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Dusk: A Vignette
It was that time of evening, just before dark. The house was empty except for the two of them. As they lay together entwined in a warm embrace, this room, this bed, was the universe. She stroked the nape of his neck. He nuzzled her erect nipple, first gently with his nose, then licked it, tasted, smelled and absorbed her body odor. It was a hot and humid August day, and they had been perspiring. Slowly he caressed her breast as he softly rolled his face over the contours of the other. He pressed his body close against her, sighed, and fully spent, closed his eyes and soon fell into a deep, satisfying sleep. Ever so slowly she slipped herself out from under him, for fear that she would disturb him; she cradled him in her arms and then moved him to his crib. Having completed his 6 o'clock feeding, the 4-month-old had just experienced another important step toward his sexual development.
Some readers would not recognize this vignette as having sexual overtones at all, while others may be surprised to realize that it isn't sexual in the way that it initially appeared to be. But this vignette illustrates two important concepts related to sexuality: It suggests the important early beginnings of our sexual development, and it also reminds us that the assumptions made about what is sexual or erotic do not always hold true across situations and cultures.
What are sexuality and sexual health?
Sexuality is reflected in the total expression of who we are as human beings. It encompasses our values, attitudes, behaviors, physical appearance, beliefs, emotions, and personality, as well as the way in which we have been socialized. It involves our sexual identity and orientation. It begins before birth and lasts a lifetime. The expression of sexuality is influenced by ethical, spiritual, cultural, and moral factors, and it involves giving and receiving sexual pleasure, as well as enabling reproduction. Sexuality is a total sensory experience involving the whole mind and body—not only the genitals. Sexual health refers to factors that enable us to enjoy and control our sexual and reproductive lives, including the quality of our sexual and other close relationships.
The expression of sexuality is influenced by ethical, spiritual, cultural, and moral factors, and it involves giving and receiving sexual pleasure, as well as enabling reproduction. Sexuality is a total sensory experience involving the whole mind and body—not only the genitals. Sexual health refers to factors that enable us to enjoy and control our sexual and reproductive lives, including the quality of our sexual and other close relationships.
Why address sexuality?
Sexuality has a major influence on what it means to be "reproductively healthy" and thus should be an integral aspect of reproductive health care.
While the connections between sexuality and reproduction or family planning may seem obvious, reproductive health services have historically disassociated sexuality from reproduction. In recent years, there has been increasing recognition of the importance of paying attention to the context in which people make decisions about their health, including sexuality and gender influences.
The importance of addressing sexuality has been brought to attention partly because of the HIV epidemic. Through addressing HIV and AIDS, providers have been confronted with the need to address clients' sexuality, since it is clear that sexually transmitted infections (STIs) such as HIV cannot be effectively addressed without addressing sexuality in a frank and direct way. Yet sexuality influences reproductive health in many ways beyond HIV.
Clients do not often seek services directly related to sexual matters. Concerns related to sex and sexuality tend to emerge when providers explore beyond the client's presenting need or physical complaint—during history taking, physical examination, or counseling sessions. If a reproductive health provider makes assumptions and fails to explore the client's needs sufficiently, the client may receive inadequate or inappropriate information and services.
For example:
Influence on client decision making
In order to make informed reproductive health care choices, clients must make decisions about sexuality and sexual practices. Sexual and reproductive health decisions (such as whether or when to have children, whether and what type of contraception to use, and the degree to which one engages in protective or risk-taking behavior) are influenced by a variety of social and interpersonal factors, including sexuality and gender.
One issue that often influences a client's decisions is the potential impact of that decision on sexual pleasure and sexual relations. For example, some hormonal family planning methods may greatly reduce libido in some women. If a woman is not prepared for this possibility, she may discontinue the method; the result could be an unintended pregnancy. Clients may avoid other methods; such as vasectomy, because of misperceptions of the potential negative impact on sexuality. Barrier methods such as spermicides and condoms may also impact sexuality, since they must be inserted or applied during the course of the sexual act, which can be negatively perceived as an "interruption." Providers must be sensitive to these perceptions, whether founded or not, and help clients to understand other, positive impacts on sexuality, to mitigate these potential barriers or to find alternatives.
Gender inequalities and women's lack of power in the realm of sexuality and partner relations may also influence their reproductive and sexual health decisions and ability to implement decisions. For example, a woman may decide that she wants to protect herself from HIV and other STIs because of a concern about her partner's behaviors, yet she may not have the power to confront her partner or even to discuss the matter without fear of reprisal. She may fear being accused of infidelity herself, violence, losing her partner, or even losing her means of economic support. In some cases, a client may not have any control over her risk of pregnancy or STIs because she lacks control over who her partner is and whether or not to have sex. She may have her partner chosen for her by her family, may experience forced sex, or may be forced into relations out of economic necessity. Providers must be sensitive to these circumstances and avoid promoting inappropriate courses of action, or actions that will place a woman at risk of negative consequences.
By taking into consideration the sexuality and gender influences that affect clients' lives, health providers are better able to help clients realize their health and life goals and achieve reproduction and healthy and enjoyable sexuality.
What providers can do
Through taking sexuality concerns into account, providers can better meet clients' needs and improve the quality of the services they offer. By exploring clients' circumstances and concerns related to sexuality, providers are better prepared to:
In order to effectively address sexuality issues, providers need to establish a certain level of comfort and trust with clients. Providers may need to increase their own level of comfort with sexuality in order to do so. While many may fear that addressing sexuality would be inappropriate in a given culture, many who have done so have found that it is indeed possible where they previously thought it would not be. They have found that clients are grateful to have an opportunity to confide their concerns in a safe environment, and that when these concerns are addressed, clients are more satisfied with the services they receive. This is an example of how sexuality is an integral part of our lives.