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 WHO meeting on
relationship to reproductive health. education and
1974 treatment in human
sexuality
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 International Conference
and social well-being and not merely the absence of disease or infirmity, in all matters 1994 on Population and
Development (ICPD)
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
WHO develops
understanding of human sexuality and behaviour, as well as recognition of the
sexual health
immense global health burden – including extensive mortality and morbidity – 2002 definitions
associated with a wide range of sexual and reproductive health conditions, including (published in 2006,
updated 2010)
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 WHO’s global
stigma, discrimination and poor quality of care on people’s sexual and reproductive reproductive health
health.
2004 strategy endorsed by the
World Health Assembly

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).
WHO publishes a
framework for action
In recognition of the need to define sexual health more clearly, WHO convened a 2010 on developing sexual
group of global experts to take on this task in 2002, and published the resulting health programmes

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 WHO publishes a report

contextualized five multisectoral factors that influence sexual health: (i) laws, policies 2015 on sexual health, human
rights and the law
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).
 Sexual health and its linkages to reproductive health: an operational approach  |  3

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 alongside reproductive health, for all populations,
with a core working group of external experts and everywhere. The graphic framework separates out the
practitioners of law, academia, research and clinical work individual components of the definition, setting them in
(see Acknowledgements) through a thorough review and relation to one another at three levels.
consultation process. WHO’s previous and ongoing work in
sexual health was reviewed along with recent evidence from 1. The foundation of guiding principles: These are six
the literature, and a first draft of the framework was crucial, cross-cutting principles (shown at the base of the
developed. This was reviewed by the Gender and Rights illustration) which must be incorporated into the design
Advisory Panel (GAP) of the UNDP/UNFPA/UNICEF/WHO/ of all sexual health (and reproductive health)
World Bank Special Programme of Research, Development interventions and which can also serve as evaluation
and Research Training in Human Reproduction (HRP), and a criteria against which these interventions should be
revised draft was produced. The core group reviewed the assessed.
revised draft; the final framework presented here is the
result of their deliberations. 2. The rosette of sexual health and reproductive health
interventions: The two groups of interventions are
At the centre of the framework is the ultimate objective of depicted on contrasting colours of the intertwined
sexual health: the attainment of physical, emotional, ribbons of a rosette – blue for sexual health and orange
mental and social well-being in relation to sexuality. In for reproductive health – to show that they are distinct
certain settings and for certain populations, crucial aspects yet inextricably linked.
of this objective may be overlooked when sexual health is
grouped under or together with the domain of reproductive 3. The climate of social-structural factors: The
health. surrounding shading in the graphic framework
represents the existing cultural, socioeconomic,
The framework, therefore, aims to operationalize WHO’s geopolitical and legal environment that forms the
comprehensive working definition of sexual health to ensure context for people’s lives in different settings, and which
that it receives full attention in programming and research, 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

ic inequalities
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Holistic Linked Respect, Multilevel Diversity Evidence-

approach nature of protection influences of needs based,
to sexual sexual health and on sexual across respectful
health and fulfilment health life course and positive
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Sexual health Reproductive health Climate of Foundation of

