what do we mean by sexual and reproductive health?

Drafted by Kerryn O Rourke, on behalf of the Sexual and Reproductive Health Strategy Reference Group of the Public Health Association of Australia (PHAA) Women s Health Special Interest Group, Sexual Health & Family Planning Association of Australia (SH&FPA) and the Australian Reproductive Health Alliance (ARHA) February 2008

what do we mean by sexual and reproductive health? Sexual and reproductive health has been variously defined in international documents, reflecting an evolving understanding of the concept of sexual and reproductive health. The International Conference on Population and Development (ICPD) in 1994, called on the world to address sexual and reproductive health. Its Programme of Action included sexual health as part of reproductive health Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of diseases or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases [1, Paragraph 7.2]. The ICPD also defined reproductive rights Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes the right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents [1, Paragraph 7.3]. 2 time for a national sexual and reproductive

The Beijing Declaration and its Platform for Action (1995) incorporated a broader view of sexuality and sexual rights The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence. Equal relationships between men and women in matters of sexual relations and reproduction, including full respect for the integrity of the person, require mutual respect, consent and shared responsibility for sexual behaviour and its consequences [2, Paragraph 96]. While sexual health is vital for (and therefore part of) reproductive health, it is important also to consider sexual health in its own right. The following definitions of sexual health, sexuality and sexual rights are working definitions developed by international experts in 2002. They reflect the continually evolving understanding of the concepts and build on the previous international consensus documents [3]. Sexual health is a state of physical, emotional, metal and social wellbeing 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. 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, behaviour, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experimented or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors. Sexual rights embrace human rights that are already recognised in international laws, international human rights documents and other consensus statements. They include the right of all persons, free of coercion, discrimination and violence, to: the highest attainable standard of sexual health, and to access to sexual and reproductive health care services seek, receive and impart information related to sexuality sexuality education respect for bodily integrity choose their partner decide to be sexually active or not consensual sexual relations consensual marriage decide whether or not, and when, to have children pursue a satisfying, safe and pleasurable sex life [3, p5]. These contemporary definitions of sexual and reproductive health are critical reference points for the development of a national sexual and reproductive health strategy for Australia. 3 time for a national sexual and reproductive

contents 6 part one 7 The sexual and reproductive health of Australians 11 Determinants of sexual and reproductive health 12 The Australian policy context 12 History of sexual and reproductive health policy 12 Current government policies and strategies 14 Current policy problems 15 part two 16 Why a national sexual and reproductive health strategy? 20 Principles of a national strategy 20 Purpose and vision 20 Aims 21 Objectives 21 Scope 22 Key processes 23 Key actions needed 24 Key elements in a strategy development and review process 24 References 28 Appendix 1: International sexual and reproductive rights 29 Appendix 2: Other countries national strategies 29 Appendix 3: Reference group for the development of the background paper

introduction This background paper argues for a comprehensive and evidence-based national sexual and reproductive health strategy to improve the health of all in our community, both women and men. In part one we begin with a descriptive snapshot of the sexual and reproductive health of Australians today and of the problems we face. We also give a brief overview of the Australian sexual and reproductive health policy context past and current. In part two we outline the argument for a national sexual and reproductive health strategy, its scope and key elements and the processes necessary in developing, implementing and evaluating such a strategy. The arguments are informed by internationally agreed definitions and treaties, scientific evidence, examples of best practice, and advice from Australian sexual and reproductive health experts. 5 time for a national sexual and reproductive

6 time for a national sexual and reproductive part one

the sexual and reproductive health of australians In Australia, where the overall population is among the healthiest in the world, we have unacceptably high levels of sexual and reproductive ill health. The following is a descriptive snapshot of the major issues. Sexual initiation and activity in young people The Australian Study on Sex and Relationships 2002, the largest and most comprehensive study of the sexual and reproductive health of Australians aged 15 to 59 years, found that the median age of first experience of sexual intercourse has declined to 16 years for both women and men [4]. This finding is consistent with results from a series of three national surveys of Australian secondary school students conducted in 1992, 1997 and 2002, which have shown an increase in young peoples sexual activity over time. In the most recent survey, 25% of year 10 students and 50% of year 12 students reported having engaged in vaginal intercourse [5]. Most young people now experience 10 to 20 years of sexual activity before committing to a life partner. This increases the risk for unplanned pregnancy and sexually transmissible infections (STIs) [6, 7]. Contraception and condom use The Australian Study on Sex and Relationships 2002 found that 95% of sexually active women were using contraception. While 42% had failsafe methods (they either had vasectomised partners or hysterectomies/tubal ligation themselves), for the majority 36% using oral contraceptives, 21.4% using condoms and 8% using withdrawal/safety periods the methods used were fallible, at least on occasion. In the same study, one in four or five men (23.8%) reported having experienced a condom failure in the previous year [8]. In the 3rd National Survey of Australian Secondary Students, HIV/AIDS and Sexual Health, 60% of sexually active male secondary school students, (46% of sexually active girls) reported always using condoms, and 31% of boys and 44% of girls said they sometimes did. At their last sexual encounter, 73% of students had access to a condom, but only 65% used one [5]. 7 time for a national sexual and reproductive

