New Views on Sexual Health

Publications of the Population Research Institute,
Series D 37/2000
New Views on Sexual Health
The Case of Finland
Edited by
Ilsa Lottes
and
Osmo Kontula
The Population Research Institute
Väestöntutkimuslaitos
Väestöliitto, The Family Federation of Finland
1
The Population Research Institute
Väestöntutkimuslaitos
Väestöliitto, The Family Federation of Finland
PO Box 849 (Iso Roobertinkatu 20–22 A)
FIN 00101 Helsinki, Finland
Telephone:+358-9-228 050
Telefax: +358-9-612 1211
E-mail: [email protected]
http://wwww.vaestoliitto.fi
ISBN 952-9605-58-7
ISSN 0357-4725
2
New Views on Sexual Health
The Case of Finland
Preface
5
Ilsa Lottes and Osmo Kontula
Sexual Health from Macro and Micro
Perspectives
1. New Perspectives on Sexual Health
Ilsa Lottes
7
2. Macro Determinants of Sexual Health
Ilsa Lottes
29
3. Sexual Health Promotion on the Individual Level
Osmo Kontula
49
3
4
Preface
In the 1990’s a new approach to sexual and reproductive health was adopted at
international conferences and promoted by international organisations. Yet many
professionals involved in the delivery of sexual health services, information, and education
lack a clear understanding of aspects of this approach—both within and outside of
Finland. Therefore, we decided to edit a book—in both Finnish and English—that explains
basic components of this new international perspective on sexual health and describes
Finland’s experience with this new framework as an example of this new approach.
Questions that this volume addresses include the following: How is sexual health defined?
Why are sexual health issues important? What are the determinants of sexual health?
How does the new approach to sexual health proposed by international health, sexuality,
and family planning professionals vary from traditional views? How well do institutions
in Finland meet the sexual health needs of the population? What is the current state of
sexual health in Finland and which aspects need improvement? How can health
professionals, educators, researchers in academia and government, social workers,
legislators and policy makers promote sexual health? These are questions that we address
in this book. The answers are provided by almost 30 experts of sexuality and sexology.
Since the 1960’s, Finland has generally adopted a non-moralistic health approach to
problems linked to sexual behaviour, such as teenage pregnancy and abortion and sexually
transmitted diseases. As a result of new policies, current teenage pregnancy and abortion
rates are only half of those in the 1970’s. The incidence of sexually transmitted diseases
also declined. In the 1970’s, some 15,000 new cases of gonorrhea were reported every
year, and in the 1990’s this rate was reduced to about 200 new cases. Which specific
policies have contributed to the dramatic changes in these indicators of sexual health?
For this book we asked Finnish authorities to tell the story of developments in their area
of expertise in sexual health.
Finland has become a leader along with the Netherlands and other Nordic countries in
providing high quality sexual health services and education. Nevertheless, the
international community is not generally familiar with Finnish sexual health policies. We
hope that the model of sexual health presented here and applied to Finland will be
useful to describe and evaluate sexual health in other countries. Finnish professionals
may also find the model and information in this book helpful to evaluate, revise, and
develop new sexual health programs.
The first Chapter describes basic elements of the new perspective and defines sexual
health. Chapters 2 and 3 use the new views and definitions to lay the foundation for
models or explanations of sexual health, from both macro and micro perspectives. The
next chapters provide descriptions of sexual health services and sources of information
5
and education. Subsequent chapters focus on the sexual health needs of specific
population subgroups—children, adolescents, non-heterosexuals, the disabled and the
elderly. In the final chapter we summarise and evaluate the state of sexual health in
Finland with respect to criteria defined by the new international approach to sexual
health and determinants discussed in the first part of the book.
Contributors were given specific guidelines to follow in describing their area of expertise
related to sexual health services or subgroups. They were told to discuss public attitudes,
laws, benefits, strengths, weaknesses, and needs related to their service or population
subgroup. In addition, they were asked to include statistics that could be compared to other
countries, if appropriate, and also to describe the extent to which a preventive approach has
been adopted in attempting to minimise sexual health problems. If applicable, authors were
also told to include issues related to rights, access, cost, quality and equity.
We are most appreciative of the interest and enthusiasm of the contributors to this book
and hope they know that we are grateful for their efforts in making this project a
success. We also thank sexual health professionals, who work at the Finnish National
Research and Development Centre for Health and Welfare, the Polytechnic School of
Health and Social Care in Jyväskylä, and the Family Federation of Finland for their
general guidance and support. Thus, a special ‘thank-you’ is extended to Maija Ritamo,
Sari Kautto, Sirpa Valkama, Dan Apter, Raisa Cacciatore, and Pia Brandt. We also
gratefully acknowledge resources made available to us by the Population Research
Institute of the Family Federation of Finland and the Department of Sociology of the
University of Helsinki.
Because most contributors to this book are Finnish, the translations of the Finnish
chapters into English posed a major challenge. The English and Finnish languages have
very different structures, and ideas expressed in one language cannot be directly captured
by word to word translations without loss of meaning. Special thanks go to Olli Stålström
for his careful and thorough job in translating half of the chapters to English. In addition,
we are grateful to authors who were able to translate their own chapters. And we thank
Mika Takoja for the layout of the book.
We hope this volume will serve as a basic sexual health textbook for professionals, their
students and clients in universities, polytechnics, and other organisations offering sexuality
information, education, and services. Ultimately, our goal is to enable readers to discover
new ways to promote sexual well-being and sexual rights in the new millennium.
Helsinki, July, 2000
Ilsa Lottes
Osmo Kontula
6
Ilsa Lottes
1. New Perspectives on Sexual
Health
This chapter elaborates on the origin, meaning, and use of the term ‘sexual health’. To
do this it is necessary to also discuss terms that have been frequently used in texts
which include ‘sexual health’– namely ‘reproductive health’, ‘reproductive rights’, and
‘sexual rights’. Distinctions between reproductive health and sexual health, and between
sexual health and sexual rights are provided. All four terms –‘reproductive health’,
‘sexual health’, ‘reproductive rights’, and ‘sexual rights’ – are relatively new in local,
regional, national, and international discourse; their use has emerged primarily within
the last three decades. In the 1990s these terms became common in international texts
but popular use of these words has varied and continues to vary greatly by country and
context. After I give a brief history of the origin and meanings of these terms and how
they are used here, it will be clear how these definitions determine the content of this
book. This chapter concludes with an introduction to aspects of sexual health in Finland
and a brief discussion of the implications of a rights approach to sexual issues.
Reproductive Health and Reproductive Rights
According to Correa (1997), members of organisations concerned about population
problems and the health of new mothers and their babies in developing countries adopted
the term ‘reproductive health’ in the 1980s and early 1990s. These include women’s
health organisations, the World Health Organization, family planning organisations and
institutions providing maternal care. Women promoted the use of the term ‘reproductive
health’ in order to emphasise an approach to family planning which included
considerations of women’s needs and views in contrast to the previous approach which
focused primarily on population control. Women’s activists wanted the interests of
women to be taken into account in population policies. For many poor women in
developing countries, such policies had failed to acknowledge, for example, the degree
to which having children is linked to social status, religious views, and other pressures
(Freeman and Isaacs 1993).
Correa (1997) emphasises that the term ‘reproductive rights’ was adopted by women’s
groups and other non-governmental organisations in the 1970s and 1980s in their struggle
to make and/or keep abortion safe and legal and to promote women’s access to safe
contraception. In 1978, for example, the Women’s Global Network for Reproductive
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Rights (WGNRR) was founded with its headquarters in Amsterdam. This organisation
is an autonomous network of groups and individuals in every continent, including 113
countries, working for and supporting reproductive rights for women. According to this
network, reproductive rights refer to “women’s right to decide whether, when, and
how to have children. This means the right and access to: full information about sexuality
and reproduction, about reproductive health and health problems ... good quality,
comprehensive health services that meet women’s needs and are accessible to all women;
safe effective contraception and sterilisation; safe, legal abortion; safe women-controlled
pregnancy and childbirth; and prevention of and safe, effective treatment for the causes
of infertility“ (Back cover of each WGNRR Newsletter). Articles in the newsletters
typically focus on health problems associated with pregnancy, contraception, and abortion.
Nevertheless, because of the overlap of issues relating to both sexuality and reproduction,
topics that affect women’s sexuality are also covered such as female genital mutilation,
prostitution, and sexual abuse and assault.
At the 4th International Women and Health Meeting in Amsterdam in 1984 feminists
from various parts of the world agreed that the use of the term ‘reproductive rights’
would promote their goals of improving the reproductive aspects of women’s lives
throughout the world. After that conference, numerous books and articles with either
the term ‘reproductive rights’ or ‘reproductive choice’ in their titles were published
(e.g., Boland and Rahman, 1997; Cook and Fathalla, 1996; Correa and Petchesky,
1994; Dixon-Mueller, 1993b; Hardon, Mutua, Kabir and Enngelkes, 1997; Hardon and
Hayes, 1997; Hartmann, 1995; Hayes and Hardon, 1996; Rahman and Pine, 1996).
At this same time, feminist lawyers joined family planning professionals and human
rights activists to place women’s reproductive health needs within a human rights and
health rights framework (Cook, 1993, 1995; Correa, 1997; Packer, 1996).
Although the term ‘reproductive rights’ was not used, some of the principles of such
rights have been acknowledged in documents of the United Nations, starting with the
Teheran Declaration. A document written at the 1968 International Conference on
Human Rights in Iran states that parents have the basic human right to decide freely
and responsibly on the number and spacing of their children and a right to adequate
education and information. These two rights were extended to individuals in the World
Population Conference at Bucharest in 1974. The right to ‘control one’s own body’
was first formally accepted by an international meeting in the 1993 United Nations
World Conference on Human Rights in Vienna. In addition, in the Vienna Declaration,
violence against women was acknowledged as a human rights abuse.
Major advances in the scope of reproductive rights were also achieved at the 1994
International Conference on Population and Development in Cairo and at the 4th World
Conference on Women in Beijing in 1995. Planners and participants of the Cairo
conference shifted the focus from one that had been concerned primarily with population
control to one that made the well-being of individuals and their rights a priority for
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economic development. The use of the word ‘rights’ was considered an important
strategic move that would promote advocacy for and acceptance of more comprehensive
reproductive health and education services. This paradigm shift also included a major
redefinition of reproductive health. Although traditional services – such as those concerned
with maternal health and family planning–were still considered important, the meaning
of reproductive health was extended to include health problems and rights related to
sexuality. The Programme of Action of the Cairo conference states that reproductive
health “implies that people are able to have a satisfying and safe sex life and that they
have the capacity to reproduce and the freedom to decide if, when and how often to do
so“ (United Nations, 1996, p.1). The document goes on to say that reproductive health
“includes sexual health, the purpose of which is the enhancement of life and personal
relations, and not merely counseling and care related to reproduction and sexually
transmitted diseases.“ (p.1) In the new approach, agreed upon by 184 governments,
sexual health is considered a vital part of a person’s physical and psychological well
being. This was the first time that an international document explicitly acknowledged
the importance of sexuality in people’s lives.
It is important to note that members of the Nordic delegation to Cairo were major
promoters of getting the term ‘sexual health’ in the Programme of Action. Although
they were unable to also have ‘sexual rights’ included, progress had been achieved
when the terms ‘reproductive rights’ and ‘sexual health’ were retained. Correa (1997,
p. 108) notes that the use of the term ‘sexual rights’ did not even come up for consideration
until “practically the eve of Cairo“. In Beijing one year later, the term ‘sexual rights’
was again discussed but still was not officially incorporated into the conference
documents. Nevertheless, important references to women’s sexual well-being were stated
in the Platform of Action. For example, Paragraph 96 (Correa, 1997, p.109) states,
“The human rights of women include their right to have control over and decide freely
and responsibly on matters related to sexuality, including sexual and reproductive health,
free of coercion, discrimination, and violence. Equal relationships between women and
men in matters of sexual relations and reproduction, including full respect of the integrity
of the person, require mutual respect, consent and shared responsibility for sexual
behaviour and its consequences.“ Thus, the Beijing documents are significant because
they mark the first international consensus on recognising the principle of sexual rights.
Since the Cairo and Beijing conferences, international organisations including the World
Health Organization, the International Planned Parenthood Association, the United
Nations Population Fund, and the World Association of Sexology as well as many
national, regional and local organisations have tried to expand upon and implement the
programs these conferences endorsed. The United Nations sponsored workshops and
supported the publication of a series of reports about the conference issues, including
“Reproductive Rights and Reproductive Health: A Concise Report“ in 1996.The World
Health Organization (WHO) identified sexual and reproductive health as one of its four
priorities and provided country and regional co-ordinators with useful guidelines and
9
information to facilitate needs assessment and service provision. In addition, a meeting
attended by regional, national, and international experts in family planning was held on
“Operationalising Sexual and Reproductive Health“. As a result the following problem
areas of sexual and reproductive health were highlighted: aspects of couple relationships,
including safer sex practices; unwanted pregnancy; maternal mortality; sexually transmitted
diseases, HIV/AIDS; unsafe abortion; infertility; violence against women, female genital
mutilation; and special population groups such as adolescents, the poor and marginalised
(International Planned Parenthood Federation, 1995). Recommendations involved the
following activities: advocacy, information, education, communication, service delivery,
evaluation, and research. The United Nations Population Fund (UNFPA) published
“The Right to Choose: Reproductive Rights and Reproductive Health“ in 1997 which
includes sections on rights, empowerment and development; rights for sexual and
reproductive health; sexual and reproductive self-determination; and reproductive health
and sustainable development. In 1998, ENTRE NOUS, a publication of UNFPA and
WHO, added the word ‘sexual’ to its subtitle, which now reads “The European Magazine
for Reproductive and Sexual Health“. These examples represent only a small proportion
of the recent use in international contexts of the terms ‘sexual and reproductive health’
and ‘reproductive rights.
More needs to be said about the International Planned Parenthood Federation (IPPF).
According to its web page (www.ippf.org), IPPF links autonomous national family
planning associations in over 150 countries world-wide. IPPF has been an aggressive
promoter of the programs initiated in Cairo and Beijing. Soon after these conferences
IPPF was quick to supply its regional and national member organisations with materials
and information to help them widen the scope of their activities to include health problems
and concerns related to sexuality. These materials include “Sexual and Reproductive
Health, Family Planning Puts Promises into Practice“ (1995), “Charter on Sexual and
Reproductive Rights“ (1996), and “Sexual and Reproductive Rights, A New Approach
with Communities“ (1997). Their booklets on sexual and reproductive rights are especially
significant because they contain the 12 basic rights IPPF believes are implied by the
documents produced by international consensus at the conferences in Vienna, Cairo,
and Beijing as well as the 1995 UN World Summit for Social Development in Copenhagen.