intervention areas intervention areas social-structural factors guiding principles
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 Multilevel influences on sexual health
all of equal importance – must be incorporated into the A range of factors exert influence on an individual’s
design and implementation of all sexual health sexual health, operating at multiple levels. Informed by
interventions, and they are also the criteria against which an ecological approach, attaining sexual health therefore
these interventions will be evaluated. These guiding requires interventions not only at the level of the
principles, represented at the base of the graphic framework, individual, but also at the levels of family and peers;
are intended to provide a strong foundation upon which community (social, organizational); and law, policy and
sexual health can be achieved for all. other structural factors, since these ever-widening circles
of influence can affect an individual’s sexual health (9).
Holistic approach to sexual health Sexual health and reproductive health intervention areas
This principle reflects the comprehensive working therefore can and do and, indeed, must encompass
definition of sexual health (Box 1) which emphasizes that multiple levels of programming and research, from
it is more than just the absence of ill health, but also the interventions for individuals in a clinical setting to social
attainment of a state of physical, emotional, mental and and policy reform.
social well-being in relation to sexuality. Sexual health
programming (including health services) and research Diversity of needs across life course and
should address not only the prevention of disease and populations
dysfunction, but also the active promotion of positive Sexual health exists on a dynamic continuum, with needs
sexual health and general well-being. that change across the lifespan and which vary
depending on a complex mix of individual characteristics,
Linked nature of sexual health and as well as the cultural, socioeconomic, geopolitical and
reproductive health legal environment. Particular combinations of these
Sexual health and reproductive health have unique factors can create vulnerabilities – which can be
aspects to them but they are also inherently intertwined, temporary or lasting – that may increase susceptibility to
both conceptually and at the point of programme or ill health and/or hinder access to health care. For
research implementation. For example, efforts to prevent example, certain sexual health interventions may not be
and control chlamydia (an STI) have important available because they are not culturally acceptable or
implications for future fertility, as chlamydia is a major legally permissible; available sexual health interventions
cause of infertility. Meanwhile, issues of access to and use may be difficult to access for a range of reasons; and the
of contraception can impact sexual pleasure and sexual health needs of some individuals, populations or
enjoyment. The inherent interlinkages between sexual age groups may not be recognized or acknowledged.
health and reproductive health are represented in the Sexual health programming and research must therefore
graphic framework both as a guiding principle and also in be inclusive of the diversity of needs among individuals
the interlocked nature of the two ribbons – sexual health at various points across the life course and in various
and reproductive health – which together form a rosette. settings or circumstances.

Respect, protection and fulfilment of Evidence-based, respectful and positive

human rights approach
Well established regional and international human rights Sexual health and reproductive health interventions
principles, norms and standards relating to the right to must meet standards for quality of care, including being
the highest attainable standard of health apply to sexual evidence-based and being provided in a respectful and
health (7). All individuals have the right to exercise positive manner. Specifically for sexual health
control over, and to decide freely and responsibly on, interventions, this includes: maintaining an individual’s
matters related to their sexuality as well as their sexual privacy and confidentiality; presenting information
and reproductive health – and to do so free of coercion, clearly, without coercion and in a manner that fosters
discrimination and violence. There is also widespread informed decision-making; ensuring providers are
acknowledgement that sexual rights are a necessary adequately trained, competent and nonjudgemental in
condition for attaining sexual health (6, 8). Accordingly, delivering health services; and ensuring that health
programme implementers and researchers are obliged to services utilize and stock adequate quantities of quality
ensure that sexual health interventions respect, protect supplies (including commodities and equipment) (6).
and fulfil relevant human rights.
 Sexual health and its linkages to reproductive health: an operational approach  |  7

2.  The rosette of sexual health and reproductive health interventions

Neither sexual health nor reproductive health subsumes the Gender-based violence prevention,
other. Rather, the two are inextricably interlinked as support and care (12, 13)
represented in the graphic framework by a rosette, which is Gender-based violence (GBV) can take many forms,
formed by two contrasting but interwoven ribbons. In this including physical, sexual and emotional. GBV has
configuration, the eight intervention areas – four each for previously been defined as male violence against
sexual health (blue ribbon) and reproductive health (orange women, but in recent years, the term has been used to
ribbon) – are of equal weight. More importantly, in a include violence that is based on gender identity or
mutually supportive and protective arrangement, each sexual orientation. Health sector interventions to address
intervention area enhances the impact of the others, and as GBV include: early identification through clinical inquiry;
a result, strengthens the attainment of sexual health as a first-line support and response; treatment and care for
whole. intimate partner violence and sexual assault (e.g.
emergency contraception, presumptive treatment for
Across all eight areas depicted within the rosette in the STIs, post-exposure prophylaxis for HIV, mental health
framework, the interventions may take place in a health-care care). Education for girls of secondary school age,
setting provided by the health sector (e.g. delivery care and economic empowerment of women, work on
STI treatment), but some may be provided in other settings, masculinities and changing social norms, and home
as initiatives of the education, justice, economic and/or visiting programmes to reduce child maltreatment are all
social care sectors, for example. As underlined in the important complementary intervention points outside
previous section, actions in these eight intervention areas the health sector. Freedom from violence supports safer
must be planned and designed based on the six guiding sexual relationships, reduces the risk of STIs, enables
principles. The four sexual health intervention areas are access to contraception and maternal health care, and
described below, followed by the four reproductive health increases access to needed health care, including sexual
intervention areas. health and reproductive health care.