In the Sex and Relationships study, only 19.2% of women reported ever having used emergency contraception [9]. A recent South Australian study (Calabretto, cited in [10]) found that while 38% of 627 university students were aware that emergency contraception was available over the counter, 75% believed it could only be used the morning after, and more than half confused it with the abortifacient RU-486. Alcohol, other drugs and sex Rates of alcohol use and binge drinking have increased among young people. Binge drinking is associated with increased perpetration of sexual violence, coercive sexual activity and victimisation [11]. For males, 29.1% in year 10 and 37% in year 12 reported binge drinking three or more times in the previous fortnight. For females, 22.1% in year 10 and 27.4% in year 12 reported such frequency [5]. Twenty-three per cent of sexually active secondary school students reported that they were drunk or high at their most recent sexual encounter [5]. Unwanted sex and sexual violence Of secondary school students, 28% of sexually active females and 23% of males had experienced unwanted sexual intercourse. While 13% reported pressure from their partner as the reason, more reported the influence of alcohol (16%). A drug or drugs other than alcohol were reported in 6% of cases [5]. The Australian Bureau of Statistics (ABS) 2005 Personal Safety Survey found that since the age of 15 years, 19.1% of women and 5.5% of men have experienced sexual violence (sexual assault or threat). Young women experienced the highest rates of sexual violence [12]. Women with disabilities are also overrepresented in sexual violence statistics [13]. Sexual violence in Aboriginal communities has been of concern for some time. A literature review of available data concludes that sexual violence in Indigenous communities occurs at rates that far exceed those for non-indigenous Australians [14, p56]. Sexual violence is associated with poor health outcomes including unwanted pregnancies and poor mental health [15]. Child sexual abuse The prevalence of child sexual abuse in Australia has been estimated from seven studies to be 27.5% in females and 5.1% in males of ever having been abused. Onset of abuse occurs at an average age of 10 years. The perpetrator is known to the child in 75% of cases, is a family member in 40% of cases, and is most often male [16]. Whilst child sexual abuse is evident across the community, particular concerns have been identified in relation to child sexual abuse in the Indigenous population where the rate of substantiated child protection notifications is 4.5 times higher for Indigenous children [17]. The recent Northern Territory Little Children are Sacred report carefully documents not only evidence of the problems, but also articulates a set of wide-ranging recommendations for addressing them and importantly, the need to act within a framework of engagement of, and leadership by Indigenous communities [18]. Sexual diversity, heterosexism, homophobia and transphobia Nine per cent of men and 15% of women in The Australian Study on Sex and Relationships 2002 reported feelings of attraction or sexual experience with the same sex. Attraction differs from identity, with 98% of Australian women (97% of men) identifying as heterosexual, 1% as lesbian (2% as gay) and 1% of men and women as bisexual [19]. Three per cent of male and 7% of female secondary school students report being attracted to their own sex. Another 1% of males and 2% of females report being unsure. 2% of sexually active students reported that their most recent sexual encounter was with someone of the same sex [5]. 8 time for a national sexual and reproductive

In a 2005 national survey of 5,476 gay, lesbian, bisexual, transgender and intersex Australians aged between 16 and 92 years, depression prevalence was high (49% of men and 44% of women), with 16% of all participants reporting suicidal thoughts in the previous two weeks. Levels of distress are associated with age, with younger people more at risk [20]. A 2004 national survey of 1,749 same-sex attracted young people aged between 14 and 21 years, found that 44% had experienced verbal abuse (e.g. name-calling, insults, threats or rumour mongering) and 16% had experienced physical assault (bashed up, had clothing or possessions damaged, raped or hospitalised for injuries). 74% of all abuse occurred at schools. Young people who reported abuse and discrimination were also more likely to report feeling unsafe in various settings, drug use, an STI, self-harm and attempted suicide [21]. Sexually transmissible infections (STIs) and HIV STIs are common in Australia, and contribute to a significant level of ill health and long-term complications, especially chronic pain and infertility. Although the epidemiology differs for each STI, population groups that suffer the greatest burden of notified infection are young people, Indigenous people and homosexually active men [22-24]. Chlamydial infection is the most commonly reported infection in Australia, with over 47,000 cases reported in 2006. Notification rates doubled between 1997 and 2001, and more than doubled again between 2001 and 2006. Notification rates are higher in females. The 2006 female population notification rate was 203 cases per 100,000, and the male rate was 185.1 per 100,000 population [24]. The population rate of notified gonorrhoea almost doubled over the past 10 years, to a rate of 42.2 per 100,000 in 2006 [24]. The population rate of infectious syphilis has remained below 10 per 100,000 for more than six years. The 2006 rate of 4.0 per 100,000 population was an increase from 3.1 in 2004, largely seen in men in Victoria and Queensland [24]. Rates of notified newly acquired HIV in Australia increased by 31% between years 2000 and 2006. While NSW recorded a stable rate of around 6.1 per 100,000 population, Queensland, South Australia, Victoria and Western Australia have seen rises from 3.5, 2.0, 4.5 and 2.4 in 2002 to 4.0, 4.1, 5.6 and 3.5 in 2006 [24] Fertility and infertility Australia s total fertility rate in 2005 was 1.81 babies per woman over her reproductive lifetime. The median age of all women who gave birth was 30.7 years. The median age of fathers was 32.9 years. Indigenous women had a somewhat higher fertility rate of 2.06 babies per woman. Seventy-five per cent of Indigenous women who gave birth were under 30 years of age, compared with under 50% for all women who gave birth [25]. Australian birth rates are the highest they have been in 10 years [25], however, one in six couples has experienced fertility problems [9, 25]. The dominant cause of infertility has been attributed to male factors in up to 30% of couples, female factors in up to 37% of couples, and both male and female in 20 to 35% of cases [Boyle, cited in 26]. Chlamydial infection is an important cause of infertility, (as is also gonorrhoea). Between 10 to 40% of untreated infections in women may lead to pelvic inflammatory disease, and 20% of women with pelvic inflammatory disease may become infertile [22]. 9 time for a national sexual and reproductive

