Abstract
Sexuality is inseparable from sexual health and can refer to sex, gender identities, orientation, pleasure, intimacy, expression, and reproduction. While each element of human sexuality is important, all of these components interconnect to make us complete sexual beings. Educators and other human service providers thus require professional preparation to ensure they can meet the needs of their learners, effectively manage programming, and successfully implement strategies that allow individuals to embrace or manage their sexual existence. An inclusive approach to sexual health is best to meet the sexual health needs of all women, while ensuring their agency and control of their own bodies.
Sexuality is a natural occurrence, but one that is sometimes controversial. Female sexuality and the sexual health rights of women are particularly controversial. To understand the evolution of female sexuality, consider the shift in power dynamics between men and women [1]. The status of female sexuality and sexual health can be largely attributed to the change in power relations between men and women over time.
Specifically, male dominance in society is connected with the role of men in reproduction. This was discovered through livestock domestication, when men observed the lack of reproduction if female animals were separated from male animals; they also observed that a ram or bull could impregnate several ewes or heifers. Extending from this discovery, women in some societies were viewed as being useful only for procreation and had very little social status; this view may have led to patriarchal standards for controlling female sexuality and female reproduction [1]. Even today, women's sexuality continues to be suppressed in some circles, while male sexuality has been generally dominating and accepted.
This view has been both the foundation for and an obstacle to public health services for women. Because female sexuality has traditionally been equated with reproduction, most women's health programs are focused on women of childbearing age in an effort to prevent or support healthy pregnancies and parenting. Also, much of the debate regarding sexual rights and female sexuality is rooted in the legal issues of family planning and policies for reproductive health and contraceptive service provision [2].
Title X is the sole federally funded program focused on ensuring family planning and preventive reproductive health services for women [3]. The Title X program services have significant health, social, and economic benefits, as they not only help women and couples avoid unintended pregnancy but also make invaluable contributions related to cervical cancer, sexually transmitted diseases, infertility, and preterm and low birth weight babies [4]. While Title X programs continue to prioritize reproduction as the key issue in women's health, Title X empowers women to make choices about their reproductive health.
At the state level, the North Carolina Division of Public Health, Women's and Children's Health Section (WCH) works to promote and protect the health and development of families with an emphasis on women, infants, children, and youth. WCH programs place a major emphasis on the provision of preventive health services, beginning in the prepregnancy period and extending throughout childhood. Much of the work of this section focuses on developing and promoting programs and services that protect the health and well-being of infants, children, and women of childbearing age. The section also administers several programs serving individuals who are developmentally disabled or chronically ill, and it houses both the Women's Health Branch and the Children and Youth Branch. Some of the programs' goals are to improve the overall health of women, reduce infant sickness and death, and strengthen families and communities.
These very important programs and services provide education on topics such as breastfeeding, preconception health, pregnancy prevention, and reproductive life planning, but they place little emphasis on the broader issues of female sexuality. However, the various constructs of female sexuality deserve to be addressed in public health and other medical settings. Fortunately, program administrators are starting to gain a better understanding of the foundational element of woman's sexuality and are moving beyond a preventative and controlling paradigm to a sex-positive, inclusive, and consent-based framework.
The World Health Organization defines sexual health as 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” [5]. Sexuality is inseparable from sexual health and can refer to sex, gender identities, orientation, pleasure, intimacy, and reproduction. In order to realize or sustain optimal sexual health, the sexual rights of all persons must be valued, honored, protected, and attained. Sexual rights include the right and the ability to live a sexual life free of inequality and discrimination. This includes the right to personal agency and bodily autonomy with respect to sexuality and the right to sexual health [5]. These rights are most often associated with reproductive health and a clear understanding of sexual health. Sexuality and sexual health also include the ability to experience pleasure while in control of sexual reproduction and sexual behaviors.
Circles of Sexuality Model
A useful model for understanding the various components of sexuality is the circles of sexuality model developed by Dennis Dailey. This model depicts sexuality as having 5 main components: sexualization, identity, health and reproduction, intimacy, and sensuality. Each component consists of several subtopics related to its characteristics and influences on human sexuality (personal communication; Dennis Dailey, June 9, 2016).
One component of the model is sexualization, which is the use of the body to influence, control, and manipulate others. Sexualization includes sexual teasing, flirting, seduction, sexual harassment, rape, and sexual misuse.
Another component of the model is sexual identity. As defined by Dailey, sexual identity is one's sense of self as a sexual being and how one may live or is identified. This component of the model includes gender identity, sexual orientation, and gender roles.
A third component of the model is health and sexual reproduction, which is often the foundation of sexuality education. The circles of sexuality model expands beyond the basic understanding of sexuality for procreation and includes contraception, fertility management, infertility, abortion, menopause, and sexually transmitted diseases.
The fourth component of the circles of sexuality model is intimacy, which Dailey describes as the need and ability to experience emotional closeness to another human being and to have this closeness reciprocated (personal communication; Dennis Dailey, June 9, 2016).
Finally, this model includes sensuality, which is the need and ability to accept one's body as an erotic possibility and sexual entity. The components of sensuality include body image, anatomy, skin hunger, the sexual response cycle, and attraction.