These are listed in Table 1. The purpose of including the explanation of these rights in a
guideline booklet prepared by IPPF is to “increase the capacity of Family Planning
Organisations and other non-governmental organisations to undertake effective advocacy
within the field for sexual and reproductive health“ (Newman, 1997). In order to guide
social policy and hold governments responsible for enabling people to exercise their
sexual and reproductive rights, the meaning and interpretation of these rights must be
clear. The guidelines help clarify these meanings and provide numerous illustrations of
how each of the rights is linked to sexual and reproductive health. For example, the
‘right to privacy’ means that all individuals, including adolescents, have the right to
confidentiality when seeking sexual and reproductive health care services. The IPPF
guidelines also illustrate how each right can be violated. The prohibition of access to
10
sex education and information to adolescents is an example of how the ‘right to
information and education’ is violated.
Table 1
SEXUAL AND REPRODUCTIVE RIGHTS as formulated by the INTERNATIONAL PLANNED
PARENTHOOD FEDERATION
1. The Right to Life
IPPF claims that the right to life applies to, and should be invoked to protect, women whose lives
are currently endangered by pregnancy.
2. The Right to Liberty and Security of the Person
IPPF claims that the right to liberty and security of the person applies to, and should be invoked
to protect, women currently at risk from genital mutilation, or subject to forced pregnancy,
sterilisation or abortion.
3. The Right to Equality and to be Free from all Forms of
Discrimination
IPPF claims that the right to equality and to be free from all forms of discrimination applies to, and
should be invokes to protect, the right of all people, regardless of race, color, sex, sexual
orientation, marital status, family position, age, language, religion, political or other opinion,
national or social origin, property, birth or other status, to equal access to information, education
and services related to development, and to sexual and reproductive health.
4. The Right to Privacy
IPPF claims that the right to privacy applies to, and should be invoked to protect, the right of all
clients of sexual and reproductive health care information, education and services to a degree of
privacy, and to confidentiality with regard to personal information given to service providers.
5. The Right to Freedom of Thought
IPPF claims that the right to freedom of thought applies to, and should be invoked to protect, the
right of all persons to access to education and information related to their sexual and reproductive
health free from restrictions on grounds of thought, conscience and religion.
6. The Right to Information and Education
IPPF claims that the right to information and education applies to, and should be invoked to
protect, the right of all persons to access to full information on the benefits, risks and
effectiveness of all methods of fertility regulation, in order that any decisions they take on such
matters are made with full, free and informed consent.
7. The Right to Choose Whether or Not to Marry and to Found and Plan a Family
IPPF claims that the right to choose whether or not to marry and to found a family applies to, and
should be invoked to protect, all persons against any marriage entered into without the full, free
and informed consent of both partners.
8. The Right to Decide Whether or When to Have Children
IPPF claims that the right to decide whether or when to have children applies to, and should be
invoked to protect, the right of all persons to reproductive health care services which offer the
widest possible, affordable, acceptable and convenient services to all users.
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9. The Right to Health Care and Health Protection
IPPF claims that the right to health care applies to, and should be invoked to protect, the right of
all persons to the highest possible quality of health care, and the right to be free from traditional
practices which are harmful to health.
10. The Right to the Benefits of Scientific Progress
IPPF claims that the right to the benefits of scientific progress applies to, and should be invoked
to protect, the right of all persons to access to available reproductive health care technology
which independent studies have shown to have an acceptable risk/benefit profile, and where to
withhold such technology would have harmful effects on health and well-being.
11. The Right to Freedom of Assembly and Political Participation
IPPF claims that the right of freedom of assembly and political participation applies to, and should
be invoked to protect, the right to form an association which aims to promote sexual and
reproductive health and rights.
12. The Right to be Free from Torture and Ill Treatment
IPPF claims that the right to be free from torture and inhuman or degrading treatment applies to
and should be invoked to protect children, women and men from all forms of sexual violence,
exploitation and abuse.
Those attending five-year follow-up meetings to evaluate progress in achieving the
goals of the programmes of action of Cairo and Beijing reaffirmed commitments to
continue the approaches agreed upon at those mid 1990s conferences. In particular, the
humans rights context for sexual and reproductive health and rights was again endorsed.
Reports and documents from numerous NGOs revealed that language and concepts
considered new and difficult in the original conferences were now generally understood
and being used to guide programs in sexual and reproductive health. One of the documents
presented at the Cairo follow-up meeting in The Hague was a Nordic Resolution on
Adolescent Sexual Health. In this resolution, developed by the five Nordic countries,
specific ways to promote the sexual health of adolescents are described and linked to
sexual rights. Another paper stressed the need to devote more attention to the enactment
of laws that would protect sexual and reproductive rights.
Sexual Health and Sexual Rights
In the examples cited so far, the word ‘sexual’ has almost always been used together
with ‘reproduction’, as in ‘sexual and reproductive health’ or ‘sexual and reproductive
rights’. In fact, at Cairo, sexual health was defined as part of reproductive health. There
are some sexuality and health professionals who have separated the two terms. For
example, some educators have used the term ‘sexual health’ since the 1980s, even
though the use of this term was popularised only in the 1990s. So now I discuss the use
of the terms ‘sexual health’ and ‘sexual rights’ without the addition of ‘reproductive’.
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The terms ‘sexual health’ and ‘sexual well-being’ can be found in documents of the
WHO from the 1970s and 1980s. The definitions of these terms have been vague and
ambiguous. For example, one WHO definition of ‘sexual health’ is “the integration of
physical, intellectual, and social factors which enriches and strengthens personality,
communication and love“ and that of ‘sexual well-being’ is “the identification of sexual
versatility and individuality in the sexual experiences and needs of each society and its
members“ (in Advisory Committee on Health Education, p. 27, 1989). Helfferich (1996)
states that the aim of such definitions is not to describe a real state of health, but to
formulate an ambitious ideal that will encourage governments to create conditions
conducive to health, including political and economic empowerment that allow people
to make free and informed decisions relating to their health.
After the Cairo conference in 1994 family planning organisations and professionals in
the health field have also more frequently used the term ‘sexual health’ in their
publications. A review of articles published in five major family planning journals over
the 12 year period from 1980 to 1991 revealed that less than 4% of publications discussed
topics that related to sexuality and/or gender-power dynamics (Dixon-Mueller, 1993a).
Now references to sexuality and gender are common. In 1996 the editor of “Planned
Parenthood in Europe“ changed the name of his journal to “CHOICES, Sexuality and
Family Planning in Europe“. The theme of a subsequent issue of this journal was
“Sexual Health Today“. Also in 1996, the first African conference on sexual health was
held in Ghana (Nair, 1997). In 1997, a doctor who specialises in sexually transmitted
diseases from the New York University Medical Center launched a new magazine,
called SEXUAL HEALTH. The purpose of this magazine is to “provide the best available
information about all matters sexual and open a new dialogue about the breadth of
human sexuality in an effort to make sex safer and more satisfying for everyone.“
(Premiere Issue, pp.2-3, 1997). At a 1997 symposium organized by the Japan Family
Planning Association and the Japan Federation of Sexology, Barbara Axelson from
Sweden and president of the IPPF’s European Network, was a major speaker. Her talk
included a focus on sexuality and the importance of sexual enjoyment. She emphasised
that in Scandinavia, people accept responsible sexual expression as a significant human
value for the entire life cycle. She went on to say that the three conditions necessary for
an individual’s sexual enjoyment were a loving partner, sexual knowledge and
contraceptives. She also said that cultures with supportive rather than restrictive sexual
ideologies can best promote sexual health and well-being (JOICEP, 1997). In 1998 the
journal “Genitourinary Medicine“ changed its name to “Sexually Transmitted Infections“
– with the subtitle next to it “The Journal of Sexual Health and HIV“. It is advertised as
one of the leading journals in the sexual health field and as the oldest journal in the field
of sexual health issues.
In addition to the trend for family planning organisations to consider sexual health
issues as important, sexuality organisations have increasingly used the terms ‘sexual
13
health’ and ‘sexual rights’ in their texts. The Swedish Association for Sex Education
together with the Danish Family Planning Association published a booklet entitled “Sexual Rights of Young Women in Denmark and Sweden“ (Lindahl, Vikorsson and Rasmussen, 1995). The 1998 IVth Congress of the European Federation of Sexology included
‘Health, Well-Being, and Sexuality’ as one of its five themes for paper topics. The
Eastern Region of the Society for the Scientific Study of Sexuality in the USA devoted
its entire 1998 eastern region meeting to the topic of sexual health. Additional examples
could be cited but we give just one more. The 1997 World Congress of Sexology in
Valencia focused on the theme of ‘Sexuality and Human Rights’. Major plenaries involved
a discussion of sexual rights for special population groups. As a result of this Congress,
the Valencia Declaration of Sexual Rights was written. This document, updated at the
more recent meeting in Hong Kong, is important for an understanding of sexual health
and sexual rights and is presented in Table 2.
Table 2.
Declaration of Sexual Rights of the World Association for Sexology
Sexuality is an integral part of the personality of every human being. Its full development depends
upon the satisfaction of basic human needs such as the desire for contact, intimacy, emotional
expression, pleasure, tenderness and love.
Sexuality is constructed through the interaction between the individual and social structures. Full
development of sexuality is essential for individual, interpersonal, and societal well being.
Sexual rights are universal human rights based on the inherent freedom, dignity, and equality of
all human beings. Since health is a fundamental human right, so must sexual health be a basic
human right. In order to assure that human beings and societies develop healthy sexuality, the
following sexual rights must be recognized, promoted, respected, and defended by all societies
through all means. Sexual health is the result of an environment that recognizes, respects and
exercises these sexual rights.
The right to sexual freedom. Sexual freedom encompasses the possibility for individuals to
express their full sexual potential. However, this excludes all forms of sexual coercion,
exploitation and abuse at any time and situations in life.
The right to sexual autonomy, sexual integrity, and safety of the sexual body. This right
involves the ability to make autonomous decisions about one’s sexual life within a context of
one’s own personal and social ethics. It also encompasses control and enjoyment of our own
bodies free from torture, mutilation and violence of any sort.
The right to sexual privacy. This involves the right for individual decisions and behaviors about
intimacy as long as they do not intrude on the sexual rights of others.
The right to sexual equity. This refers to freedom from all forms of discrimination regardless of
sex, gender, sexual orientation, age, race, social class, religion, or physical and emotional
disability.
The right to sexual pleasure. Sexual pleasure, including autoeroticism, is a source of physical,
psychological, intellectual and spiritual well being.
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The right to emotional sexual expression. Sexual expression is more than erotic pleasure or
sexual acts. Individual have a right to express their sexuality through communications, touch,
emotional expression and love.
The right to sexually associate freely. This means the possibility to marry or not, to divorce, and
to establish other types of responsible sexual associations.
The right to make free and responsible reproductive choices. This encompasses the right to
decide whether or not to have children, the number and spacing of children, and the right to full
access to the means of fertility regulation.
The right to sexual information based upon scientific inquiry. This right implies that sexual
information should be generated through the process of unencumbered and yet scientifically
ethical inquiry, and disseminated in appropriate ways at all societal levels.
The right to comprehensive sexuality education. This is a lifelong process from birth
throughout the lifecycle and should involve all social institutions.
The right to sexual health care. Sexual health care should be available for prevention and
treatment of all sexual concerns, problems and disorders.
Sexual Rights are Fundamental and Universal Human Rights
Distinctions: Sexual Health vs Reproductive Health
and Sexual Health vs Sexual Rights
Long time consultant for the IPPF Evert Ketting (1996) has advocated a separation of
sexual and reproductive health areas. He states that the decision in Cairo to incorporate
sexual health as an aspect of reproductive health was done in part to legitimise and
make less controversial services related to sexuality. Ketting would like to see sexual
well being or sexual health considered worthy of attention on its own. Ketting defines
reproductive health problems as “medical problems related to pregnancy, childbearing
and infancy“ (1996, p.1), whereas sexual health involves “helping people to gain full
control of their own sexuality and to enable them to accept and enjoy it to its full
potential. It is not primarily about diagnosis, treatment, or medical care but about lack
of knowledge, self-acceptance, identity, communication with partner and related issues“
(1996, p.1). Ketting further states that because of the different nature of sexual and
reproductive health problems that health providers can offer more effective services
and programs if they are considered separately. In addition, he notes that for much of
Europe, maternal and infant mortality and morbidity rates and health complications due
to illegal abortions are minimal, whereas sexual problems caused by lack of information,
knowledge, and education are common. Areas that especially need attention in Europe
involve problems with sexual identity, communication with and empathy toward one’s
partner, and sexual abuse and coercion. In fact, many European family planning
organisations are becoming sexual health institutions. In Finland, the need to deal with
sexual health problems has been acknowledged and the name of the former Family
Planning Clinic in Helsinki was changed in 1996 to Sexual Health Clinic (Väestöliitto,
1997).
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Others have also made distinctions in the definitions of sexual health and reproductive
health. For example, Klouda (1996) stated that while sexual health depends on, and
always relates to relationships, reproductive health has to do with reproductive organs,
fertility, clinical services and illness. WHO’s current definition of sexual health is “the
integration of the physical, emotional, intellectual, and social aspects of sexual being in
ways that are positively enriching, and that enhance personality, communication, and
love...every person has a right to receive sexual information and to consider sexual
relationships for pleasure as well as for procreation“ (www.siecus.org). The Sexuality
Information and Education Council of the United States (SIECUS, www.siecus.org)
has formulated the following definitions – Sexually Healthy Adult: Sexually Healthy
Adults appreciate their body, take responsibility for their behaviours, communicate with
both sexes in respectful ways, and express love and intimacy consistent with their own
values. SIECUS has worked with non-governmental organisations around the world to
develop a consensus about this definition and in such different countries as Brazil,
Nigeria, Russia and the United States, groups have affirmed a similar vision. Sexually
Healthy Relationship: A sexually healthy relationship is based on shared values and
has five characteristics: it is consensual, non-exploitative, honest, mutually pleasurable,
and protected against unintended pregnancy and sexually transmitted diseases including
HIV/AIDS. Sexual Rights: The rights of individuals to have the information, skills,
support and services they need to make responsible decisions about their sexuality
consistent with their own values. These include the right to bodily integrity, voluntary
sexual relationships, a full range of voluntary accessible sexual and reproductive health
services, and the ability to express one’s sexual orientation without violence or
discrimination.