Chronic disease and erectile dysfunction Twenty-one percent of Australian men over 40 are affected by erectile dysfunction [112]. Since the late 1990s services for erectile dysfunction have proliferated in Australia, and there is increasing advertising for products and services in the media, yet important links to associated chronic diseases such as cardiovascular disease and diabetes are seldom made. Contrary to popular belief, men over 40 report high levels of health service use, yet discussion of sexual problems and treatment of sexual dysfunction by health professionals fall well short of the extent of reported problems [112]. Teenage pregnancy and births The Australian Study on Sex and Relationships 2002 found that 17% of women aged 20 to 29 years in 2001 reported at least one pregnancy in their teen years [9]. The 3rd National Survey of Australian Secondary Students, HIV/AIDS and Sexual Health found that 6.1% of female and male secondary school students reported having had sex that resulted in pregnancy. A further 7.5% were uncertain as to whether this was the case (perhaps due to loss of contact with their female partner, possible miscarriage, or potential pregnancy at the time of survey) [5]. Australia s rate of 18.4 teenage births per 1,000 women aged 15 to 19 years is significantly higher than some developed nations (e.g. Korea, Japan and Switzerland, with rates respectively of 2.9, 4.6 and 5.5, but lower than others (eg 20.2 in Canada, 29.7 in the UK and 51.1 in the US). Teenage motherhood is more common in rural and remote areas of Australia, and is associated with poor social, economic and health outcomes. Teenage mothers tend to access antenatal care at lower rates, have poorer birth outcomes and their children have higher rates of hospitalisation as infants and beyond. In the long term children of teenage mothers are more likely to live in poverty, experience neglect or abuse, do less well at school, and become teenage parents themselves [27-30]. In 2003, the teenage birth rate among Indigenous women was more than four times the overall Australian teenage birth rate [31]. However, it is unclear how much this can be attributed to differing cultural practices and to the desire of Indigenous women to have babies at an earlier age, or to what extent it relates to the wider issues of dispossession, poverty, or a lack of access to contraception or abortion services [Evans, cited in 31]. Abortion Current national abortion data are known to be inaccurate, with significant limitations associated with the available data sources [33-36]. There were an estimated 84,218 induced abortions in Australia in 2003, with a rate of 19.7 per 1,000 females aged 15-44 years. Females aged 20-24 years had the highest rate at 32.7 per 1,000 females, and the lowest rate was for those aged 40-44 years (6.7 per 1,000 females). The Australian estimated rate is high, compared with rates in Germany (7.7 per 1,000), the Netherlands (8.7) or Finland (10.9) [36]. 10 time for a national sexual and reproductive

determinants of sexual and reproductive health Like many other areas of health, sexual and reproductive health is multidimensional, influenced by a complex interplay of biological, psychological and social determinants. Social determinants such as income, employment, housing, education, gender roles, and access to community resources, heavily impact on sexual and reproductive health, causing gross inequalities between population groups. In general, the lower an individual or group s social status, the lower their access to resources and opportunities that enable control over their lives (and health) [37-40]. Sexual and reproductive ill health disproportionately affects the following groups in Australia: Adolescents and young people Indigenous people People with disabilities People living in rural and remote areas People from culturally and linguistically diverse backgrounds, including refugees Same-sex attracted, gay, lesbian, bisexual, transgender and intersex people Sex workers People in prison Homeless people [7, 13, 20, 21, 37, 39, 41-48] In addition to these general social determinants, sexual and reproductive health is particularly vulnerable to societal attitudes [37]. The best sexual and reproductive health outcomes are found in countries with egalitarian attitudes about sexuality, that are reflected in popular culture, laws, policies and programs that respect, protect and fulfil sexual and reproductive rights [IPPF, cited in 49-51]. 11 time for a national sexual and reproductive

