a diverse population.
Gender and socioeconomic inequalities (34, 35) Gender inequality results from gender norms and roles, cultural or institutional practices, policies and laws, and economic factors perpetuating unequal power relations between women and men. Socioeconomic inequality refers to the unequal distribution of, access to and control over resources, social status, power and privileges based on social factors (e.g. race, ethnicity, gender, religion, age) and economic factors (poverty or wealth). Gender and socioeconomic inequalities are
10 | Sexual health and its linkages to reproductive health: an operational approach
Conclusion The Sustainable Development Goal on health (SDG 3) sets a global challenge to “ensure healthy lives and promote well-being for all at all ages by 2030”. The focus on “health for all” cascades to SDG 3’s target on ensuring universal access to sexual and reproductive health-care services by 2030 (target 3.7). Although the indicators associated with target 3.7 are focused on reproductive health, still the inclusion of the concept of sexual health in the target, as well as the promotion of “well-being for all” as a key part of SDG 3, create opportunities for enormous progress in sexual health in the SDG era. With this in mind, the framework presented in this brief seeks to fully describe the components of sexual health, as well as its linkages to reproductive health, to place these two distinct but intertwined concepts on an equal footing. By separating out and explaining the components of WHO’s working definition of sexual health, this operational approach provides guidance and structure to sexual health programming and research, thereby supporting achievement of sexual and reproductive health targets.
Acknowledgements This brief was written by Lianne Gonsalves (WHO), under the guidance of Lale Say (WHO). Rob Stephenson (University of Michigan) led the review leading to the development of the framework, assisted by Erin Riley (University of Michigan). Lianne Gonsalves and Lale Say collaborated with Rob Stephenson on the development of the framework. The members of a core WHO working group of external experts are gratefully acknowledged for their extensive inputs and feedback on the framework. This group included: Joanna Erdman (Dalhousie University), Regina Kulier (consultant and clinician in sexual and reproductive health), Rob Stephenson (University of Michigan), Paul Van Look (consultant in sexual and reproductive health), Kaye Wellings (London School of Hygiene and Tropical Medicine). Doris Chou (WHO), Rajat Khosla (WHO) and Sofia Gruskin (University of Southern California) are also acknowledged for their substantive contributions throughout the process. The following members of the WHO Department of Reproductive Health and Research provided input to various technical areas of this brief: Moazzam Ali, Avni Amin, Ian Askew, Nathalie Broutet, Venkatraman Chandra-Mouli, Doris Chou, Mario Festin, Mary Eluned Gaffield, Bela Ganatra, Claudia Garcia-Moreno, A. Metin Gülmezoglu, Brooke Ronald Johnson Jr, Rajat Khosla, James Kiarie, Antonella Lavelanet, Stephen Nurse-Findlay, Olufemi Oladapo, Matti Parry, Karin Stein, Melanie Taylor, Igor Toskin, Özge Tunçalp, Kate Whitehouse and Teodora Wi. The members of the HRP Gender and Rights Advisory Panel are thanked for their thoughtful reflections on the framework, as are the colleagues and collaborators in the sexual health field who provided comments on the initial version of the framework. Finally, Stephen Sullivan (University of Michigan) is thanked for his assistance in the design of the graphic framework. Editing was provided by Jane Patten and design/layout by Christel Chater, both of Green Ink, United Kingdom (greenink.co.uk).
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