Based on the background information provided above I now present the definition of
sexual health used in this book. I agree with Ketting that sexual health and reproductive
health have different areas of focus. Nevertheless, there are areas of overlap between
the two. For example, sexually transmitted diseases can impact one’s sex life including
one’s enjoyment of sexuality and therefore one’s sexual health. But sexually transmitted
diseases such as chlamydia, syphilis, herpes and HIV/AIDS can also have a negative
impact on a woman’s reproductive health by limiting her fertility or harming the health
of her new born infant. The ability to control the timing and spacing of children, an
aspect of reproductive health, depends on having access to safe and effective
contraceptives. The ability to enjoy one’s sexuality, an aspect of sexual health, also
depends on being able to experience sex without the fear and worry of an unwanted
pregnancy. Because of this overlap there is an argument for combining sexual health
and reproductive health. Furthermore, many in the family planning and health fields
believe that using the words sexual and reproductive together can widen the scope of
and legitimise services and education to include more comprehensive coverage of both
sexual and reproductive matters. Nevertheless, the major part of this book includes
topics that relate to the forthcoming definition of sexual health. I should also add that an
16
argument could be made to define reproductive health as part of sexual health rather
than the reverse view currently expressed in international documents that sexual health
is a part of reproductive health. Sex can be considered to have a variety of purposes
and reproduction is only one among several. Indeed, many social scientists have
emphasised that the trend in the 20th century was to move from an ideology of
procreational sex to one whose purpose is recreation or the promotion of intimacy in
relationships (e.g., see Gill, 1977). Most would agree that the majority of sexual acts
(including, of course, self-masturbation) are not for reproductive purposes. Certainly,
the use of the term reproductive health excludes sexual health issues for gays and
lesbians.
Next I present the definitions of sexual health and sexual rights that guided the framework
for this book. I use slightly modified definitions prepared by a subgroup of the International
Women’s Health Coalition with the name HERA, which stands for Health,
Empowerment, Rights and Accountability (www.iwhc.org/hera.index.html). This group
was active in promoting the agreements reached in Cairo and Beijing and has continued
to work together to advocate for and help implement the action programs of these two
conferences. SEXUAL HEALTH is the ability of women and men to enjoy and express
their sexuality and to do so free from risk of sexually transmitted diseases, unwanted
pregnancy, coercion, violence and discrimination. In order to be sexually healthy, one
must be able to have informed, enjoyable and safe sex, based on self esteem, a positive
approach to human sexuality, and mutual respect in sexual relations. Sexually healthy
experiences enhance life quality and pleasure, personal relationships and communication,
and the expression of one’s sexual identity. As stated in a HERA Action Sheet
(www.iwhc.org/hera.index.html), “sexual health is fundamental to the development of
one’s full potential, to the enjoyment of human rights and to an overall sense of wellbeing. By endorsing sexual health for all, legal, health and educational systems build a
strong foundation for preventing and treating the consequences of sexual violence,
coercion, and discrimination.“ SEXUAL RIGHTS are “a fundamental element of human
rights. They encompass the right to experience a pleasurable sexuality, which is essential
in and of itself and, at the same time a fundamental vehicle of communication and love
between people. Sexual rights include the right to liberty and autonomy in the responsible
exercise of sexuality“ (www.iwhc.org/hera.index.html). These statements by HERA of
course state ideal generalities and are subject to ambiguous interpretations but we present
them here because the value of sexual health and sexual rights has only recently been
acknowledged by an international consensus. HERA also provides a more comprehensive
and yet still somewhat vague listing of what sexual rights include (see Table 3). The
content of the lists of rights by the international organisations – namely by IPPF, the
World Association of Sexology, and HERA – provides evidence of the international
trend to value sexual relationships with particular characteristics. A list of ten ways to
promote sexual health was given by Eli Coleman, current president of the World Association of Sexology, at a plenary talk in Valencia in 1997 (see Table 4). I hope that the
17
lists concerning sexual rights and sexual health will encourage discussions in educational
and health settings. Knowledge of such rights should contribute to efforts to promote
the realisation of these rights at both the personal and societal level. In addition, the lists
of sexual rights and ways to promote sexual health can be used as the basis for formulating
more precise evaluation mechanisms of sexual health services and educational programs
for various populations in different geographical areas.
Table 3.
COMPONENTS OF SEXUAL RIGHTS AS LISTED BY HERA
1. The right to happiness, dreams and fantasies.
2. The right to explore one’s sexuality free from fear, shame, guilt, false beliefs and other
impediments to the free expression of one’s desires.
3. The right to live one’s sexuality free from violence, discrimination and coercion, within a
framework of relationships based on equality, respect and justice.
4. The right to choose one’s sexual partners without discrimination.
5. The right to full respect for the physical integrity of the body.
6. The right to choose to be sexually active or not, including the right to have sex that is
consensual and to enter into marriage with the full and free consent of both people.
7. The right to be free and autonomous in expressing one’s sexual orientation.
8. The right to express sexuality independent of reproduction.
9. The right to insist on and practice safe sex for the prevention of unwanted pregnancy and
sexually transmitted diseases, including HIV/AIDS.
10. The right to sexual health, which requires access to the full range of sexuality and sexual
health information, education and confidential services of the highest possible quality.
Note. HERA is an international group of women’s health activists working together to implement strategies that promote sexual and reproductive rights and health throughout the world
Table 4.
TEN WAYS TO PROMOTE SEXUAL HEALTH BY ELI COLEMAN
1. Offer comprehensive sexuality education throughout the life span.
2. Include comprehensive sexuality education for health professionals and educators.
3. Carry out needed research in child and adolescent sexuality.
4. Overcome homophobia, biphobia, and transphobia.
5. End sexism.
6. End sexual violence.
7. Promote masturbation.
8. Promote sexual functioning.
9. Create better access to sexual health care.
10. Recognise sexual health as a basic human right.
Note. Eli Coleman is currently president of the World Association of Sexology (WAS).
18
Because most of the new views about sexual health and sexual rights expressed in the
aforementioned definitions and lists reached an international consensus largely due to
the efforts of women’s health and feminist advocates, conference documents provide a
more thorough description of sexual health needs and sexual rights issues relating to
women than to men. The approach here is to consider issues and problems that concern
everyone – men and women. In taking this inclusive approach, it is stressed that there
are multiple sources of inequality and that gender is only one such dimension. The
needs of many special populations have to be considered, such as the poor and
marginalised, non-heterosexuals, ethnic and racial minorities, the disabled and the
institutionalised. In addition, the major focus of this book is not on reproductive health
where women’s health needs require special considerations and resources. Thus, an
egalitarian perspective on sexual health and sexual rights is intended here.
I make one final point about sexual health definitions. There are a few who warn
against attempts to define ‘sexual health’. Helfferich (1996, p.2) emphasises that health
is a normative concept and asks whether the term ‘sexual health and reproductive
health’ will become the “new normative straight jacket“. She also calls for discussions
on the meanings and implications of these concepts and I hope that this book contributes
to these clarifications. The German sexologist Gunter Schmidt (Coleman, 1998) believes
that these health definitions prescribe what is healthy or proper sex and in that way may
be promoting only a certain type of sex that is socially desirable. He notes – and of
course is correct – that all definitions are social constructs and that linking the term
health to sexuality will encourage people to regard definitions and explanations of sexual
health as medical truths.
Sexual Enjoyment and Pleasure as Components of
Sexual Health
I want to emphasise an additional aspect of the new approach to sexuality that was
endorsed by international consensus. The new view of sexual health recognises the
importance of sexual pleasure or sexual enjoyment to a person’s well-being and health.
What is remarkable is the variety of sources that within a decade came to endorse this
point and I give a few examples. In an article entitled “The Sexuality Connection in
Women’s Reproductive Health“, Dixon-Mueller (1993a) proposed an analytic framework
which links four dimensions of sexuality to reproductive health. In this framework,
sexual enjoyment is one element of sexual health. The importance of sexual pleasure to
health is also emphasised by Basso (1993) in a book published by the Pan American
Health Organization (PAHO) of the WHO. Basso has been Co-ordinator of joint work
in sexual and health education carried out by the PAHO, and she has also been active in
Uruguay to formulate national curricula for sex education programs. She has been
involved with health care practices, sex education, and working groups of women,
19
men, couples, and adolescents for more than two decades. Basso believes that sexuality
has been relegated to a marginal position in health programs despite the fact that sexuality
is an intrinsic part of the life course. Basso (1993, p. 113) writes “As a source of
pleasure and well-being, it is personally enriching, and has far-reaching repercussions
for the family and society as well.“ She further notes that sexual expression contributes
to one’s capacity to love, to bond with others, to communicate feelings, and it is a
source of creativity, pleasure, and personal enrichment. She argues for a reciprocal
relationship between health and sexuality. In her view, comprehensive health could not
be achieved for people without a “harmonious development of their sexuality“ and a
satisfying sexual development could not be possible if other aspects of physical and
psychological health are not attended to.
Canada provides another example. In that country in the early 1990s committees and
working groups agreed that there is a great need in their country to make sex education
more comprehensive and accessible. In response to this need government funding was
provided to produce a booklet to describe the Canadian guidelines for sexual health
education. In these guidelines sexual health is acknowledged as a major aspect of personal
health that affects people at all ages. The goals of sexual health education are “to help
people achieve positive outcomes (e.g., self-esteem, respect for self and others, nonexploitative sexual satisfaction, rewarding human relationships, the joy of desired
pregnancy and to avoid negative outcomes“ (Ministry of Supply and Services, 1994,
p.5). “The terms ‘sexual health’ and ‘healthy sexuality’ are widely used in federal,
provincial and local health promotion initiatives to support the positive integration of
sexuality and the prevention of sexual problems, at all stages of people’s lives.“ (p.4).
Feminist literature also links sexual rights to sexual enjoyment. Correa and Petchesky
(1994, p.113) stress that the “principle of bodily integrity or the right to the security in
and control over one’s body, lie at the core of reproductive and sexual freedom.“ This
means that women need to be protected against policies and situations that involve
sexual violence, genital mutilation, denial of access to information and birth control,
coerced marriage and child-bearing, and prohibitions against homosexuality. Correa and
Petchesky further state that “bodily integrity also involves affirmative rights to enjoy
the full potential of one’s body – for health, procreation, and sexuality“ (p.113). These
feminists – one from Brazil and the other from the United States – emphasize that the
boundaries among health, sexuality and human rights issues are dissolving throughout
the world. They point out that not only in industrialised countries of the North but also
in Latin America, Africa and Asia, phrases like ‘the right to sexual pleasure’ and ‘sexual
self-determination’ appear in policy statements and strategy documents of women’s
health and family planning organisations. In this regard, it is worthwhile to note that of
the 24 active members of HERA almost all were from less developed countries including
Bangladesh, Argentina, Peru, Mexico, Cameroon, South Africa, Nigeria, Kenya, Pakistan, and India.
20
Research Support for Sexuality and Health
Linkages
Research findings have supported the connection between sexuality and positive health
outcomes. Some of this research was inspired by studies that indicated that touch
deprivation causes irreversible damage and even death for young children (Colton,
1983; Montague, 1978). Spitz (1947) reported that good nutrition, medicine and clean
surroundings were not enough to ensure the survival of infants and toddlers deprived of
touch in orphanages. The studies of Harlow in the United States in the 1960s and 1970s
confirmed the negative health consequences of touch deprivation for young monkeys.
More recent research has shown that lack of touch causes permanent neurological
damage and chemical imbalance, whereas wanted touch has positive health outcomes
(Hatfield, 1994). Some researchers (e.g., Prescott, 1975) argue that severe touch
deprivation as an infant/young child inhibits one’s ability to form healthy intimate adult
relationships, hinders the development of empathy, and promotes sexually abusive and
assaultive behaviour. These touch studies are relevant here because sexual expression
includes touching and many receive pleasure from being held and caressed. Touch
therapy is a major technique used by sex therapists to help individuals and couples who
come to them for help with sexual problems.
Within the last decade research findings by those in the sexuality and health fields has
also found evidence linking sexual behaviour and health. David (1994, p. 345), former
Director of the World Health Foundation for Mental Health in Geneva wrote, “research
in Denmark and elsewhere has shown that successful fertility regulation heightens adaptive
abilities and coping abilities. Good contraceptive control makes for good family health
and thus good mental health.“ Another researcher for the WHO, Odile Frank (1994)
reported the results of studies on mental health and female sterilisation in five countries.
Women in the sterilisation groups reported improved sexual satisfaction and improved
relationships with their husbands due to removal of the fear of unwanted pregnancy.
Frank illustrated how sexual behaviour both directly and indirectly influences health.
Effects include sexually transmitted diseases, unwanted pregnancies, and emotional
and mental problems due to sexual dysfunctions. The results of a longitudinal study
reported in the British Medical Journal support the view that sexual activity involving
orgasms has a protective effect on men’s health (Smith, Frankel, and Yarnell, 1997).
Mortality risk from coronary heart disease was 50% lower in a group with high orgasmic
frequency compared to one with low orgasmic frequency. Although the researchers in
this study acknowledge the complex nature of causal inferences, they emphasize that if
the findings are replicated, there would be clear implications for health promotion and
prevention programs. Apt, Hulbert, Pierce, and White (1996) found that compared to
married women with low sexual satisfaction, married women with high sexual satisfaction
reported higher degrees of life satisfaction and fewer symptoms of psychological distress
such as somatisation, depression, anxiety, and anger/hostility. Two recently published
21
books provide additional evidence of the sexuality and health links: “The Science of
Love, Understanding its Effects on Mind and Body“ by Anthony Walsh (1996) and
“Love and Survival, The Scientific Basis for the Healing Power of Intimacy“ by Dean
Ornish (1998). Walsh, a sociologist and criminologist, focuses on how human
neurophysiology, the endocrine system and areas of the brain are affected by touching.
He also discusses the ways that love and touch influence physical and mental health
and lawlessness. Ornish, a medical doctor, includes a long chapter describing the results
of specific studies that support the intimacy and health connection. He states ( p .3)
“Love and intimacy are at a root of what makes us sick and what makes us well, what
causes sadness and what brings happiness, what makes us suffer and what leads to
healing. If a new drug had the same impact, virtually every doctor in the country would
be recommending it for their patients. It would be malpractice not to prescribe it – yet,
with few exceptions, we doctors do not learn much about the healing power of love,
intimacy, and transformation in our medical training. Rather, these ideas are often ignored
or even denigrated.“ In this discussion, there is the danger of overvaluing relationships
and perhaps encouraging people to stay in abusive or unhappy ones. If sexual relationships
become a symbol of health, then people preferring single lifestyles may feel stigmatised
by this choice. In addition, some may argue that the stressful aspects of relationships,
including break-ups, often contribute to serious mental health problems. Nevertheless,
for the majority of people, healthy sexual relationships do add significantly to the quality
and happiness of their lives, at least for major life periods.
Finland’s Approach to Sexuality
For the past three decades Finland has taken a health rather than a moralistic approach
to social problems that relate to sexual behaviour. Health care is recognised as a right in
Finland, and thus many sexual health services are readily available to its citizens. The
authorities contributing to this book illustrate how their country has attempted to improve
the quality of its sexual health information and services. Co-operation and co-ordination
among providers of health, education and social services have greatly aided these efforts.
Other factors that have promoted sexual health have been the lack of official restrictions
on both sex education and the distribution of contraceptives and the support of the state
church with respect to many sexual policy issues.