the australian policy context History of sexual and reproductive health policy Australian sexual and reproductive health policy stems back to the end of the 19th and beginning of the 20th centuries. Concern about declining birth rates prompted political interest in abortion, infanticide, contraception and STIs. Policies of the time focussed on controlling sexual behaviour and protecting marriage and the family unit, as the basis of a healthy society [Weeks, cited in 52]. This led to the introduction of laws about the age of consent for sexual intercourse, marriage, divorce, obscenity, pornography, homosexuality, prostitution and STIs (venereal diseases) [52]. The Royal Commission on Human Relationships between 1973 and 1978 prompted reform in many of these areas, to reflect changing societal views. The introduction of the oral contraceptive pill (OCP) in Australia in 1961 was described as a technological revolution, but it was not until the 1970s when the Federal Government took action, that it became widely available. Removal of the sales tax on all contraceptives (then at 27.5%), the addition of the OCP to the Pharmaceutical Benefits Schedule, the removal of advertising restrictions, and investment in family planning organisations significantly increased women s access to contraception [53]. The Australian Government s partnership, preventive, and human rights approaches to HIV/AIDS in the 1980s are recognised as best practice in sexual health promotion worldwide. The first National HIV/AIDS Strategy [54] brought together governments, affected communities, researchers and other stakeholders. Strong national leadership ensured that local and sometimes parochial views did not influence unduly the major planks of the strategy [37, p xxi]. Such leadership and commitment to sexual health and rights (albeit narrowly focused on infection) have not since been matched. Today, sexual health strategies still focus heavily on STIs and neglect broader sexual and reproductive health issues. Similarly, the former federal government s pregnancy counselling initiative [55, 56] was not developed with appropriate consultation, and is isolated from its context of unplanned pregnancy prevention and related issues. Australia has never had a comprehensive national sexual and reproductive health strategy, despite one being recommended some seven years ago in a report commissioned and published by the (then) Commonwealth Department of Health and Aged Care [57]. Current government policies and strategies A plethora of current policies and strategies address particular aspects of sexual and reproductive health, as can be seen opposite, with examples of current national and state and territory strategies. Sometimes sexual and reproductive health issues are also referred to in women s policies, which means that sexual and reproductive health issues as they affect both women and men are not addressed in any integrated way. No policy or strategy to date addresses sexual and reproductive health as a whole, within a comprehensive and evidence-based framework that also attends to the inter-connections with other relevant areas, such as mental health, education or drug and alcohol strategies. The South Australian Sexual Health Strategy, currently being implemented, can be expected to do this for the South Australian community. 12 time for a national sexual and reproductive

Examples of current national, state and territory strategies relevant to sexual and reproductive health National strategies: National Sexually Transmissible Infections Strategy 2005-08 [58] National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy 2005-08 and Implementation Plan [59] National Emergency Response to Protect Aboriginal Children in the Northern Territory, 21 June 2007 [60] National HIV/AIDS Strategy, Revitalising Australia s Response 2005-08 [61] Public Health Outcome Funding Agreements which include services in sexual and reproductive health Chlamydia Prevention and Screening Projects 2005-08 [62] National helpline and counselling by GPs and allied health professionals for women with an unplanned pregnancy [55, 56] National Framework for Sexual Assault Prevention (2004) [63] National Mental Health Plan 2003-08 [64] Relevant national school based programs led or sponsored by the Australian Government: - Talking Sexual Health [65]; National Safe Schools Framework [66]; MindMatters [67]; - National School Drug Education Strategy; [68] Rock Eisteddfod [69] State and territory strategies: Victoria Women s Health everyone s business: Victorian Women s Health and Wellbeing Strategy Stage Two 2006-2010 [70] Department of Human Services Health Promotion Priorities 2007-2012 (sexual and reproductive health is priority number seven) [71] Health and sexual diversity: A health and wellbeing action plan for gay, lesbian, bisexual, transgender and intersex (GLBTI) Victorians [72] Victorian Sexually Transmissible Infections Strategy 2006-2009 Queensland Queensland Indigenous Sexual Health Strategy 2003-2006 [73] Queensland HIV, Hepatitis C and Sexually Transmissible Infections Strategy 2005-2011 [74] South Australia SA Women s Health Action Plan: Initiatives for 2006/07 [75] SA Sexual Health Strategy (2007) Western Australia West Australian Aboriginal Sexual Health Strategy 2005-2008 [76] Northern Territory Aboriginal Health and Families a five year framework for action [77] New South Wales NSW HIV/AIDS strategy 2006-2009 NSW STI strategy 2006-2009 NSW HIV/AIDS, STI and Hep C strategies- Implementation plan for Aboriginal people 2006-2009 Aboriginal Maternal and Infant Health Strategy Aboriginal Safety Promotion Strategy NSW Sexual Health Promotion Guidelines 2002 Australian Capital Territory HIV AIDS, Hepatitis C, Sexually Transmissible Infections Strategic Framework for the ACT 2007-2012 Tasmania Tasmania s Health Plan 2007 13 time for a national sexual and reproductive

