EDITORIAL: Sexual Health Comes of Age

Lindsay Edouard


The concept of sexual health continues to be elusive in intergovernmental fora, due largely to certain conservative groups that hinder progress during negotiations by overriding evidence-based positions.  The international battle for support to contraceptive services was won in the 1960s through the arduous fight of a few member states at the World Health Assembly but opposition to induced abortion continues.  In the Declaration of Alma Ata of 1978, family planning was merely a component within maternal and child health, one of the eight essential elements of primary health care.  The consecration of sexuality at the altar of population and development in Cairo in 1994 led to recognition of the importance of sexual and reproductive health but the ensuing rights-based programming excluded sexual rights, which was perceived as being too controversial.  The continuing lack of consensus around the contentious issues of sexual orientation and gender identity is responsible for their marginalization in the official discourse on global health.  Despite having featured among the priorities of the high-level panel of the United Nations1, lesbian, gay, bisexual, transgender and intersex (LGBTI) issues were not specifically mentioned in the sustainable development goals of 2015 that will guide the global agenda until 2030: hope is limited to inclusion through the official rhetoric of “leaving no-one behind”.

In parallel with the above political processes, the World Health Organization was meanwhile carrying out its assigned role of setting norms and standards with programming guidance on sex education as part of adolescent health, clinical guidelines for inducing abortion and the introduction of misoprostol and mifepristone in the list of essential medicines among others.  Much less known is its role regarding medical nomenclature whereby the consistent application of uniform terminology enables international comparisons besides ascertainment of occurrence of conditions, disease mapping, resource allocation, public health surveillance and monitoring of progress towards development goals.

The International Statistical Classification of Diseases and Related Health Problems, commonly referred to as the International Classification of Diseases (ICD), underwent decennial revisions from 1900 to 1968.  With the recognition that reproduction deserved special consideration, an innovative feature of the eighth revision, operational from 1968 through 1978, consisted of the P list for conditions during the perinatal period2.  The tenth revision was endorsed in 1990 and with major progress in medical knowledge over the last three decades, the nosology for the eleventh revision (ICD-11) has moved, away from organs, towards functional systems: the classification has better clinical utility through improved relevance of its rubrics for service delivery3.  The traditional paper version is being replaced by a user-friendly electronic platform and new sections are devoted to sexual health and traditional medicine4.

Entitled “Conditions related to sexual health”, chapter 17 of ICD-11 has extensive cross-references to other chapters for relevant conditions as exemplified by conventional items such as unwanted pregnancy and induced abortion.  Female genital mutilation now makes its grand entrance in the ICD by being listed with conditions of the genitourinary system and with its own alphanumeric code GC51 supplemented by two digits for subcategories specifying the type.  There are groupings for conditions such as sexual pain and paraphilic disorders whereas for sexual infections, subtle distinctions are made between disease, infection and infestation besides whether transmitted or transmissible.  Sexual maltreatment features in the chapter on external causes whereas in the section on extension codes, a distinction is made for the context of assault by specifying whether sexual or related to altercation from personal perspectives on either gender or sexual orientation.  Provision is also made for coding

of the context of rape or attempted rape.  The chapter on ‘Factors influencing health status or contact with health services’ incorporates contraceptive management, partner sexual violence, suspected sexual maltreatment, counselling related to sexuality including sexual orientation, and screening for infections with a predominant sexual mode of transmission.

Advances in the understanding of, and different attitudes to, sexuality have led to a major reform through the transfer of rubrics from sections on mental and behavioural disorders to the chapter on sexual health.  Accordingly, the approach to sexual orientation and gender identity is in accordance with current principles of human rights: the rubric gender incongruence addresses differences between experienced gender and assigned sex.  A noteworthy feature of this chapter on sexual health consists of the coexistence of items that have migrated from the disparate genitourinary and behavioural sections of the previous classification.  Discarding erroneous beliefs on the roles of mind and body in the aetiology of organic and non-organic disease, an innovative approach is used to classify sexual dysfunctions: related items have been merged and the opportunity was exploited to discard behavioural rubrics that have become obsolete through either scientific advances or changing clinical practice5.  On the other hand, emerging concepts justified the introduction of certain conditions in ICD-11, if only for facilitating research through documentation of their occurrence6 as for rare conditions7.

Service providers should be aware of subtleties in the use of rubrics for coding whether for institutional case-notes, insurance reimbursement or death certification2. Better health statistics will lead to more robust research studies, improved monitoring of service delivery and effective resource allocation8. For familiarization with the rubrics, sexual and reproductive health practitioners should browse ICD-11 at its electronic platform.  ICD-11 is currently undergoing field testing whilst open for public comments as the last steps in the revision process before its anticipated endorsement by the forthcoming World Health Assembly in May 2019.

Not having attained its deserved prominence after the sexual revolution, sexual health had to reinvent itself somehow.  Along with current initiatives for promoting universal health coverage, the imminent revision of the ICD provides a unique opportunity that should not be missed.  Service statistics on sexual health will routinely accumulate in various administrative databases but the onus will be on advocates to exploit those valuable resources to distil out the evidence for support to policy formulation

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