The Parliament of Finland has ratified the following four international documents upon
which the previously listed sexual and reproductive rights were based: the International
Covenant on Economic, Social and Cultural Rights; the International Covenant on Civil
and Political Rights; the UN Convention on the Rights of the Child; and the UN
Convention on the Elimination of all Forms of Discrimination Against Women. Finns
have been part of the Nordic delegations to international meetings where they have
worked to promote an understanding of policies that have been shown to effectively
reduce sexual health problems. Even before the focus on reproductive and sexual health
22
in the mid 1990s as a result of the Cairo and Beijing conferences, Finns recognised the
link between sexuality and health. In 1989, the Finnish National Board of Health
published a report entitled “Eroticism and Health“. The message of this report was
clear: Sexual expression can improve the health and general quality of life of individuals
and their families. The primary author of this publication, Osmo Kontula, wrote,
“Positively experienced sexual activity is an efficient antidote against the ill-effects of
stress...sexual intercourse produces thorough relaxation and alleviates the problems
caused by hurrying and various kinds of discomfort. Romantic and sexual relationships
have been found to effectively prevent loneliness and the resulting anxiety and depression“ (p. 123). One of the recommendations of this report was that health care providers
give guidance on sexual matters to parents, adolescents, the ill, disabled, and the elderly.
In more recent work, Kontula (1998) has argued that a satisfying and safe sex life is the
most important determinant of sexual health.
A representative sample of Finns has also acknowledged the connection between health
and sexuality in a recent national survey: 88% of men and 79% of women agreed that
sexual activity was beneficial for health and well being (Kontula and Haavio-Mannila,
1995). In this same survey sexually satisfied people reported better states of health and
well being and less loneliness than did sexually unsatisfied people. Kontula and HaavioMannila (1997, p. 14) in an article on quality of life as a function of sexual satisfaction
conclude “ it would be beneficial to both individuals and society on the whole to adopt
such social policies that would help people overcome their fears, worries, and problems
concerning sexuality as well as provide favourable conditions for sex life, for example
by teaching rewarding sexual practices.“
The aforementioned examples illustrate views about sexual health in Finland. In the
concluding chapter of this book, the state of sexual health in Finland will be evaluated
with respect to recent criteria outlined by international groups of health, family planning,
and sexuality professionals and also with respect to macro and micro determinants of
sexual health. Such determinants are the focus of the next two chapters and will facilitate
an understanding of sexual health in all countries, not just in Finland. To conclude this
chapter, however, I discuss briefly the meaning and implications of the newly adopted
rights approach to sexual health for such a discussion will help the reader understand
the linkages among the issues and concepts presented in chapters 1 and 2.
Meaning and Implications of Rights
The use of the word ‘rights’ has important implications. Dixon-Mueller (1993b, p. 6)
states that the notion of rights involves the “concept of individual liberty in which the
primary role of the state is to ensure freedom of the citizenry from abuses of power.“
She also states that another “concept of human rights is one of social entitlement, that
is, the responsibility of society and the state to guarantee not only freedom of opportunity
23
to all its citizens but also achievement of results.“ An additional concept that is associated
with rights or individual liberty is one of responsibility and obligations – on the part of
individuals, parents, and families as well as of governments and institutions. Correa and
Petchesky (1994) stress that the concepts of POWER and RESOURCES are essential
components of rights. For example, they emphasize that rights are meaningless unless
people have the POWER to make informed decisions about reproductive and sexual
matters and the RESOURCES to carry out their decisions safely and effectively. Thus,
people must have enough resources in terms of knowledge and economic and political
power in order to exercise their sexual rights.
In a recent publication by the United Nations Population Fund (UNFPA) (1997) several
reasons were given to support the importance of human rights. One use of the
descriptions and lists of human rights agreed upon at international meetings is to promote
change that will benefit large numbers of people. Several global trends create a need for
an international consensus to set a standard of ethics by which nations can act to reduce
the negative impact of the abuse of power that these trends typically encourage. The
global commonalities cited by UNFPA (1997) include increasing urbanisation which
often results in people of varying attitudes and cultures interacting with each other;
increased international and internal travel and migration which also bring diverse groups
in contact with each other. Other commonalities listed were increasing complexity and
decentralisation of government, the collapse of civil administration, and the rising power
of transnational entities and multinational corporations. All of these trends make the
protection of less advantaged groups more difficult and promote the need for safeguarding
basic rights of groups and individuals. Thus, rights agreed upon by representatives of a
large number of countries at international conferences can serve as universal guidelines
to express the “international conscience on matters of human rights“ (UNFPA, p. 7,
1997). They can be one mechanism to protect against the strong tendency – documented
so thoroughly by social scientists – for the more powerful to abuse the less powerful
and marginalised of society.
The view of the meaning of rights endorsed here, and sexual rights in particular, is that
rights always involve responsibility. Several ‘responsible’ actions are implied by the lists
of sexual rights. For example, heterosexual couples must use contraception to avoid an
unwanted pregnancy. Responsibility for birth control ideally should involve both
participants in sexual activity. To have sex without unnecessary risks of getting a sexually
transmitted disease, of course, means that safer sex techniques have to be known,
discussed and enacted. Participants in sexual activities need to consider the wishes of
their partner as well as their own in deciding how to interact sexually. These are just a
few of the obvious responsibilities that are implied in the lists of sexual rights.
International discussions about rights have involved a good deal of debate and controversy.
For example, rights have been associated with Western notions of individualism, and
those who value a more collectivist worldview have been critical of the emphasis on
24
individuals and their rights. Several questions have been raised. For example, how are
rights of individuals reconciled with the good and benefit of the larger community and
society? What responsibilities should accompany the exercise of someone’s rights?
How should conflicts of rights between individuals be resolved? Thus, the ‘rights’
concept does not always imply simple or obvious actions.
During the same time that family planning, women’s health, human rights, and sexuality
education and counseling organisations initiated their focus on sexual health and sexual
rights, members of academic disciplines in the humanities and social sciences also began
to focus upon these same topics. In the academic world, rights are commonly discussed
in the context of inequality and the meaning of citizenship. A citizen is a member of a
community/country and the rights and status of citizens vary considerably, both within
and between communities/countries. It has been common to identify three types of
citizenship. Civil citizenship relates to personal freedoms and property rights. Political
citizenship concerns the right to organise, vote, and hold public office. Social citizenship
includes the right to education and economic well being. In the last decade, a new
dimension of citizenship has been discussed, sexual citizenship. Jeffrey Weeks (1998)
writes about the sexual citizen who can claim a new form of belonging. In his view,
sexual citizenship is about protecting the choices for one’s private life in a more inclusive
society. This notion of citizenship expands previous views of citizenship to include the
sexual realm. A new international journal was launched in 1997 to deal with this as well
as the more traditional aspects of citizenship – Citizenship Studies. In addition, in
1999 the UK sponsored an international conference entitled “Sexual Diversity and
Human Rights“. Most conference themes involved linking aspects of rights, sexuality,
and citizenship. In the next chapter, relationships among rights, empowerment
mechanisms and sexual health are discussed more thoroughly.
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Prescott, James. 1975. Body pleasure and the Origins of Violence. Bulletin of the
Atomic Scientists, 31, 10-20.
Ornish, Dean. 1998. Love and Survival, The Scientific Basis for the Healing Power of
Intimacy. New York: Harper Collins.
Packer, Corinne. 1996. The Right to Reproductive Choice: A Study in International
Law. Turku-Åbo, Åbo Academy University: Institute for Human Rights.
Rahman, Anika and Rachael Pine.1996. An International Human Right to Reproductive
Health Care: Toward Definitions and accountability. Health and Human Rights; 1,
401-427.
Smith, G. D., S. Frankel and J. Yarnell. 1997. Sex and Death: Are they Related?
Findings from the Caerphilly Cohort Study. British Medical Journal, 315, 1641-1644.
Spitz, Rene. 1947. Hospitalism: A Follow-Up Report. In D. Fenichel, P. Greenacre and
A. Freud (Eds.) The Psychoanalytic Study of the Child, Vol. 2. New York: International
Universities Press.
27
United Nations. 1996. Reproductive Rights and Reproductive Health: A Concise Report.
New York: United Nations.
United Nations Population Fund. 1997. The Right to Choose: Reproductive Rights and
Reproductive Health. New York: United Nations Population Fund.
Väestöliitto. 1997. Annual Report 1996 of The Family Federation of Finland. Helsinki:
Väestöliitto (The Family Federation of Finland).
Walsh, Anthony. 1996. The Science of Love, Understanding Love and its Effects on
the Human Body. Buffalo, NY: Prometheus Books.
Weeks, Jeffrey. 1998. The Sexual Citizen: Who or What? Invited Lecture presented in
May in the Department of Sociology of the University of Helsinki.
28
Ilsa Lottes
2. Macro Determinants of Sexual
Health
What factors improve or impede sexual health? This question can be addressed from
both macro and micro perspectives. A macro level analysis examines entire social systems
and the way basic institutions and values influence people’s lives. A micro level analysis
focuses on interactions and communication among individuals and small groups. Osmo
Kontula uses the approach where the individual is typically the unit of analysis (see
Chapter 3). My purpose here is to lay the foundation for a macro level analysis of
sexual health. Thus, I will look at how institutions of society, namely those related to
the economy, government, the family, education, religion, and medicine as well as
values and norms impact upon sexual health. In the approach I take, an entire society is
studied. Basic questions include: What are the characteristics of countries where people
enjoy good sexual health? In what ways do societal institutions affect sexual health? If
the determinants of sexual health at the macro level are understood, then policy makers
and legislators can direct their efforts to promote programs which have high probabilities
of improving sexual health.
Issues and Problems in Explaining Sexual Health
To develop an explanation of sexual health, I first review its definition. Sexual Health is
the ability of women and men to enjoy and express their sexuality, and to do so free
from risk of sexually transmitted diseases, unwanted pregnancy, coercion, violence and
discrimination. Thus, sexual health is a complex, multi-dimensional concept that is not
easily measured. But based on this definition, it is possible to define indicators of sexual
health, and it is also clear that there is great variation in sexual health among individuals
both within one country and between countries. Indicators can be used for within
country evaluations and between country comparisons of sexual health. For example,
countries which keep statistical records of rates of sexually transmitted diseases,
contraceptive prevalence, unplanned pregnancy, abortion, and rape can be compared,
or trends in these rates within one country can be studied. To investigate discrimination,
values and laws related to various groups can be examined and compared. Is there a
double standard of sexuality which punishes women more harshly than men for the
same sexual act? Does the country have laws restricting gays and lesbians from engaging
in sexual activities? Sexual enjoyment is difficult to measure directly. However, countries
conduct national surveys on partner status, amount of satisfaction with sex life, and
degree of loneliness. Thus, even though a comprehensive reliable and valid measure of
29
sexual health is impossible to calculate for a country, there are indicators that give some
idea of at least some of the dimensions of sexual health.
The multi-dimensionality of sexual health also makes the task of developing its explanation
difficult. Not all aspects of sexual health have the same set of determinants. Indeed, it
would be a challenge to develop an explanation for any one dimension. It might even be
best not to attempt a construction of a general model but instead focus on trying to
understand each separate component of sexual health. I believe both approaches are
important because although there are different models for each aspect of sexual health,
there are factors that impact upon every aspect. Furthermore, the state of well-being in
one area of sexual health is related to the state of well-being in other areas. Another
problem in developing a general model of sexual health is that somewhat different
models are likely needed for different types of countries (e.g., industrialised vs. developing)
and different population subgroups (e.g., women vs. men or heterosexuals vs. nonheterosexuals). Nevertheless, although refinements are needed to account for differences in
types of countries and population subgroups, some principles have general application.
Common determinants of the multiple aspects of sexual health can be identified.
Literature Review
In my review of the literature in a variety of fields including sexuality, health, family
planning, and sociology, I could find no previous attempts to provide a macro level
explanation or model of sexual health. This is not surprising for sexual health is a
relatively new concept. Only in the past decade have attempts been made to define it by
identifying its specific components. Furthermore, the study of sexuality has only recently
become legitimised by established disciplines. It was not until the 1990s, for example,
that the American Sociological Association formed a separate section on sexuality.
Nevertheless, social scientists have tried to provide explanations for various aspects of
sexuality, including some, but not all, of the components of sexual health and for behaviour
and attitudes that relate to sexual health. From these studies, we can get extensive
guidance and clues on how to develop an explanation for sexual health.
The works of American sociologist Ira Reiss (1980, 1986, 1990, 1997) have been
particularly valuable in providing insights into understanding sexuality. In his 1986 book,
he attempted to provide macro level explanations for aspects of sexuality and also
stated several propositions which he argued applied to all societies. Some of these are
relevant to sexual health. First, he emphasised that all societies view sexuality as
important, irrespective of the permissiveness or restrictiveness of their sexual norms.
He argued that sexuality was valued not so much because of its reproductive outcome
but because of its value as a source of pleasure –physical pleasure as well as psychological
and emotional pleasure. Reiss also stated that stable relationships are valued in all
societies and that physical pleasure and intimacy are the “building blocks“ of stable
30
social relationships (p. 215, 1986). Reiss further argued that the ability to have sexual
relationships was a valued social goal. A basic premise of sociology, in general, is that
there is great variation in people’s ability to obtain valued social goals. This access
depends on people’s location in the social structure as determined by many factors
including their social class, gender, race, and power. Social scientists generally agree
that from both historical and cross-cultural perspectives, men have had and continue to
have more power than women. Thus, one may expect that men enjoy sex and satisfy
their sexual needs more than women because of their greater power in important societal
institutions. In addition, norms regarding sexual expression have usually been more
permissive for men than for women, with the exception of norms for same sex interactions;
here restrictions have generally been harsher for men.
Sexual Health of Women
Since the 1960s, as a result of the new feminist movement, women’s sexual freedom
and the control of their sexuality have been topics of scholarly investigation. McCormick
and Jessor (1983, p.68) listed five characteristics of societies where women have more
sexual freedom, including low militarism, and high egalitarianism in the family, politics,
the economy and religion. Thus, the same principle is supported, namely that the degree
of power in the basic institutions of society determines people’s ability to enjoy and
express their sexuality. By sexual freedom, the authors mean the ability for women to
exercise control over their sexual lives. The first characteristic was stated as follows
“women enjoy more sexual freedom where there is little or no emphasis on warfare or
militarism.“ It is clear that military organisations are male dominated and allow greater
opportunities for men than women to advance in the hierarchy. Second, “women control
their own sexuality more where men participate in child rearing or where child-care
services are available.“ One basic theme throughout feminist literature is that women’s
role as primary care taker of children has prevented them from assuming other roles
and duties in society that are more highly valued and rewarded. The other three
characteristics seem self-evident: Women are more sexually emancipated when “they
have greater political representation“, when they have “economically productive roles“
and when they have “helped mold the mythology, religious beliefs, and world view of
their groups.“ McCormick and Jessor (1983, p. 68) conclude that the more power
women have in society, the weaker the double standard of sexuality, which favours
men and restricts women.