Current policy problems Many current sexual and reproductive health policies, and others affecting sexual and reproductive health are not consistent with best practice. Current policies: Focus on single issues, usually diseases (e.g. STIs), and neglect the promotion of broader sexual and reproductive health [22, 59, 61] Do not address or are not linked with strategies that address the social determinants of sexual and reproductive health [22, 59, 61] Mistakenly aim to alter health outcomes in isolation (e.g. pregnancy counselling to reduce abortion rates) [55, 56] Fail to link with inter-dependent strategies (e.g. mental health or substance abuse with sexual and reproductive health) [64, 68] Result in the full range of sexual and reproductive health services not being available [78-81]. Fail to address: - the full range of strategies necessary to reduce unplanned and unwanted pregnancy - marked differences in sexual/reproductive health legislation between the states and territories (e.g. regulation of the sex industry [37], abortion [83], and access to assisted reproductive technologies [84] - variability in the delivery and quality of sexuality education in the absence of minimum standards [85, 86] - sexualised media representation of girls and women [7, 49] - significant gaps in accurate and comprehensive data on which to base policies and evaluation [33, 34, 49, 51]. 14 time for a national sexual and reproductive

15 time for a national sexual and reproductive part two

why a national sexual and reproductive health strategy? The need for a national sexual and reproductive health strategy is justified in terms of a number of key indicators.* Public health importance Sexual and reproductive health is important throughout life. It is fundamental to a positive identity and for the enjoyment of social relationships [37]. Unwanted pregnancy, sexual violence, homophobia, STIs and infertility are major contributors to morbidity and associated costs in Australia [37, 43, 88]. Many sexual and reproductive health problems are preventable. Current levels of ill health and government investment in treatment services require urgent attention [37]. Sexual and reproductive ill health disproportionately affects population groups already experiencing inequalities related to gender, cultural background, sexual orientation, disability, and other factors [37]. The Australian Government is a signatory to international treaties that require the respect, protection and fulfilment of sexual and reproductive rights for all people [89]. *The need for a national strategy for sexual and reproductive health has been assessed here utilising the National Public Health Partnership Guidelines for Improving National Public Health Strategies Development and Coordination [87] and the recommendation for a national approach from 2000 [57]. 16 time for a national sexual and reproductive

The available evidence base A wide range of evidence exists in support of preventive approaches to sexual and reproductive health. Best practice examples come from the Netherlands, where young people are acknowledged as sexual beings, receive comprehensive sexuality education throughout their schooling, and can easily access contraception and condoms at no or low cost. These initiatives have produced the best sexual and reproductive health outcomes in the world [49-51]. Best practice sexual and reproductive health promotion involves a broad and comprehensive approach that incorporates a range of ongoing and sustained interventions [49, 51, 90]. Interventions are most relevant, effective and sustained when communities are involved in their development [91]. There is evidence to suggest that addressing social determinants as part of a strategic approach, will contribute to preventing and reducing sexual and reproductive (and other) health inequalities [39, 40]. The egalitarian societies of Northern Europe fare best on all sexual and reproductive health outcomes [49-51]. Is more information required about the problem? We have sufficient evidence to support the development of a comprehensive national strategy [49, 92]. Nevertheless, Australia requires a comprehensive, uniform national data collection system for sexual and reproductive health. Currently, there are obvious information gaps in the areas of unplanned and unwanted pregnancies, use of contraception, including emergency contraception, abortions and sexually transmitted infections [33, 34, 36, 51, 90]. A national strategy should also include the development of a research agenda for sexual and reproductive health [87]. A national strategy would include cost-benefit analysis. To date, economic analyses of sexual and reproductive health interventions are limited to resource poor settings [93]. The views of states and territories There is extensive support for a national strategy for sexual and reproductive health. In addition to our own consultation, a number of calls for a comprehensive approach have been published [35, 49, 51, 90]. Some states have developed their own strategies. South Australia s strategy is currently being implemented and a Victorian strategy is in development stages. Western Australia and Queensland have implemented state strategies focusing on their Indigenous populations [73, 76]. 17 time for a national sexual and reproductive