The circles of sexuality model is a fairly encompassing model, but discussions of female sexuality should also consider culture, values, beliefs, and historical social constructs. Despite the existence of many positive constructs of healthy sexuality, many teachings and experiences have been grounded in the dangers and risks of sexuality, especially for women. Indeed, women's health places considerable focus on preventative measures and habits such as use of contraception and cancer screenings. To take a more holistic approach to women's health, it may be useful to reframe our thoughts around the circles of sexuality model. The use of this model can be useful for many disciplines related to sexuality and sexual health. Also, Dailey notes that all sexuality—regardless of gender, expression, or exploration—is relevant, and it is fair to recognize the lack of autonomy in female sexuality.
Evolution of Female Sexuality
In addition to viewing sexuality broadly in scope, the evolution of society's view of sexuality for men and women should be considered. Dr. Elizabeth Crane, professor at Widener University's Center for Human Sexuality Studies, provides an overview of the issues that impact female sexuality, gender roles, and the history related to each. As described by Crane, sexuality and gender differences can be used to influence systems and overall culture. Crane describes the dichotomy of the “good girl” versus the “bad girl” by looking at current roles and relationships as social constructions of the past rooted in a heritage of male supremacy [6]. This dichotomy is still present and often appears in popular culture, as in the contrast between Kim Kardashian and Taylor Swift.
As women become a key demographic politically, financially, and socially, it is critical that they have access to and knowledge of the resources they need to become sexually healthy. Female sexual health is directly affected by their status in society and their impact on the economy. Women typically have less sexual autonomy, which increases their risk for sexual health problems and decreases their ability to obtain treatment and support when a sexual health concern arises. This is especially evident for marginalized women, including women of color, poor women, and women who are addicted to alcohol or drugs, some of whom may exchange sex for drugs or money [7].
Addressing Inequity
The dichotomy between the “good girl” and the “bad girl” becomes more critical when addressing health disparities and health inequity. Women of color are often depicted as oversexed, sexually objectified, and plagued with myriad negative sexual stereotypes. The policing, regulation, and shaming of female sexual bodies serves to reinforce the dichotomy of good and bad female sexuality and places a value distinction on specific women.
The Women of Color Sexual Health Network was established in 2009 both to tackle issues encountered by women of color and other marginalized populations and to address issues of racism, tokenism, and lack of inclusion within the profession of human sexuality. While increased support for female sexual health is needed for all women, women of color in particular should embrace a central role in this field, as many past sexual health travesties and discoveries occurred at the expense of women of color. Examples include the life of Saartiie (Sarah) Baartman [8]; enslaved African and black women experimented on by “doctors” such as James Marion Sims [9]; the unethical treatment of Henrietta Lacks [9]; the withholding of treatment from black families involved in the Tuskegee experiment; and the forcible sterilization of black, African American, Puerto Rican, and Native American people in many areas in the United States (personal communication; Bahby Banks, August 27, 2015).
The Women of Color Sexual Health Network and other sexual health organizations are now making every effort to become more vocal, visible, and cognizant of the lack of discussion regarding the intersection of sexuality and race/ethnicity; this is part of a need, commitment, and desire for diversity, inclusion, and social justice. At the individual level, learning about the circles of sexuality model may translate into people becoming better educators and counselors, as studying this model means finding oneself in the model and gaining a better understanding of self. There is also an opportunity to include more feminist approaches when understanding and addressing issues of sexual health and human sexuality. Women's health and female sexuality programs must include a basic understanding and appreciation of the needs of diverse women. An inclusive approach to sexual health is needed to best meet the sexual health needs of all women, while ensuring their agency and control of their own bodies [7].
Education About Female Sexuality
As our view of female sexuality has grown, education of physicians also needs to change. Female sexuality can be framed and normalized by use of a sexual wellness model, rather than the standard medical model that focuses on disease, prevention, and dysfunction [10]. Indeed, it is becoming more apparent that patient-centered, lifespan approaches to sexual health may assist providers and clinicians in having conversations about sexual health that include but are not limited to romantic/sexual relationships; initiation or change of contraceptive method; diagnosis of new medical conditions or changes regarding existing conditions; new medications; or hormonal changes due to pregnancy, breastfeeding, menopause, or aging.
Medical students typically receive less than 20 hours of sexual health education. For the most part, their educational experience is a lecture course, often an elective. Very few medical schools offer practicum experience with patients obtaining medical care for a sexual health concern other than a sexually transmitted disease [11]. Prevention specialists may gain greater insight into condom use, contraception, and prevention screenings such as Pap smears and mammography. However, health and medical professionals need a better understanding of sexual health and sexuality in order to offer more effective trauma-informed care and greater sensitivity regarding sexual history taking.
In August 2016, the inaugural North Carolina Sexual Health Conference (NCSEXCON) created a space to discuss issues and topics related to sexuality and sexual health. The conference included individuals working in organizations involved in clinical care, education, reproductive health and justice, HIV/STDs, LGBTQ health care, advocacy, policy development, and overall sexuality from birth to death. The conference promoted interdisciplinary coordination among members of advocacy, clinical care, education, human/social services, and research, and it provided a forum for these individuals to share innovative approaches, best practices, and practical applications for the enhancement of sexual health across the lifespan in North Carolina.
Professional development opportunities with a focus on these issues—such as the inaugural NCSEXCON—are available to improve the sexual health of all women. Overall, health care delivery may improve with a better understanding of sexual health through support of sex-positive, inclusive, and consent-based frameworks.
Acknowledgments
Potential conflicts of interest. T.B. is the founder of the North Carolina Sexual Health Conference and is a member of the Women of Color Sexual Health Network.
- ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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