In preparation for and in response to the conferences in Cairo and Beijing, there has
been an emphasis on the ‘empowerment of women’ as a means for improving their
sexual health and acquiring sexual rights. Here empowerment means gaining control
over material assets, intellectual resources, and ideology (Batliwala, 1994). Thus, the
empowerment of women involves a process whereby power or control over material
31
resources, and access to knowledge and information would be more evenly distributed
between men and women. Empowerment mechanisms commonly cited include the
formal and informal education of women, women’s political participation, and group
formation to build solidarity so women can work more effectively to achieve goals such
as improving their economic security or increasing their self-esteem and self-worth. In
addition, social scientists have attempted to examine how many types of social policies
are gendered, that is how they differentially affect women and men, often resulting in
greater empowerment for men than women.
Previously I emphasised that the Nordic countries and the Netherlands are the leading
countries with respect to many indicators of women’s sexual health – rates of abortion,
teenage pregnancy and birth, unplanned pregnancy – as well as indicators which influence
the sexual health of both women and men such as sexual knowledge and rates of
sexually transmitted diseases (Alan Guttmacher Institute, 1994; David et al., 1990;
David and Rademachers, 1996; Eng and Butler, 1997; Friedman, 1992; Jones et al.,
1986, 1989; Ketting, 1994; Kosunen and Rimpelä, 1996; Population Action International,
1995; Skjeldestad, 1994; Vilar, 1994). Women in these countries have many rights
(e.g., the right to safe, accessible, low cost or free abortion; the right to low cost or free
family planning services; the right to information about sexuality via education and the
media) denied to their counterparts in other countries. In the aforementioned countries
women also have positions of power in the basic societal institutions. Women are well,
albeit not equally, represented in their country’s national legislature. In addition, maternity
and family social benefits are comparatively high and with the possible exception of the
Netherlands, a high proportion of women are in the labour market. A comparison of
many aggregate indicators (e.g., educational attainment of women and poverty levels of
women and their children) also supports the view that in the Nordic countries women
have a higher degree of material assets and information resources than do women in
most other countries (Bradshaw and Wallace, 1996; Population Crisis Committee, 1988;
Siaroff, 1994; Smeeding, 1997; UNICEF, 1996; United Nations Development Programs,
1996, 1997, 1998). Indeed, on the United Nations gender empowerment measure
calculated for 94 countries, Norway, Sweden, Denmark and Finland consistently rank
in the top 5 with the Netherlands ranking as 9th or 10th (United Nations Development
Programme, 1997, 1998). Thus, these countries illustrate a strong association between
the empowerment of women and their sexual health.
32
Sexual Health of Men
In contrast to the emphasis on the sexual freedom of women, the sexual and reproductive
health of women, and women’s empowerment, the topics of men’s sexual health and
men’s empowerment have received little attention. The common assumption is that
men have the freedom to enjoy their sexuality because men historically have had more
power than women and because the norms regarding sexual behaviour for men have
been quite liberal. Indeed, men are often blamed for the poor sexual health of women
and for the lack of control that women have had over their sexuality. Men’s role in
sexual restriction and coercion is well-documented; men have put the sexual health of
women at risk and have denied women sexual autonomy. The conferences of Cairo
and Beijing and much work since those conferences has continued to highlight the
disadvantaged position of women in sexual relationships. Yet, it would be wrong to
state that the majority of men in most societies have excellent sexual health. Men are
also subject to systems of inequality, and in many countries, class, and race/ethnicity
are more powerful means of determining access to valued resources than gender. In
almost every society one can identify groups of ‘dis-empowered men’, such as minorities,
homosexuals, transsexuals, and those living in poverty. The status of gay men is
problematic in countries where there have been and continue to be, numerous violations
of their rights, which have resulted in serious negative physical, mental, and sexual
health outcomes (Blumenfeld and Raymond, 1988; Rofes, 1983; West and Green,
1997).
Although women are more prone to contract many sexually transmitted diseases, more
affected by an unwanted pregnancy, and more likely to experience sexual violence,
men also have many unmet sexual health needs. Many men lack knowledge about
sexual and gender issues, or suffer from sexually transmitted diseases, infertility,
impotence or premature ejaculation. Rape and sexual abuse of men and boys – although
less common than for women and girls – result in serious health consequences. In
addition, for many economically disadvantaged men, it can be difficult to find a partner.
Studies on mate selection continually highlight the importance of status and wealth as
factors that attract women to men (Buss, 1990).
Basu (1996) makes some important comments about the 1994 Cairo conference. First
Basu points out that the barriers to improving the sexual and reproductive health of
women involve more than gender issues. A focus entirely on patriarchy ignores other
important socio-economic and cultural problems that need to be addressed. Basu (1996,
p. 226) emphasises that poor, illiterate, unskilled, and/or unemployed men may exploit
their women at home, but “their situation can be described as advantageous only in
very relative terms“. Further, Basu states that the “sexually able, fertile male is much
less likely to exploit his male prerogative to abandon or ill-treat his wife“ than a male
with sexual problems. Basu questions the strategic value of documents containing
33
antagonistic one-sided rhetoric that focus exclusively on the sexual health needs and
rights of women and the responsibility of men to change and support women. Basu
wants the needs and rights of men as well as the responsibilities of women to be part of
sexual health programs. This approach is advocated as the best way to improve the
sexual health of both women and men. Principles that apply to women’s ability to
control their sexual lives and enjoy their sexuality can be extended to men – namely that
the higher the level of power in basic institutions of society, the more opportunities a
man or a woman has for sexual enjoyment. People’s degree of power in institutions
also determines their ability to access valued resources such as education and health
services. Thus, a person’s institutional power influences the amount of sex education
and sexual health services he or she receives.
Other Determinants and Considerations
There is great variation within and between countries regarding the distribution of
power, wealth and income of their citizens. One way to evaluate a country’s sexual
health is to examine the extent of inequality of wealth and power. If wealth and power
are concentrated in only a small proportion of the population, then it is likely that only
this small proportion will have access to reliable and comprehensive sources of information
and quality sexual health services. If a high proportion of the population is living in
poverty, then this population group is unlikely to have access to adequate sexual health
information and services. Levels of both absolute and relative poverty can be
approximated for a country and provide indicators of the extent of poor sexual health.
The gross national product per member of the population gives one measure of the
wealth of the entire country and thus offers some information about the general amount
of resources available to all citizens. One measure of the distribution of wealth is to
compare the incomes of a top group with a bottom group. The higher this ratio, the
greater the inequity of income distribution (see Awad and Israeli, 1997; Osberg and Xu,
1997; Smeeding, 1997 for details about measures of poverty and income distribution).
The sexual ideology of a culture is another major determinant of sexual health. By
sexual ideology I mean the belief system about what is acceptable and appropriate
sexual behaviour for men and women at various stages of their life and in various types
of relationships. In most countries, the degree of religiosity and the commonly accepted
doctrines of the major religions are dominant factors influencing sexual ideologies.
Societies vary considerably with respect to their sexual belief systems. Some only approve
of sexual relationships for married couples and even approve of the murder of a young
women suspected of having premarital sex. Some have strict punishments for both
men and women suspected of engaging in sexual relationships with someone other than
their spouse. Other societies leave most sexual relationships that do not involve force,
abuse or fraud outside the legal system and regard the majority of sexual interactions
34
between consenting adults as private matters, not appropriate for public consideration.
Sexual ideologies also differ in their degree of egalitarianism. As stated earlier, most
sexual ideologies still grant men and heterosexuals more freedom to express their sexuality
than they do for women and non-heterosexuals. If one examines the definitions of
sexual health and sexual rights provided by international organisations and conferences,
it is clear that a sexual ideology regarded as promoting sexual health and sexual rights is
egalitarian, one that does not discriminate on the basis of gender, race, religion, class or
sexual orientation. In evaluating the sexual health of a country, the attitudes toward
gays and lesbians need to be examined. Such attitudes, if condemning or disapproving,
also often contribute to job discrimination and the denial of benefits provided to
heterosexual couples, which in turn hinders the economic status of homosexuals. Thus,
in addition to the general level of a country’s wealth and the distribution of wealth,
power and income, the dominant sexual ideology accepted by its citizens is a major
determinant of their sexual health.
Next, consider determinants of another threat to sexual health, force in sexual interactions.
Since the 1970s, rape, sexual coercion and sexual abuse have been studied extensively
by social scientists and numerous models have been proposed to try to understand
these phenomena (e.g., Finkelhor, 1984, Finkelhor et al. 1990; Lottes, 1988; Malamuth
and Donnerstein, 1984; Pirog-Good and Stets, 1989; Reiss, 1997). A review of these
studies is beyond the scope of this book. What is relevant here is to stress that since the
early 1980s, socio-cultural theories of sexual violence and sexual abuse have received
more support compared to the previously commonly accepted psychological and
pathological ones. General findings regarding rape of women by men, for example,
support the views that rape occurs more frequently in cultures where violence and
sexual involvement with women are highly valued male characteristics. In such societies
rates of interpersonal violence and other types of crimes are high, women are not highly
valued compared to men, punishment for rape is lenient and difficult to ensure, and
there are harsh infant-child raising practices. Factors that overlap with the determinants
of other aspects of sexual health include power differentials between the victim and the
aggressor and the general sexual belief system.
Another aspect of sexual health that has received a good deal of attention is contraceptive
use. From a comparative perspective, the most comprehensive work in this area has
been done by the Alan Guttmacher Institute (AGI) of the USA. The AGI is a not-forprofit corporation for reproductive health research, policy analysis and public education.
In the 1980s AGI published two books – one on teenage pregnancy in industrialised
countries and the other on pregnancy, contraception and family planning in industrialised
countries. The teenage pregnancy study involved an analysis of factors influencing teen
pregnancy for 37 countries together with an in-depth case study of six countries. The
other study involved 20 countries with case studies for four countries. Factors that
were associated with higher rates of teenage pregnancy were restrictive ideas and lack
35
of openness about sexuality, less equal distribution of income, high levels of poverty,
low availability of contraceptive education and contraceptive services, low level of
tolerance of teenage sexuality, and higher levels of religiosity.
The main emphasis in the second book was to explain why the USA had higher rates of
abortion and unplanned pregnancies than most other countries. Reasons include the
lack of an integrated national health care service which encourages preventive care, the
reliance on specialist private doctors for family planning services and the high cost of
such services, the high cost of contraception, and low advertising of contraception
methods. The model presented to explain contraceptive use in the AGI study had three
major types of explanatory variables: laws and policies, service delivery, and information
delivery. A fourth type of variables, national characteristics, was hypothesised to influence
these direct explanatory variables.
The AGI model of contraceptive use can also be applied to explain the variation of rates
of sexually transmitted diseases (STDs). Factors that influence both contraceptive use
and safer sex activities involve both educational information and access to quality and
affordable services. Other factors influencing rates of STDs include poverty, inequity
of wealth and resources, lack of sex education and media coverage of information
about STDs, conservative attitudes fostering secrecy, shame, and punishment, inadequate
access to health care, alcohol and drug use, and inadequate attention to special population
groups, such as substance abusers, sex workers, teenagers, the homeless, immigrants
and those in detention facilities (Eng and Butler, 1997).
Model of Sexual Health
Now that I have presented a general overview of the literature related to determinants
of the components of sexual health, I propose a model of sexual health. Figure 1
presents a model of direct influences on sexual health. For this model, I define a direct
influence as one where the arrow starts at the influencing variable and ends at the
‘sexual health’ box. In the model three basic determinants of sexual health are sexual
ideology, sexual health information/education and sexual health services. A sexual
ideology which includes an acceptance of the views endorsed at the Cairo and Beijing
conferences is one that is supportive of positive sexual health outcomes. These views
were stated in the list of rights in Chapter 1. Although the quality and comprehensiveness
of school sex education curricula, media programs related to sexual health issues, and
sexual health services are obvious determinants of sexual health, it is difficult to obtain
measures of these determinants. Evaluations would have to include equity, access and
cost investigations of services, content analyses of curricula and media text, and
examination of sexual health outcomes.
36
Figure 1. Model of direct influences on sexual health
Sexual Health
information and
Education
Sexual
Ideology
Sexual Health
Sexual Health
Services
Figure 2. Model of direct and indirect influences on sexual health
Political and
Economic
Power
Distribution
Country
Characteristics
Laws and
Policies
General
Education
Level
Health and
Social
Benefits
Sexual Health
Information and
Education
Sexual
Ideology
Sexual
Health
Sexual Health
Services
The model presented in Figure 2 is considerably more complex for it shows how other
aspects of society are inter-related and influence the three direct determinants of sexual
health. An indirect determinant is one where the arrow starts at the determining variable
and ends at one of the three direct determinants or at another indirect determinant.
Here I focus on a brief discussion of the indirect determinants of sexual health for the
contributors to this book describe the direct influences on sexual health. Some of the
connecting lines have an arrow at both ends, indicating that the hypothesised relationship
is reciprocal or operates in both directions. For example, consider the relationship between
laws and policies and distribution of economic and political power. Laws and policies
37
about elections influence the choice of candidates for political office and those with
political power – elected officials – influence the content and passage of laws. The basic
message of this diagram is to promote an understanding and acknowledgement of
important factors that influence the more obvious direct determinants of sexual health.
These indirect factors – country characteristics such as religiosity and political ideology,
laws and policies, general level of education attainment, distribution of economic and
political power, and quality and delivery of health and social benefits – all need to be
included when sexual health policies are examined.
Table 1 lists the values of indicators of these indirect influences on sexual health for
Finland. Overall, Finland compares favourably with respect to other countries on indirect
indicators. Finland’s welfare state policies are guided by principles of equity and social
justice and the goal is to ensure basic services for all citizens. In my examination of
these indirect factors, I could discern only a few areas of concern. One definite problem
has been the high rate of unemployment of this past decade. This has contributed to
lower tax revenues which in turn has led to reduction of social and health benefits. Cuts
in benefits – which have disproportionately hurt people with the lowest income and
assets – combined with long term unemployment have produced problems associated
with poverty, social exclusion and alienation (Heikkilä, 1996; Mäntysaari, 1994; Ollila
et al., 1997; Taipale, 1998; Uusitalo, 1996,1998). Another concern regarding the indirect
indicators involves the increased autonomy given to local governments. The fear is that
without adherence to national guidelines, local and regional inconsistencies will result in
inequities of or differences in services, benefits, information provision, and educational
curricula. However, the excellent monitoring, statistics and record keeping, and evaluation
programs in Finland provide some check on ill-advised decisions.