The value adding of a national approach Capacity for evaluation A national strategy would help coordinate and streamline a wide range of interventions such as: More accurate data collection (eg abortion statistics) [33, 34, 87] Development and operation of national standards (eg for relationships and sexual health education, workforce training, and health service delivery [57, 86, 87, 94] Development of nationally appropriate resources (eg for relationships and sexual health education) [87] Communications/media campaigns [95] Linking of inter-dependent strategies (eg mental health, or alcohol and other drug strategies, with sexual and reproductive health) [57, 87] Workforce development [57, 87] Law reform where appropriate [83, 87, 90] Equitable access to programs and services throughout the country [57] Comprehensive, uniform national data collection would enable appropriate monitoring and evaluation across Australia, including aggregate data for priority populations. Existing studies and surveillance would need to be expanded to include all states and territories, and focus on specific issues in population groups of interest [34, 51, 86, 90, 96]. A rigorous evaluation process (with process, impact and outcome indicators) would need to be developed as part of a national strategy [49, 87]. Can the issue be effectively addressed by an existing strategy or set of strategies? Current national strategies addressing sexual and/or reproductive health focus narrowly on STIs and HIV/AIDS, and most are due to expire in 2008 [20, 59, 61]. There is now a great opportunity to incorporate further work on STIs and HIV into a broader strategy. Other strategies currently fail to address links with sexual and reproductive health. Two examples are: the current National Mental Health Plan [64] and the National School Drug Education Strategy [68]. 18 time for a national sexual and reproductive

National leadership on Sexual and Reproductive Health requires commitment to a co-ordinated and co-operative approach across inter-connected policy and program areas at Federal, State and Territory levels 19 time for a national sexual and reproductive

principles of a national strategy Sexual and reproductive health is a human right Sex should be a positive, normal and healthy aspect of life Enhancement of sexual and reproductive health will be best achieved by a broad public health and health promotion approach, incorporating a range of interventions All interventions should be safe, effective and evidence based Access to sexual and reproductive health programs and services should be equitable and responsive, and not limited by discrimination based on age, gender, cultural background, language, marital status, sexual orientation, religion, socio-economic status, disability or geographic location purpose and vision A national sexual and reproductive health strategy would provide leadership for a cohesive and consistent approach between government and non-government agencies, research organisations, service providers, private practitioners, community groups and the wider community, for the improvement of sexual and reproductive health outcomes for all Australians. aims The aims of a national sexual and reproductive health strategy would be to: Support people in acquiring and maintaining the knowledge, skills and values necessary for good sexual and reproductive health Improve the quality, range, consistency, accessibility, affordability and integration of sexual and reproductive health services Influence the cultural and social determinants of sexual and reproductive health REDUCING UNWANTED PREGNANCIES Promote respectful, equitable, non-violent relationships Promote and provide a full range of affordable contraceptives Invest in comprehensive sexual and reproductive health services, including equitable and affordable access to abortion services Provide consistent, high quality, comprehensive relationships and sexual health education across Australian schools Reduce alcohol binge-drinking among young people 20 time for a national sexual and reproductive

objectives To improve the overall sexual and reproductive health and wellbeing of the Australian community, the objectives of a national strategy would be to: Promote respectful, equitable, non-violent relationships Reduce rates of unwanted sex and sexual violence Reduce rates of unplanned and unwanted pregnancy Reduce poor birth outcomes associated with intimate partner violence, and with teenage parenthood Improve comprehensive and appropriate data collection on sexual and reproductive health in Australia Reduce preventable infertility Reduce the associated economic costs of sexual and reproductive ill health Reduce the transmission and prevalence of STIs and HIV Reduce discrimination on the grounds of sexuality and gender identity, and associated poor health Reduce the stigma associated with STIs and HIV Reduce discrimination associated with early parenthood, and associated poor health Enhance the availability, acceptability, accessibility, affordability and quality of sexual and reproductive health services for those who need them, including woman-focused pregnancy counselling, abortion, and assisted reproductive technology scope A broad and comprehensive strategy should include all aspects of sexual and reproductive health, as well as related health issues. A national strategy should encompass the following: Sexuality, sexual health and relationships education Contraception (prevention of unintended and unwanted pregnancy ) Pregnancy counselling Abortion Sexual harassment, unwanted sex, sexual violence, and childhood sexual abuse Sexual and gender diversity (heterosexism, homophobia and transphobia) Mental health, related to sexual and reproductive health Alcohol and other drugs, related to sexual and reproductive health STIs and HIV/AIDS Fertility, sub-fertility and infertility Reproductive cancers The value of such a broad and comprehensive strategy includes identification of common risk factors, common priority populations, common settings, and common infrastructure needs and investments (such as workforce development) [87]. 21 time for a national sexual and reproductive