Prevention and control of HIV and other

Sexual health (blue ribbon) sexually transmissible infections (14–18)
Sexually transmitted infections (STIs) are caused by
Comprehensive education and pathogens – such as bacteria and viruses – that can be
information (10, 11) transmitted through sexual contact (oral, anal, vaginal)
Comprehensive education and information involves the as well as through other mechanisms, such as mother-
provision of accurate, age-appropriate and up-to-date to-child transmission or vectors. Also included in this
information on physical, psychological and social aspects intervention area are reproductive tract infections (RTIs)
of sexuality and reproduction, as well as sexual and such as bacterial vaginosis and candidiasis, which can be
reproductive health and ill health. Accurate information associated with sexual activity although they are not
can address gaps in knowledge, dispel misconceptions sexually transmitted. Common STIs include chlamydia,
and build comprehensive understanding, as well as gonorrhoea, syphilis, trichomoniasis, herpes simplex
foster empowering skills, positive attitudes and values, virus (HSV), human papillomavirus (HPV), HIV and some
and healthy behaviours. This is rightly a critical part of all types of viral hepatitis. More recently, outbreak-
intervention areas in the rosette. All interventions should associated viral infections, such as Zika and Ebola, which
ensure that individuals have the knowledge and skills are primarily transmitted through vectors or physical
necessary to make well informed choices about sexuality contact, have been identified as also sexually
and reproduction and to follow up on their choices. transmissible. Many STIs can occur without noticeable
Within the health sector, information can be made symptoms. Left untreated, STIs can have short- and
available in the context of preventive or curative care long-term psychological, social and financial effects on
consultation, or in non-clinical settings in the context of individuals, in addition to effects on overall health,
health education outreach. Within the education sector, fertility and sexuality. STIs can be prevented through
age-appropriate comprehensive sexuality education delaying sexual debut, non-penetrative sex, use of
(CSE) curricula guidance and standardized content are condoms, vaccination to prevent HPV and hepatitis B,
available for preschool through university levels, and can circumcision for HIV prevention, and pre- and post-
be provided in school as well as in out-of-school settings. exposure prophylaxis. STIs can be controlled through
8  |  Sexual health and its linkages to reproductive health: an operational approach