In Table 1, laws and policies that relate to gender equality and ‘women’s empowerment’
are highlighted due to their importance in affecting the sexual health of women. A
recent national survey in Finland reflects the views about attitudes toward women and
gender equality. The majority of respondents felt that on the whole women did not
enjoy the same status as men. Still, only 22 percent of men and 10 percent of women
thought that the status of women was clearly inferior to that of men (Statistics Finland,
1999). Both women and men gave strong support to the views that men and women
should share family responsibilities and that women should continue to take active and
important roles in politics. From an international perspective, Finnish women fare quite
favourably with their counterparts in other countries. Yet as Table 1 shows and others
(e.g., Rantalaiho and Heiskanen, 1997) have illustrated, Finland is still not a gender
equal country.
Laws and policies which affect the direct determinants of sexual health – information,
education and services are omitted from Table 1 for they are discussed by the experts
who have contributed to this book. In addition, authors describe aspects of sexual
ideology related to their area of expertise in sexual health.
38
Figure 3 lists components of two direct influences on sexual health as applied to
Finland. These components correspond to the chapters of this book. For organisational
and conceptual purposes, the distinction between information provision and service
provision has been made. In reality, information provision is a part of service provision
and some organisations described in this book (e.g., Väestöliitto, SEXPO, SETA and
STAKES), are involved in supporting and providing both services and information
delivery. I have also listed some of the indicators of sexual health for they will be
discussed in the forthcoming chapters and included in the conclusion when the strengths
and shortcomings of sexual health policy in Finland are summarised. To conclude this
chapter, I present a short overview of elements of the health care system in Finland.
The quality and delivery of general health services is a major determinant of sexual
health services in all countries. Also this overview will help the reader understand how
specific sexual health services are provided in Finland.
Figure 3. Components of Sexual Health Information / Education and Services
Applied to Model
Sexual Health Information and Education
• Support from Ministry of Social Affairs and Heath,
Ministry of Education, Lutheran Church and the
National Research and Development Center for
Welfare and Health
• Sex education in schools
• Media presentation of sexual issues
• Finnish Foundation for Sex Education and Therapy
Sexual Health Services related to:
• Family planning and abortion
Medical treatment of sexual problems
• Väestöliitto clinics
• Sex therapy
• Sexual abuse and assault
• Diagnosis and treatment of sexually transmitted
diseases
• Reproductive health care
• Needs of special population subgroups —
children, adolescents, nonheterosexuals and
transgender individuals, disabled and the elderly
39
Sexual Health
Indicators
• Sexual knowledge
• Sexual satisfaction
• Incidence and
prevalence of sexual
problems
• General abortion rates
• Teen pregnancy and
abortion rates
• Contraceptive
prevalence
• Sexual abuse and
assault rates
• Maternal and infant
mortality and morbidity
rates
• Infertility rates
Basic Elements of Finland’s Health Care System
Finland has a national system of health care that is funded by general taxation.
Traditionally, major goals have been to provide universal access and equity in service
provision, to promote prevention strategies and high quality of primary care, and to
increase efficiency and cost containment. Finland also highly monitors its health care
quality by obtaining comprehensive and detailed statistics and by regularly obtaining
evaluations from both clients and health care providers. Every two years reports on
public health, health services and health policy are given to the Parliament by a Health
Policy Monitoring of the Country Action Team. Health care costs accounted for 7.7%
of the GDP in 1996 (Salo, 1998).
A basic strategy and assumption of Finnish health policy is that one’s state of health is
an important part of one’s well-being and thus access to health care is the right of
everyone. In 1992, the Act on the Status and Rights of Patients was enacted. This law
establishes “patients’ rights to get good care and treatment within the limits of resources,
to information, self-determination, access to documents, complaining procedures, and
medical ombudsmen“ (Ministry of Social Affairs and Health, p. 117, 1995). Additional
provisions of this law require that patients must be informed about their health condition,
alternatives and risks involving care, and where to obtain treatment. Patients must also
understand enough about their treatment to give their consent to it.
Finland has three levels of government – central, provincial and municipal. The 453
municipalities – which range in size from 150 people to 500,000 in the most populated
area – are responsible not only for providing public health care but also general social
services and education. Until the end of 1992, health services were provided locally by
the municipalities but were strongly controlled by the central government. The
municipalities received state subsidies amounting to 29% to 66% of their costs for
health care services, social welfare and running schools and the municipalities supplied
the remaining financing (Ministry of Social Affairs and Health, 1995). As a result of the
recession that began in the early 1990s, the principle of state subsidies changed to a
block grant system in 1993. Thus, currently, each municipality determines the proportion
of money to be spent on the three areas of health, social services and education. According
to Hermanson, Aro, and Bennett (1994), the tight system of central planning was
criticised for high costs involved in monitoring, rigid uniformities across municipalities
that inhibited incentives to cut costs and improve organisational efficiency, and lack of
responsiveness to patient preferences. The size of the block grants to the municipalities
is determined by a special formula which takes into account population size, age
distribution, morbidity rates, population density, land area and financial capacity of the
municipality.
40
As stated earlier, a basic feature of health care in Finland is its focus on primary health
care (Hemming, 1995; Hermann, 1994). The Primary Health Care Act of 1972 states
that the emphasis on health care should be at the primary level. This act made
municipalities responsible for the provision of primary care, and listed the basic tasks
that should be provided at local health centres. The municipalities are required, for
example, to provide family planning services and maternal and child health care. The
specialists at local health centres are mostly general practitioners and public health
nurses. Patients who need consultation or extra care are referred to other specialists in
hospitals or within the private sector. The health centres also offer laboratory and x-ray
services, physiotherapy, and bed wards mainly for long term care.
A private system of health care also exists in Finland and a portion of the payment to
private health professionals is reimbursed by the state through a special fund. Hermanson
et al. (1994) report that public expenditure on health (75%) still outweighs private
expenditure. In 1998, out-of-pocket payment for health care represented about 20% of
total health care expenditure; these expenditures comprised mainly user charges in public
health services, purchases of private physicians’ examinations and treatments,
pharmaceuticals, and adult dental care. The proportion of health care provided by
private expenditures and by the municipalities compared to the central government has
increased (Salo, 1998). A minority of Finns has private health insurance and this is
mostly used by parents who want their children to have access to a private pediatrician.
A sizeable part of health care for the adult population is provided by occupational health
care (OHC). Employers are required to offer services to their employees, and a special
funding covers a large part of the cost. For the employee, the preventive OHC services
are free of charge. Many employers also offer a number of curative services as part of
their occupational health care including consultations to private specialists.
Hermanson et al. (1994) state that the standard of education of Finnish health care
personnel is high. In 1998, 48% of all physicians were women (Taskuheto 1999). To
attract public health physicians to the health centres, pay for physicians has been higher
than physician pay in hospitals. Partly due to strong unionisation, the medical profession
in Finland has managed to retain its high status and leadership roles. Hemminki (1995)
emphasises that the goal of prevention of health problems is facilitated by the high
proportion of public health nurses in Finland. In health centres public health nurses
outnumber physicians. These highly educated professionals who traditionally have
worked in maternity and child health have broadened their services to include a focus
on health promotion and prevention of health problems in all age groups.
In a recent evaluation of Finland’s health care system by an OECD report (OECD
Economic Surveys, 1998), its functionality and quality were praised. According to the
41
report, “Finland’s health care infrastructure is modern and the personnel are highly
skilled“ (p. 15, Socius, 1998). The report also emphasises that among all EU member
states, Finns are the second most satisfied with the health care they receive; only the
Danes are more satisfied. A few recommendations for changes were made to eliminate
inequities and increase efficiency. For example, the OECD recommended a new pay
scheme for doctors that would encourage doctors working at the municipal health centres
to decrease their work as private practitioners, facilitate longer term care of patients,
and reduce unnecessary consultations. A second recommendation was that no more
cuts should be made in governmental appropriations for health care.
In summary, health services have been considered a public responsibility for decades in
Finland. The health care system has been characterised by an emphasis on primary
care, where a variety technological services are also available. Malpractice issues are
not a problem. It is rare for malpractice actions to occur despite the fact that the legal
system permits such suits. The major concerns seem to be to guard against forces
which reduce equity in and access to health care provision and which decrease preventive
health care. Despite longstanding persistent efforts to achieve these goals, statistics
have consistently indicated that the more affluent are characterised by more positive
indicators of healthy well-being. Under the new system of decentralised control, Rehnström (1997) already reports some problems in the area of preventive health care and
health promotion. Decisions by some municipalities to decrease funding for health
prevention and promotion efforts have resulted in higher curative expenses. From an
international perspective, health care services in Finland have fared well in terms of
equity, access and prevention goals. Under the new decentralised system in which
municipalities have been granted new powers and control, it seems the greatest challenge
for health care professionals and policy decision makers will be to find ways to continue
to maintain and improve health services so they are characterised by equity, universal
access and good preventive care.
Just before this book was to go to print in June of 2000, Finns got upset when their
country’s health system performance was ranked 31st out of 191 countries by the
WHO World Health Report (www.who.int/whr/2000/en/report.htm). Finns have
traditionally taken pride in the high quality of their health care, and so this low ranking
was both a disappointment and surprise. Health officials, measurement experts, and
statisticians examined the means by which countries were ranked. Although they did
find flaws in measurement techniques, authorities were in general agreement that the
World Health Report had indeed identified weakness – known to some experts – in
Finnish health care. Weaknesses acknowledged by the report and Finnish commentators
were 1) high mortality of men of working age, 2) wide differentials in health outcomes
by social class, 3) reduction in funding and health services, especially for the elderly,
chronically ill, and mentally ill patients, 4) over-burdening of those providing health
care, 5) lack of dental care support for the entire population, and 6) health problems
linked to crowded living conditions, the environment, and traffic and workplace
42
conditions. Nevertheless, concerned policy makers, health professionals, and legislators
hope to use the low WHO ranking as an advocacy measure to stop the reduction in
health care funding and work for restoration of monies for vital health care needs.
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45
Table1. Values of Indirect Influences of Sexual Health for Finland
Country Characteristics
Political Ideology:
Democratic and egalitarian; Presidential elections
every 6 years and parliamentary elections every 4
years, voter turnout in final vote for president in
2000–83% for women and 77% for men.
Stability:
No wars, internal or external since the 1940s
Gross Domestic Product:
$20,150, per capita (US$, 1997)
Information access:
Finland leads the world in internet connections and
2
mobile phones per capita and printing and writing
paper consumed in 1995.3
Share of households with 1 - 6 radios – 99%,
1
Number per 1000 persons who have the television licenses (each covering several television
4
following :
sets) – 382, daily newspapers - 455, mobile
telephones – 572, main telephones – 553, internet
connections – 107.
Religiosity:
Religious leaders generally support rather than
oppose sexual health policy
Damaging Cultural Customs:
No obvious ones such as female genital mutilation
Alcohol and Drug use:
Since 1998 HIV cases have increased due to
intravenous drug use; Alcohol consumption in liters
3
per capita in 1995 – 6.4
Laws and Policies
1878 Women and men receive equal rights with regard to inheritance
1901 Women receive the right to study at university on equal terms with men
1906 Women receive voting rights in national election (first country in Europe to do so) and the
right to be electoral candidates ( first country in world )
1917 Women receive general voting rights for local governmental elections
1919 Women gain the right to work without their husbands’ permissive
1930 Marriage Act released wives from the guardianship of their husbands= and wives given the
right to own property
1962 The principle of equal pay for work of equal value established both in public and private
sector
1978 The father receives the right to 12 days= paternity leave for birth of his child
1980 Law passed granting the father the right to share parental leave with the mother
The first Plan of Action for the Promotion of Gender Equality of the Government of Finland
proposed
1986 Finland ratifies the UN Convention on the Elimination of All Forms of Discrimination
Against Women (CEDAW)
1987 The Act on Equality between Women and Men passed
1988 The first female priests consecrated in the Evangelic Lutheran Church of Finland
1990 Children up to age 3 guaranteed a municipal child care place
1996 Children under school age guaranteed municipal day care
An Updated Plan of Action for Promotion of Gender Equality of the Government of Finland
proposed
46
Education Level
Literacy rate:
99%1
Percent of population aged 15 or over with basic education, grades
1-9 only, 19974
Women
44%
Men
42%
Percent of population with at least upper secondary level
qualifications, 19974
Percent of population in 1997 with a tertiary education4
Women
56%
Women
7%
Women
58%
Men
58%
Men
7%
Men
42%
Percent of graduates from universities in 1997 by gender4
Political and Economic Distribution of Power
The first woman, Tarja Halonen, was elected President, 2000
Percent women elected to parliament, 19994
(This percent has varied from 23% to 39% from 1975 to 1995)
37%
Percent women cabinet members (8/18), 19994
44%
Percent women in municipal councils, 19974
32%
4
Percent women on municipal executive boards, 1997
45%
Percent women on municipal committees, 19974
1998 labour force participation rate (15 - 64 years)4
47%
Women
70%
Women
12%
1998 unemployment rates4
Percent
of population below 50% of median disposable income,
19953
Long term unemployment, 12 months or more as percent of all
unemployment1
Men
75%
Men
11%
6.2%
Women
Men
Long term unemployment, 12 months or more as percent of total
labour force, 19953
6.1%
Women’s earnings as a percent of men’s averaged over 7 levels of
education, 19965
80%
28.2%
33.9%
Women’s average assets subject to taxation per income recipient as
64%
a percentage of men’s, 19974
25%
Percent of women administrators and managers, 92-963
Percent of women professional and technical workers, 1992-963
63%
Income distribution measure - Ratio of high to low incomes, 19915
(Most equitable of 15 industrialised countries compared)
Extent of Poverty in 19915
2.74
47
Elderly
Adults
Children
14.4%
5.8%
2.7%
6
4 in 1996
United Nation GEM rank out of 102 countries participation and
decision making where 1 is least gender inequality and 102 = most 4 in 19977
gender inequality
5 in 19983
6 in 19991
Health and Social Benefits
Average life expectancy, 19984
Women
Men
Social protection
expenditure as percent of gross domestic
8
product
Rate of taxation as percent of gross domestic product, 1997
80.8
73.5
32% in 1996
30% in 1997
8
47% in 1997
Overall budget surplus/deficient as percent of gross national
-6.3% in 1996
product1
Public expenditure on health as percent of total public expenditure7 14.7% 1989 - 91
Private expenditure on health as percent of total health
expenditure7
19.1% 1989 - 91
1. Human Development Report, 1999, United Nations.
2. ”The Future is Finnish”, Newsweek International, May 24, 1999.
3. Human Development Report, United Nations, 1998.
4. Women and Men in Finland, Statistics Finland, 1999, updated by Statistics Finland, November
1999: www.stat.fi
5. Luxembourg Income Study, Paper No 155, 1997.
6. Human Development Report, United Nations, 1996.
7. Human Development Report, United Nations, 1997.
8. Facts About Finnish Social Welfare and Health Care, STAKES, 1999.
48
Osmo Kontula
3. Sexual Health Promotion on the
Individual Level
Earlier in this book the concept of sexual health was discussed as a large thematic unity
linked to culture, societal structure and public health. From the point of view of an
individual, however, sexual health is shaped in various practical couple and other
sexual interaction events, which have both physiological and psychological effects. These
factors can have both positive and negative effects on a person’s sexual health. Sexual
health is promoted when the individual has a possibility of realising his or her sexuality
in a spontaneous, enjoyable, and safe way.