WORKFORCE AND INFRASTRUCTURE DEVELOPMENT Develop core teaching competencies for relationships and sexual health education in schools Invest in comprehensive sexual and reproductive health services combined with comprehensive health professional education Fund a national research program addressing gaps in sexual and reproductive health knowledge Develop a national minimum data set of key sexual and reproductive health indicators for policy review Establish a sexual and reproductive health clearinghouse for policy, research and program evaluation key processes A best practice sexual and reproductive health strategy would use broad public health and health promotion approaches that involve a range of interventions. There is no simple solution, and no one intervention is likely to work in isolation. A national strategy for sexual and reproductive health should: Involve key stakeholders in planning, implementation and evaluation [87, 90, 91], with particular attention given to appropriate consultation with, and engagement of Indigenous communities at every stage Be evidence-based, with key systematic reviews of the relevant evidence commissioned at the outset [90] Involve intersectoral collaboration [49, 87, 90, 95] Invest heavily in prevention and early intervention [49, 90] Be consistent with international human rights obligations [92, 97] Include a range of infrastructure developments, such as: - workforce and service development [57, 94] - research priorities [49, 87] - legislation reform [90, 98] - information and surveillance [90, 96] Include an action plan [90] Include a communications strategy [49, 51, 95] Include an evaluation strategy [49, 87] Include a central management resource [87] Have funding and other incentives attached [90, 99] A national strategy should be accompanied by a full economic evaluation. Whilst the burden of disease of sexual and reproductive ill health and the associated costs have been calculated at a global level, most of this has been focused on the needs and issues facing developing countries [93]. Consequently, little is yet known about the costs of sexual and reproductive ill health in Australia, nor of the potential cost benefits of a comprehensive approach to improving sexual and reproductive health, either in Australia or in other similar OECD countries. 22 time for a national sexual and reproductive

key actions needed Key actions in a co-ordinated national strategy and action plan to improve the sexual and reproductive health of the whole community would include: Development of core teaching competencies and minimum standards for relationships and sexual health education in Australian schools Development of a comprehensive approach to national minimum data collection on key sexual and reproductive health indicators Review and further development of health professional education in all aspects of sexual and reproductive health Full burden of disease assessment for sexual and reproductive ill health in Australia and thorough economic evaluation of the implementation of a national strategy Commitment to a national program of research to address evidence gaps in knowledge about improving sexual and reproductive health Improved provision of a full range of widely accessible, safe and affordable contraception, accompanied by appropriate community information strategies Significant federal and state government investment in comprehensive sexual and reproductive health services, with major investments needed in prevention and early intervention, and in workforce development. A collaborative effort with all states and territories to ensure access to legal, safe and affordable pregnancy termination services for all Australian women, regardless of their area of residence. Establishment of a national clearinghouse on sexual and reproductive health issues. REDUCING SEXUALLY TRANSMISSIBLE INFECTIONS Promote respectful, equitable, non-violent relationships Provide consistent, high quality, comprehensive relationships and sexual health education across Australian schools Promote and provide a full range of affordable contraceptives, emphasising the role of condoms and safe sex practices in reducing STIs Invest in comprehensive sexual and reproductive health services Reduce alcohol binge-drinking among young people 23 time for a national sexual and reproductive

key elements in a strategy development and review process Establish need/issues Criteria for a strategy have been met (pp17-19) Political endorsement Draw together key stakeholders and those with expertise in: - Content - Data analysis, risk factor modelling and cost effective interventions - Infrastructure in states/territories - Social and contextual knowledge of issues Develop and disseminate policy options Seek validation of the proposed options - Consultation - Pilot projects - National or State panels of relevant service providers & communities - Local site visits to discuss viability of implementation Refine policy and develop strategic plan Implementation A mix of strategies including policy, program and infrastructure development Monitoring & evaluation - Development of a minimum national data set - Impact and outcome evaluation, including economic evaluation (Adapted from [87, p25]). 24 time for a national sexual and reproductive

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100 UNICEF. Convention on the Rights of the Child. 1989, UNICEF. [Accessed 1 June 2007]; Available from: http://www.unicef.org/crc/index_30177.html. 101 Center for Reproductive Rights, Reproductive Rights 2000: Moving Forward. 2003, Center for Reproductive Rights: New York. 102 Ministry of Foreign Affairs of Denmark, The Promotion of Sexual and Reproductive Health and Rights. 2006, Ministry of Foreign Affairs: Copenhagen. 103 The National Institute of Public Health, STI/HIV prevention: The Swedish National Action Plan for STI/HIV Prevention 2000-2005. 2003, National Institute of Public Health: Stockholm. 104 The National Institute of Public Health, Sweden s New Public-Health Policy. 2002, The National Institute of Public Health: Stockholm. 105 Health Canada, Report from Consultations on a Framework for Sexual and Reproductive Health. 1999, Health Canada: Ottawa. 106 The Urban Institute, Young Men s Sexual and Reproductive Health: Toward a National Strategy. 2000: Washington, DC. 107 UK Government Department of Health, The national strategy for sexual health and HIV. 2001, Department of Health: London. 108 New Zealand Ministry of Health, Sexual and Reproductive Health Strategy. 2001, Ministry of Health: Wellington. 109 New Zealand Ministry of Health, HIV/AIDS Action Plan: Sexual and Reproductive Health Strategy. 2003, Ministry of Health: Wellington. 110 New Zealand Ministry of Justice, Safer Communities: Action Plan to Reduce Community Violence and Sexual Violence. 2004, Ministry of Justice: Wellington. 111 WHO Regional Office for Europe, WHO Regional Strategy on Sexual and Reproductive Health. 2001, WHO: Copenhagen. 112 Holden, C. A., D. J. Jolley, et al. Men in Australia Telephone Survey (MATeS): predictors of men's help-seeking behaviour for reproductive health disorders. Medical Journal of Australia 2006;185(8): 418-22. 29 time for a national sexual and reproductive