early identification and treatment, appropriate case Contraception counselling and provision
management, improving health care-seeking behaviour, (3, 22–25)
partner notification, and preventing and managing Contraception is the intentional prevention of pregnancy
complications (e.g. pelvic inflammatory disease). by artificial or natural means. A range of modern
contraceptive methods, commodities and services
Sexual function and psychosexual should be accessible, acceptable, available and
counselling (11, 19) affordable, and they should be provided without
Sexual function represents the complex interaction of coercion by skilled providers in settings that meet
various physiological, psychological, physical and standards for quality of care (26). Contraception is one of
interpersonal factors. Poor sexual function or sexual the most cost-effective health-care interventions,
dysfunctions are syndromes that comprise a cluster of preventing unintended pregnancies and abortions (as
ways in which adults may have difficulty experiencing well as related complications of unsafe abortions) while
personally satisfying sexual activities. Identifying and also contributing to reducing maternal and neonatal
addressing sexual concerns and difficulties, as well as mortality, and enhancing newborn and child health.
offering treatment for sexual dysfunctions and disorders, Prevention of unintended pregnancy through
are critical components of sexual health care. contraception also opens up more educational
Psychosexual counselling provides patients with both opportunities for girls, thereby improving their
support and specific information or advice relating to socioeconomic status and overall well-being.
their sexual concerns; this can facilitate a return to
satisfying sexual activity. Such treatment focuses on the Fertility care (27)
need to make adjustments in sexual practices or to Failure to become pregnant after 12 months of regular,
enhance methods of coping with a sexual event or unprotected sexual intercourse is defined as infertility. In
disorder. Pharmacotherapies may also be part of the addition to the psychosocial impact on individuals of not
treatment. 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
Reproductive health (orange ribbon) to ostracism from the family or community. GBV is more
likely among individuals and couples suffering from
Antenatal, intrapartum and postnatal care unwanted childlessness or involuntary infertility.
(20, 21) Interventions for fertility care range from improved
Pregnancy, childbirth and the first six weeks after fertility awareness to advanced medical technologies,
childbirth are critical times for maternal and newborn including assisted reproductive technologies, such as
survival. Good quality antenatal, intrapartum and in-vitro fertilization (IVF). Offering fertility care also
postnatal care are vital to reducing adverse outcomes of provides an important opportunity to engage men, who
pregnancy, labour and delivery, and to optimizing the are generally less willing to access health services or
well-being of women and their infants. Interventions discuss issues related to sexual and reproductive health.
during this period may include: overall promotion of a
healthy lifestyle and nutrition; risk identification, and Safe abortion care (28–31)
prevention and management of pregnancy-related or Where legal services are readily accessible and available,
pre-existing conditions; management of labour and abortions are generally safe. Where access and availability
childbirth; provision of respectful, dignified care, and of legal services are highly restricted, abortions tend to be
effective communication between women and unsafe and can be a significant cause of maternal
caregivers; care and support for GBV victims during and mortality and morbidity. Safe abortion care includes:
after pregnancy; postpartum contraception; diagnosis provision of information; counselling; provision of medical
and treatment of STIs; and provision of mental health and/or surgical abortion; recognition and management of
care. These maternal health services provide a platform complications from unsafe abortion; provision of post-
for other important health-care functions beyond abortion contraception, when desired; and having in place
pregnancy and childbirth, such as: health promotion referral systems for all required higher-level care.
(e.g. tobacco and alcohol cessation), screening and
diagnosis (e.g. diabetes, HIV, malaria, syphilis,
tuberculosis), and disease prevention (e.g. vaccination).
 Sexual health and its linkages to reproductive health: an operational approach  |  9

3.  The climate of social-structural factors

Four interrelated, often overlapping dimensions collectively reflected in intimate and/or interpersonal relationships
determine the cultural, socioeconomic, geopolitical and legal as well as at the family, household, community, societal,
environment in which sexual health and reproductive health institutional and political levels. These inequalities
are experienced by individuals and in which the relevant influence who has power and control, including in
interventions are implemented. Consequently, these factors decision-making surrounding sexual relations. They also
– the realities of the settings in which we live – also have an form the foundation of norms related to sexuality (e.g.
influence on the effectiveness and impact of health acceptable expressions of sexuality), and can hinder
interventions. The four dimensions encompassing all of these access to services and resources.
contextual factors are represented in the graphic framework
by the shading surrounding the rosette of interventions. This Human rights (6)
current climate or existing context should be considered Sexual health cannot be achieved or maintained without
when designing and implementing sexual health (and respect for, and protection of, human rights. National
reproductive health) interventions in order to optimize laws, international human rights documents and other
effectiveness. It should be noted that progress in each of these consensus statements recognize human rights related to
dimensions is also necessary to support lasting improvements the enjoyment of sexual health and expression of
in sexual health. sexuality, which are sometimes referred to simply as
“sexual rights” (see Box 1). Recognition and enforcement
Cultural and social norms around of these rights (or lack thereof) affects the extent to
sexuality (32, 33) which all persons can control and decide freely on
Social norms are shared expectations or informal rules matters related to their sexuality; are free from violence,
among a group of people (known as a “reference group”) coercion or intimidation in their sexual lives; have access
as to how people should behave. Norms manifest as: (i) a to sexual and reproductive health information, education
reflection of values or ideologies about sexuality (e.g. and services; and are protected from discrimination
men have the right to control women’s bodies, or a based on their sexuality. Human rights also inform the
woman’s place is in the home); (ii) behaviours that are legal and policy environment of sexual health, sexuality
considered acceptable or unacceptable (e.g. and related interventions, and this environment modifies
heterosexual relationships are acceptable, same-sex the impact of other social-structural factors on sexual
ones are not); and (iii) patterns of behaviour that are health (e.g. social norms, gender inequalities).
perceived as “normal” (e.g. having unprotected sex,
multiple concurrent sexual relationships or transactional Laws, policies, regulations and
sex; sexual abuse and sexual harassment; child, early and strategies (6)
forced marriage; female genital mutilation). Health-care Laws, policies, regulations and strategies set institutional
providers often espouse the same norms, and may and other parameters for the design and implementation
reinforce or further perpetuate these in their interactions of sexual health-related programmes, interventions and
with clients. Therefore, existing cultural and social norms research. Thus, in any given country or context, they play
relating to sexuality may affect access to and quality of an important role in either fostering or undermining
sexual health interventions. sexual health, and in promoting and protecting or
violating people’s human rights related to sexual health.
Gender and socioeconomic inequalities These include national laws and policies governing the
(34, 35) provision of health services, as well as criminal, civil,
Gender inequality results from gender norms and roles, administrative and other laws that are applied to
cultural or institutional practices, policies and laws, and sexuality-related matters and which thus impact sexual
economic factors perpetuating unequal power relations health. The legal and regulatory framework can also
between women and men. Socioeconomic inequality serve to establish guarantees for access to justice
refers to the unequal distribution of, access to and mechanisms for people whose human rights are
control over resources, social status, power and violated, and can support transparent monitoring and
privileges based on social factors (e.g. race, ethnicity, review processes to record and improve sexual health
gender, religion, age) and economic factors (poverty or outcomes across a diverse population.
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 SDG era. With this in mind, the framework presented in this
global challenge to “ensure healthy lives and promote brief seeks to fully describe the components of sexual health,
well-being for all at all ages by 2030”. The focus on “health for as well as its linkages to reproductive health, to place these
all” cascades to SDG 3’s target on ensuring universal access to two distinct but intertwined concepts on an equal footing. By
sexual and reproductive health-care services by 2030 separating out and explaining the components of WHO’s
(target 3.7). Although the indicators associated with target 3.7 working definition of sexual health, this operational approach
are focused on reproductive health, still the inclusion of the provides guidance and structure to sexual health
concept of sexual health in the target, as well as the programming and research, thereby supporting achievement
promotion of “well-being for all” as a key part of SDG 3, create of sexual and reproductive health targets.
opportunities for enormous progress in sexual health in the