As its definition implies, sexual satisfaction is a necessary condition for sexual health.
Although some may find sexual satisfaction unnecessary or seek satisfaction alone, the
vast majority feel that the best way to promote their sexual health is in a relationship
with a suitable partner. The engagement and quality of this kind of a partnership are
regulated by various factors. Important factors that impact the individual’s sexual health
are shown in Figure 1 and I discuss them in more detail in this chapter.
Figure 1. Sexual health promotion on an individual level
Sexual rights
Public and private
services
The partner's
resources
Quality of the
relationship
Sexual health
49
Own resources
Sexual health is determined through a process of interaction situations and couple
relationships which in turn are affected by the conditions and norms set by the community
and larger cultural environment. In addition, the interaction process is influenced by the
characteristics and resources of a person and his/her partner. Adequate sexual rights are
a necessary condition for the satisfactory realisation of sexuality. Unsatisfactory sexual
relationships may be the result of lack of adequate information, inexperience, functional
disturbances or conflicting goals. Public and private services can be used to improve the
quality of the sexual relationship and thus the sexual health of the partners.
Professionals in the fields of general social, health and sexual policy all make decisions
which impact greatly on sexual health. When they acknowledge the sexual rights of all
human beings, the rights of everyone to the services promoting sexual satisfaction will
also be granted. These services can create the necessary pre-conditions for forming
partnerships and relationships characterised by sexual satisfaction.
Sexual counselling and treatment offer the practical means in an inter-human context of
improving an individual’s resources, such as knowledge or skills, or providing relief for
a physiological ailment. Some resource or property or lack of them means much more
to some individuals than others. Problems connected with sexuality and ways to solve
them vary according to these individual meanings.
Sexual Rights
We have already dealt with sexual rights on a general level. I shall only recapitulate the
most common factors related to forming a partnership and with the availability of
services.
Culture, society and the community affect sexual interaction by, for instance, through
legislation determining the limits of acceptability. They can affect, even censor
information that can be disseminated in the general media and information material
about sexuality and values and ideals connected with it. This will determine what kind
of knowledge and resources people have in forming partnerships, with what kind of
partners and how their experiences are going to develop.
The independent sexual choices and activities based on the needs and desires of an
individual are limited in some cases by legal sanctions (punishment), in some cases by
the reluctance of the partner to fulfil the other partner’s wishes, arising from general
opinions or values. Sexual choices and activities are limited and often practically blocked
by the opinions of family members and other close people about what kind of a partner
or sexual life is considered appropriate. The social environment can put pressure on an
individual to act against his or her inclinations or desires. Most people avoid contacts
with people who are labelled perverts in order to avoid stigmatisation. The basic question
50
is public acceptance or condemnation. In many individuals this can lead to totally avoiding
the desired relationship.
The intimate social environment and the family also affect the quality of the relationship.
From his or her environment the individual gets information, opinions and feedback to
help him or her construct his/her self-esteem and interactive skills. When problems
occur in the sexual life of an individual, there is reason to question if they have common
points with the social network of the individual.
Each person ought to also respect the sexual rights of other people. The present-day
discourse on sexual morality does emphasise negotiation and mutual understanding
instead of judging the acceptability of single acts or inclinations. If consenting adults
have formed a relationship and agree on what they want to experience, no sexual
activity is to be condemned or considered a perversion. But if either one pressures or
forces the other one to something against his/her own will, the right to sexual selfdetermination is violated and sexual health is damaged. The society attempts to save its
members from these deeds.
Human beings have the right to obtain from the society services promoting sexual
health. Everybody has the right to get the information, counselling and treatment he or
she requires. This applies to both establishing and maintaining the relationship. These
services can be used in various ways to promote and enrich the individual’s resources
for interaction and sexual satisfaction.
Own Resources and Characteristics
The individual puts into practice his or her sexuality in relationships, the initiation and
maintenance of which requires certain resources and characteristics. The more versatile
and valued resources a person possesses, the easier it is for him or her to form
relationships which provide mutual satisfaction. Humans are unequally endowed with
resources. This inequality also relates to our sex appeal. This characteristic is affected
by many of the resources we possess.
The resources often needed in promoting and sustaining sexual health will probably
become most tangible in situations where one is looking for and selecting a partner.
Looking at the characteristics people assign to their ideal partners in contact advertisements,
some necessary conditions can be discerned which the partners are expected to fulfil. At the
same time these are characteristics beneficial to good sexual health.
Age, size (length and height), physical appearance, health and a good physical condition
are basic factors determining the desirability to form a relationship with a certain person. A high age can be a significant impediment in forming a relationship especially for
51
women. Of course we cannot affect age. Also, many other expectations connected with
partner selection are connected with the genetic-biological basic characteristics of the
individual. Good genes are beneficial also in sexual health.
Human beings can control their weight, dress well and exercise. All these activities
increase the possibility of initiating a desired relationship. Active physical exercise can
also bring together partner candidates interested in the same kind of activities. Often
birds of a feather flock together. On the other hand, the more a person comes into
contact with different people, the more likely he or she is to meet a satisfactory partner.
Thus, a mobile job and other travel opportunities increase a person’s resources.
People have a tendency to be interested in and select partners who are in a way on the
same level regarding these qualities. An exception to this is height, for women look for
men who are typically about 10-15 centimetres taller than they are. The same kind of
tendency is connected with self-esteem to a large extent: if a person feels the other one
is for some reason on a “higher“ level, he or she is reluctant to try to initiate a contact
and views the approaches of the other one with suspicion. His or her self-esteem is not
sufficiently high to be able to trust in the sincerity of the other one.
One factor challenging self-esteem is body-image. If a person feels overweight, he or
she may lack confidence in his or her possibilities. Culture and the model world connected
with it create, especially for women, totally unrealistic ideals which only a few feel they
can ever attain. The result is a lot of plastic surgery, excessive body-building and weight
loss, sometimes leading anorexia. Some persons try to shape their bodies by any means
to meet the prevailing cultural ideals. If a person alienated with his or her body gives up,
he or she may no longer take care of him/herself. This may be the beginning of a
vicious circle difficult to break.
People search for partners who are sufficiently self-confident and independent to be
able to voice and realise their own ideas and needs. Self-confidence is one of the most
valued characteristics in the partner and simultaneously one of the most important
factors promoting sexual health. To attain high self-confidence and to help build it in
others is, unfortunately, difficult. When humans develop their resources and receive
positive feedback, they also strengthen their self-confidence. Therefore, they can maintain
some control in making choices instead of submitting to the choices of others.
From the point of view of sexual interaction and satisfaction, the opinions and beliefs
about their skills as lovers affect the courage and versatility of peoples’ sexual expression.
Peoples’ love-making skills can be improved with knowledge and guidance. If he
perception of oneself is realistic, a good sexual self-esteem and positive feedback from
partners can turn the growth curve of sexual health upward.
52
People also increase their self-confidence by gathering economic, professional, cultural
and social capital. People view each other on the basis of this accumulation and direct
their interests towards a partner assessed to be suitable. Women especially often set as
one condition of their interest that the partner should be on at least the same level
regarding these resources and properties. Some people get their resources in childhood
families while others accumulate them by studying, hard work, hobbies and other leisure
activities.
A person’s economic and social status and background affect his/her values and goals
in life as well as his/her lifestyle and time use. They also determine how much importance
and expression a person gives to factors enhancing sexual health in his/her life in general.
Part of the motives and their expressions concerning human coupling and sexual
interaction is a result of values and lifestyles. Additionally, there is a basic sexual desire
which regulates how much the person thinks about and needs sexual activities and how
much time and other resources he or she uses to initiate and support new relationships
and sexual activities in them. Desire is the potential for pleasure.
Desire also affects people’s values and attitudes. The greater the sexual desire, the
more importance he or she gives to sexual matters and the more liberal his or her
attitudes are towards the initiatives and wishes of the partner. If a person succeeds in
selecting a partner with a similarly strong desire and similar sexual liking, the preconditions for a mutually satisfactory sexual life are good.
Interaction skills significantly affect sexual health. An open and flexible communication
is always advantageous in couple and sexual relationships. A person with good interaction
skills is able to express him/herself and his/her wishes, listen to the other person and
develop interaction skills with the partner. Interaction skills are crucial also when the
situation demands the ability and courage to take care of one’s own safety in sexual
relationships. A person with interaction skills can discuss any subject in any situation
and can defend him/herself in resolving disagreements. A person with good interaction
skills knows how to touch his or her sexual partner both mentally and physically in the
right way and at the right moment.
The development of interaction skills is especially important in promoting sexual health.
A good lover provides more satisfaction to both him/herself and his/her partner. The
skills needed in lovemaking can be developed with the help of written and visual
educational material as well as counselling and guiding people in practical exercises. As
knowledge and skills grow, so will also self-esteem. A good lover provides him/herself
and the partner enjoyable sexual experiences and thus good sexual health.
53
The Resources and Characteristics of the Partner
A human being will survive without partners, but would then miss many kinds of
experiences that enrich life and make it easier. One can enjoy sexuality without a partner,
but would then miss the physical and psychological satisfaction of a good relationship.
There is a major difference already in one’s own touch and the partner’s touch.
Whether a person has a partner does not, of course, in itself produce good sexual
health. The decisive factor is the quality of the interaction in the relationship developing
with the partner. The characteristics and resources of the partner greatly influence the
relationship interaction and whether it will have positive effects on the sexual health of
its partners.
A partner can greatly enhance the sexual health of a person when he or she brings to the
relationship a lot of various resources and valued characteristics. A desired partner
gives a person inspiration and motivates him or her to display his or her best sides. In
the worst case the relationship is destructive and tiring fighting and bitterness block the
positive experiences of nearness.
It is important that the partner fulfils person’s expectations and desires of a good sex
partner. In an ideal case the partner has similar desires, he or she is pleasant,
knowledgeable, equally desirous, as well as ready to meet the partner’s sexual
expectations. A good partner is a person who is easy and comfortable to be with, who
makes it possible to discuss anything that comes to mind, and who inspires you to want
to satisfy his/her sexual wishes. In this type of situation a couple interacts co-operatively
for a mutually satisfying experience.
One of the most important resources of a partner is his/her ability to arouse desire and
lust. The wonder which awakens the sleeping prince or princess is repeated over and
over. There can be something inexplicable but also irresistible in this characteristic. A
captivating partner can help one forget inhibitions and fears as well as everyday problems
confusing one’s mind.
Sometimes the good characteristics and interaction skills of the partner remain unutilised.
This happens in long-term relationships in which both or one of the partners have lost
their interest in the relationship. A partner could have felt almost perfect in the beginning
but his or her attraction has passed with years and another man or woman may have
began to feel more tempting In this situation the person is not ready to invest all of his
or her resources in the previous relationship but may invest them somewhere else. This
creates a crisis, the solution of which requires clarification of the basic motivation of the
relationship and looking at the partner from a new and, in a way, from an outsider’s
perspective.
54
In the same way that one’s own resources can accumulate, the sexual health of the
people in a relationship can be improved by increasing the resources of a partner. A
partner can increase his or her knowledge and skills both in lovemaking and interaction
in the couple relationship. The motivation of a partner can be raised by taking a greater
interest in him or her and using more advanced skills with him or her. Desire breeds
desire and love breeds love. They also help patch up the possibly failing self-esteem of
a partner.
The Quality of the Relationship
One of the basic factors of sexual health is a relationship which adequately meets one’s
expectations. These expectations can vary greatly according to one’s life situation and
earlier experiences. Some seek in their lives excitement and ecstasy from casual
relationships while others feel they can realise their sexuality only after a marriage
which has lasted for years. One person gets satisfaction from excitement and the unknown
while another only from familiarity and safety. From the point of view of sexual health
any kind of relationship can be good if the person involved feels he or she is acting
freely and getting full satisfaction from the relationship.
In most cases one of the pre-conditions for a satisfactory relationship is adequate stability
and permanence. In a longer relationship people learn to find forms of sexual interaction
which give satisfaction to both partners. Many get the courage to express sexual ideas
and fantasies only after a relationship has lasted for months or years (even if then).
Confidence in a partner can grow only gradually.
For most people a lasting relationship is the first thorough-going trip to the roots of
one’s own sexuality and desire. Some women develop the courage to fully embrace
pleasure only after a self-examination of years or even decades. On the other hand,
some men are ashamed of their ability to perform sexually because they feel inadequate.
An eager and skilful partner is a crucial help along this trip.
In addition to the permanence of the relationship, sexual satisfaction in both sexes is
determined by the regularity of sexual life. Sometimes sexual encounters even in a
permanent relationship remain casual or periodical. Although the encounters were
satisfactory, they do not necessarily provide an adequate basis for sexual health. The
sexual health of both partners can be positively affected by increasing the frequency of
sexual interactions.
There are a number of reasons why the sexual relationship of two individuals becomes
dysfunctional or why it does not feel to be functioning after a promising beginning.
These are caused by changes in the resource balance of the partners. It is possible that
one of the partners has strengthened his or her resources while the other one seems to
55
be stagnating or even regressing. For instance, the unemployment of the other one
partner, economical difficulties or serious health problems can seriously challenge the
relationship. Also the considerable professional success of one partner can significantly
destabilise a situation which has previously been felt as stable.
Imbalance or conflict can also be caused by a significant increase or decrease in the
sexual self-esteem of either partner. The reason can be, for instance, the increasing
functional disturbances caused by ageing. As a result, a partner can be experienced as
less interesting or the other partner can begin to doubt that the other one does not
sincerely desire him or her. This can immobilise the relationship. In these situations one
has to analyse how the resource balance and the resulting adequate sexual motivation
level can be restored. The responsibility for change is mutual. Help can be received
from, for instance, family therapy or sexual therapy services.
Public and Private Services
A person’s sexual health can remain poor for very different reasons. The person may
have, for example, inadequate resources to form a relationship, he or she can have
physical or psychological difficulties with sexual interaction, the partner may be
unsatisfactory or the interaction within the relationship can prove to be or become
unsatisfactory. In these cases help from public or private services is needed to improve
sexual health.
Part of the problems of the clients is caused by sheer lack of knowledge. Public
information and educational material can be of help here. Problems can be reduced
also by publicly disseminating current information about sexological research. The
information leaflets distributed through the social and health care agencies are a useful
addition to the versatile supply of information though the mass media. Sometimes
useful information can be received by reading the medical question and answer columns
in various magazines.