The right to life (Universal Declaration of Human Rights 1948) appendix 1 international sexual and reproductive rights The right to health (Universal Declaration of Human Rights 1948, International Covenant on Economic, Social and Cultural Rights 1966, Convention of the Rights of the Child 1989) The right to enjoy the benefits of scientific progress and its applications (Universal Declaration of Human Rights, International Covenant on Economic, Social and Cultural Rights) The right to freedom from discrimination (Convention on the Elimination of All Forms of Racial Discrimination 1965, United Nations Convention on the Elimination of All Forms of Discrimination Against Women 1979). The Committee on the Elimination of Discrimination Against Women (CEDAW), the United Nations body that monitors compliance with the Women s Convention, has stated in its recommendation on health, that barriers to women s access to health care include laws that criminalise medical procedures only needed by women and that punish women who undergo these procedures. Laws that prohibit abortion and restrict advertising of contraception are among such legal barriers [89]. The right to choice and reproductive self-determination (World Conference on Human Rights 1968, Convention on the Elimination of All Forms of Discrimination against Women 1979, Beijing Declaration and Platform for Action 1995) The right to be free from all forms of violence and coercion that affect sexual and reproductive health (eg female genital mutilation, rape and forced sterilisation (ICPD Programme of Action 1994) The right to physical integrity (Universal Declaration of Human Rights 1948) The rights of the child (Convention of the Rights of the Child 1989) recognised that children and young people have the right to enjoy the highest attainable health, access to health facilities and access to information, which will allow them to make decisions about their health, including family planning. Young people also have the right to be heard, express opinions and be involved in decision making. They have the right to education which will help them reach their full potential and prepare them to be understanding and tolerant towards others. Additionally, young people have the right to not be discriminated against [100]. Legal right to life is used by people opposed to abortion, however, it has not been interpreted in any international setting to require restrictions on abortion. In 2003 the European Court of Human Rights, in the case of Vo v. France, stated that it is neither desirable, nor even possible as matters stand, to answer in the abstract the question whether the unborn child is a person for the purpose of Article 2 of the European Convention on Human Rights (providing that everyone s right to life shall be protected by law ). The court therefore refused to adopt a ruling that would have called into question the validity of laws permitting abortion [101]. 30 time for a national sexual and reproductive

appendix 2 other countries national strategies Denmark The Promotion of Sexual and Reproductive Health and Rights 2006 (Ministry for Foreign Affairs) [102] Sweden STI/HIV Prevention: The Swedish National Action Plan for STI/HIV Prevention 2000-2005 [103] Sweden s New Public Health-Policy [104] Canada Report from Consultations on a Framework for Sexual and Reproductive Health 1999 [105] US Young Men s Sexual and Reproductive Health: Toward a National Strategy 2000 [106] England The national strategy for sexual health and HIV 2001 [107], and subsequent documents, including: Recommended standards for sexual health services 2005 [94] Teenage Pregnancy: Accelerating the Strategy to 2010 [29] Scotland Enhancing Sexual Wellbeing in Scotland: A Sexual Health and Relationships Strategy (2003) [95] New Zealand Sexual and Reproductive Health Strategy Phase One 2001 [108] HIV/AIDS Action Plan: Sexual and Reproductive Health Strategy 2003 [109] Safer Communities: Action Plan to Reduce Community Violence & Sexual Violence 2004 [110] Europe WHO Regional (Europe) Strategy on Sexual and Reproductive Health 2001 [111]. appendix 3 reference group for development of the background paper The Reference group was made up of members of PHAA, SH&FPA and ARHA: Dr Kirsten Black, Ms Ann Brassil, Dr Cathy Mead, Dr Marilyn McMurchie, Ass Prof Juliet Richters, Ms Kerrilie Rice, Dr Alison Rutherford, Dr Rhonda Small, Dr Judy Straton, Dr Angela Taft, Ms Kaisu Vartto, Dr Edith Weisburg Ms Kerryn O Rourke, a Public Health Fellow with the Victorian Public Health Training Scheme, drafted the Background Paper on behalf of the Reference Group, whilst on placement with Angela Taft and Rhonda Small at Mother & Child Health Research, La Trobe University. 31 time for a national sexual and reproductive