Acknowledgements
This brief was written by Lianne Gonsalves (WHO), under the areas of this brief: Moazzam Ali, Avni Amin, Ian Askew,
guidance of Lale Say (WHO). Rob Stephenson (University of Nathalie Broutet, Venkatraman Chandra-Mouli, Doris Chou,
Michigan) led the review leading to the development of the Mario Festin, Mary Eluned Gaffield, Bela Ganatra, Claudia
framework, assisted by Erin Riley (University of Michigan). Garcia-Moreno, A. Metin Gülmezoglu, Brooke Ronald
Lianne Gonsalves and Lale Say collaborated with Rob Johnson Jr, Rajat Khosla, James Kiarie, Antonella Lavelanet,
Stephenson on the development of the framework. Stephen Nurse-Findlay, Olufemi Oladapo, Matti Parry, Karin
Stein, Melanie Taylor, Igor Toskin, Özge Tunçalp, Kate
The members of a core WHO working group of external Whitehouse and Teodora Wi.
experts are gratefully acknowledged for their extensive
inputs and feedback on the framework. This group included: The members of the HRP Gender and Rights Advisory Panel
Joanna Erdman (Dalhousie University), Regina Kulier are thanked for their thoughtful reflections on the
(consultant and clinician in sexual and reproductive health), framework, as are the colleagues and collaborators in the
Rob Stephenson (University of Michigan), Paul Van Look sexual health field who provided comments on the initial
(consultant in sexual and reproductive health), Kaye Wellings version of the framework.
(London School of Hygiene and Tropical Medicine).
Finally, Stephen Sullivan (University of Michigan) is thanked
Doris Chou (WHO), Rajat Khosla (WHO) and Sofia Gruskin for his assistance in the design of the graphic framework.
(University of Southern California) are also acknowledged for Editing was provided by Jane Patten and design/layout by
their substantive contributions throughout the process. The Christel Chater, both of Green Ink, United Kingdom
following members of the WHO Department of Reproductive (greenink.co.uk).
Health and Research provided input to various technical
 Sexual health and its linkages to reproductive health: an operational approach  |  11

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