Counselling services or actual specialised sexual counselling is often needed in solving
problems caused by psychological or physical insecurity and unsatisfying interaction in
a relationship. The more specific the problem is, the greater is the demand for advanced
professional competence of the helper. In promoting sexual health an important task is
to create and sustain the basic, advanced and specialised training for professionals in
the field. Research can also be used to promote professional know-how.
When the roots of the problem involve physiological or psychological sexual problems,
often treatment or therapy is required. In this case the sexological services providing
professional specialised know-how should be used. Health care service plays an important
role in this promotion of sexual health.
56
New Views on Sexual Health
The Case of Finland
Sexual Health Services
4. Highlights of Reproductive Health in Finland
Marjukka Mäkelä and Ilsa Lottes
57
5. Family Planning Services
Elise Kosunen
70
6. Sexual Medicine in Finland
Jukka Virtanen
85
7. Väestöliitto and Sexual Health
Pia Brandt, Raisa Cacciatore, Marketta Ritamies,
Dan Apter
92
8. The SEXPO Foundation Promotes Sexual Health
Tuisku Ilmonen
104
9. SETA: Finnish Gay and Lesbian Movement’s Fight
for Sexual and Human Rights
Olli Stålström and Jussi Nissinen
119
10. Sex Therapy in Finland
Sirpa Tukiainen and Pentti Soramäki
140
11. Sexual Violence in Finland: Legislation,
Prevalence, Public Discussion, and Services
Riitta Raijas
152
12. Treatment Services for Sexually Transmitted
Diseases
Eija Hiltunen-Back and Annamari Ranki
167
56
Marjukka Mäkelä and Ilsa Lottes
4. Highlights of Reproductive
Health in Finland
Our definition of reproductive health focuses on issues and problems related to
pregnancy and childbearing. Thus, to evaluate reproductive health care in a country, we
need to examine the extent to which quality maternal care and family planning services
and information are provided to all women; the availability of safe and effective
contraceptives; and the prevalence and treatment of infertility problems. Important
indicators of reproductive health are maternal and infant morbidity and mortality rates;
rates and types of contraceptive use; abortion rates and unwanted and unplanned
pregnancy rates; and morbidity and mortality rates due to abortion and genital mutilation.
Other measures of reproductive health are general fertility rate, average age of mothers
at birth of first child, average length of hospital stay for new mothers, and prevalence
and duration of breast-feeding. Family planning, contraceptive use and abortion deal
with both sexual and reproductive health and are discussed elsewhere in this book
(e.g., Chapters 5, 14, and 21). Family planning services are provided free of charge by
local health centres as a part of Finland’s universal government subsidised primary care
service. Contraceptive prevalence rates are high and abortion rates low by international
comparison, and illegal abortions occur rarely if at all. The issue of female genital
mutilation (FGM) has come up only during the 1990s for public discussion due to the
recent influx of African immigrants. The general criminal law makes FGM as physical
violation illegal in Finland, and these operations cannot be performed as part of the
public health services. It has been recommended that immigrant families from countries
where FGM is practised receive education from health professionals concerning the
risks of this procedure (Mölsä 1994).
This chapter discusses the structure and outcomes of health care for pregnancy, maternity
and infertility. We give a brief history of maternity care, describe the basics of its
service provision and education, and examine some concerns about the future of maternal
care. We also present indicators of reproductive health in table format, discuss some of
the issues involved in the incidence and treatment of infertility, and highlight some nonmedical factors which have an impact on maternal and infant well-being such as maternity
leave policy.
57
Brief History of Maternity Care
Concern about infant and maternal mortality can be traced to the 18th century when the
first midwife from Finland was educated in Stockholm (Rehnström, 1997). In 1816 the
first school for midwives was founded in Turku, and a Finnish-speaking school for
midwives was established in Helsinki in 1859. Nevertheless, until the 20th century most
mothers had their children at home, often in the sauna with the aid of a family member
and/or experienced woman neighbour, without the presence of a midwife or physician
(Rehnström, 1997).
In the middle of the 1800s middle and upper class women formed voluntary organisations
in order to improve the ability of poor women to care for themselves and their children.
By the beginning of the 1900s, national organisations and clinics in cities were established
to provide maternal health care and education services. Since the 1920s, national health
programs have included the care of pregnant women and their children. An important
characteristic of these programs has been the co-ordination of the provision of health
information/education with health care in their services to women. The custom of
giving poor mothers a package of supplies for their new baby also originated in the early
decades of the 1900s. This practice led to the establishment in 1941 of the useful,
valuable and carefully prepared “maternity package”, which is still available to all new
mothers today.
Finland is divided into over 400 local administrative units. These municipalities vary in
size from 150 to 540,000 inhabitants. They are responsible for providing health care for
their inhabitants. In 1944 the law mandated that all municipalities provide free health
care for expectant mothers and their children. This care was arranged in special units,
literally called “advice units” (neuvola), which were required to be staffed by midwives
and public health nurses. Rehnström (1997, p. 6) emphasises that within a year of the
law, “86% of all women giving birth had registered at a local maternity unit, and that the
average number of visits (pre-and postnatal) was 5.6.”
Registration and attendance in these maternity units increased steadily until 1975, when
the average number of visits was 16.9. This increase was partly facilitated by the
Maternity Benefits Law of 1949. A provision of this law was that new mothers would
only receive the maternity package if they consulted a nurse or doctor before the fourth
month of pregnancy. The timing of this visit allowed for the screening and treatment of
syphilis, and due to this policy congenital syphilis almost completely disappeared in
Finland. While the network of regional hospitals was completed during the 1950s,
childbirth in hospitals steadily increased. Most cases were assisted by a midwife, with a
physician called only in case of complications.
58
In 1972 the Public Health Act reinforced that municipalities continue to provide maternity
and child health care as well as family planning services as part of their primary care
services to their inhabitants. Today the local maternity unit is accepted by all social
classes and attendance is nearly universal. The Public Health Act also changed the
nature of the service provision: Public health nurses with special training in maternal
and infant health increasingly joined midwives to provide maternity and well-baby care.
Recent and Current Maternal Care
A recent guideline by the Expert Group on Family Planning and Maternity Care at
Stakes (National Research and Development Centre for Welfare and Health) states the
following comprehensive purpose of maternity care in Finland: “to ensure the best
possible health for the expectant mother, the foetus, the newborn and for family
members. The goals include prevention of disturbances during pregnancy, early detection
of any problems that may occur and prompt referral for treatment, efficient care and
rehabilitation, good care during delivery, care for newborns and support for the ill and
the handicapped” (Stakes, p. 7, 1996). Maternity care services are provided as part of
Finland’s national health care system. Delivery of these services at the local health
centre in the context of primary health care helps in relating the individual’s health to
the whole family and community. This also facilitates continuity in family planning,
monitoring pregnancy, and treatment of common problems close to the expectant
mother’s home.
The local maternity units are responsible for prenatal health examinations and screening,
personal guidance and parenthood education while hospital maternity clinics deal with
the treatment of problems and diseases during pregnancy and care during childbirth.
The resources and qualifications of health professionals at the local maternity units and
hospitals are distributed so that together they are able to provide for comprehensive
maternity care. Because good collaboration between the local maternity unit and hospital
professionals is considered important for high-quality care, multiple means of
accomplishing this have been devised. These include client participation (each pregnant
woman keeps her own copy of her maternity record - a card containing thorough
documentation of information from each prenatal visit), team work across professional
boundaries, job rotation, collaboration in monitoring and evaluation as well as regional
development of collaboration structures. Regions also schedule regular meetings for
maternity care providers to discuss problems and to provide continuing education about
new treatments and practices (Stakes, 1996).
Almost all Finnish women start antenatal care early and have many visits (Hemminki
and Gissler 1993, p.26). According to Medical Birth Register data, 97% of patients
seek care before the 16th week of pregnancy with the first antenatal visit occurring
typically at 10 weeks (Table 1). The average number of visits in 1994 was 14.9, including
59
an average of 2.2 visits to a hospital clinic. Less than a half per cent of women giving
birth had not attended a maternity unit; these women were primarily foreigners or Finns
living abroad who travelled to Finland for delivery.
Today almost all babies are born in hospitals where intensive care units for infants are
available. Midwives and nurses with a specialisation in obstetrics and gynaecology work
in hospital delivery rooms, prenatal and postnatal care wards, and maternity clinics.
More than 70% of deliveries are normal and administered by midwives/specialised
nurses. On average, 15% of deliveries involve some special procedure such as a caesarean
section, vacuum extraction, or forceps delivery. Of these procedures, caesarean sections
are the most common. Most hospitals allow the baby and mother to stay in the same
room to facilitate breast feeding. In the 1990s about half of the mothers have breast-fed
their baby for at least 6 months. A minority of mothers request an early postnatal
discharge (within 6-48 hours of the delivery). There are strict requirements for this
option, including additional home visits by a public health nurse or midwife.
In recent years the personal health professional system has increased in local health
units. Thus the same nurse may see a woman through her pregnancy and provide care
for the young child after delivery at the well-baby clinic. This system is thought to
promote coordination and individuality of care. In response to a 1994 national survey,
over 80% of women (n=2189) indicated that they thought it very important that the
primary care maternity services continue to be financed by tax money (Marja-Leena
Perälä, Stakes, personal communication). Women were also satisfied with the number
of visits with the qualification that more visits may be needed for a first pregnancy and
less for subsequent ones. In this same survey, 99% of women had visited the local
maternity unit during their latest pregnancy and 22% reported additional visits to health
professionals in the private sector (Hemminki et al., 1998). Thus, currently, local
maternity units are the primary source of prenatal care in Finland.
In the 1996 guideline by Stakes entitled “Screening and Collaboration in Maternity
Care”, the Expert Group in Family Planning and Maternity Care gave a detailed description
of basic practices of and recommendations for maternity care in Finland. For over 50
years local municipalities have provided a uniform level of centrally planned and guided
maternity services. The purpose of this book – distributed to all maternity care
professionals – was to ensure that maternity care providers at both the local units and
hospitals have the most up to date information on high quality maternity care. The book
expanded on a previous maternity care guide published by the National Board of Health
in 1988. An updated and enlarged edition of the guideline is in print (Stakes, 1999)
Besides experts’ opinions and findings from a survey of maternity care units in Finland
about the strengths and needs of care, these guidelines are based on literature in the
field, most notably on information from the Cochrane Library (1999). This international
database, which is updated quarterly, contains several hundred reviews of interventions
60
in all areas of medicine, including pregnancy and childbirth. Each review includes “data
from several studies and explains in detail how various procedures effect the course of
pregnancy and childbirth, or the child’s prognosis” (Stakes, p. 9, 1996). The
recommendations in the maternity guideline were checked against the information in
this database. The use of such data to validate medical guidelines is becoming increasingly
common in medical practice, and such information can greatly assist both the health
practitioner and patient in making decisions about medical care. The Stakes Expert
Group updated the guideline in 1999, using this database along with feedback from
local and regional providers of care.
Since 1993, local municipalities have been given more autonomy in their provision of
primary care services including maternity care. It was hoped that local decisions might
better adapt to the needs of their population. After initial enthusiasm in local planning,
national guidelines are becoming popular again. Divergences from the national guidelines
should usually have a clear justification. Despite increased local control, the expectation
is that local providers of maternity care will continue to closely follow the national
guidelines, with their emphasis on scheduled contacts throughout the pregnancy and the
final check-up 5–12 weeks post-partum. Therefore, the high quality of maternity care
should be maintained. Comprehensive local and regional statistics provide many indicators
of maternity care quality. Thus, a system is in place to discover changes or trends in
maternity care for each locality.
One of the scheduled contacts is a home visit by the local maternity unit midwife or
public health nurse during the first few days after the new mother and baby have
returned from the hospital, even during weekends. This tradition dates back to the late
1800s, when municipal midwives were important providers of health education (Niiranen, 1996). After a home delivery, the midwife often visited the new mother (especially
those with their first child) several times to teach baby care and general hygienic measures.
This tradition was continued when the 1944 law on local maternity units was enacted.
Even today, the postnatal home visit is an integral part of care in cities and rural areas
alike, giving the midwife or public health nurse a good picture of the social conditions of
the mother and the child and helping her to evaluate the need for social and psychological
support for the family together with the health centre team. All new mothers – including
health care professionals – are visited in their homes so there is no social stigma attached.
The midwife or public health nurse checks the condition of the mother and the child,
weighs the baby, and discusses breastfeeding.
61
Education and Knowledge of Maternal and
Infant Care
Preparation courses for new parents on delivery, parenthood and adjustments needed
in a family when a new child is born, are also an essential part of the work of maternity
care. In the 1960s childbirth education began to be offered at the maternity units, and
during the 1970s fathers were also permitted to be present in the delivery room. Today
the main responsibility for providing parenthood education and information to prepare
parents for childbirth rests with the midwife or public health nurse at the local maternity
unit. Future parents are given information about the course and development of pregnancy
and the associated social, emotional and physiological changes, the course of childbirth
and different modes of delivery, pain relief during delivery, abnormal deliveries,
puerperium, child care and breast-feeding, need for support of the father and older
siblings, and social support available in the community for pregnancy, childbirth and
infant care (Stakes, 1996). Both mother and father are encouraged to attend antenatal
classes. Parents are also invited to an introductory visit to the maternity hospital and
receive written information including an up to date handbook on pregnancy and baby
care called “We’re Having A Baby”. Research and feedback from parents indicates that
the education program is most appreciated when started about halfway through the
pregnancy and when implemented in small groups of four to six couples. Antenatal
classes may be larger than this, especially in the cities; increasingly, the groups continue
to keep in touch after the babies are born and act as self-support groups during the
children’s early years. The local health centre or day care centre often offers meeting
rooms for such activities.
Attendance at an antenatal class is usually a requirement set by the hospital for the
father to be present at the birth. In 1992, 61% of fathers participated in the birth of
their child (Mikkola et al., 1995) and by 1997 the rate had increased to 70% (VallimiesPatomäki 1998). Mothers appreciate the father’s presence in helping to provide emotional
support and a sense of security. Fathers generally appreciate the experience for it helps
to create a bond with their child and enhances feelings of family togetherness.
Social Support for Pregnancy and Childbirth
Parental leave
Both the mother and the father are entitled to parental leave from their work for the
birth of a child. Maternity allowance for the expectant mother is paid for 105 weekdays
and typically begins 30 weekdays before the expected date of birth. In cases where the
mother’s medical condition or the external conditions in her work require her to quit
work earlier in the pregnancy, special allowances are given. The paternity allowance of
62
12 days, which is not transferable to the mother, is paid from the time of the birth or
homecoming of the baby or later during the time of parental leave. Paternity allowance
is given to the married or cohabiting partner of the mother. In 1997, 95% of fathers
took a paternity leave in connection with confinement and/or at a later time during the
baby’s first year (Kansaneläkelaitos 1998).
Parental leave subsidy begins after maternity leave and extends for 158 weekdays.
Although parental leave can be divided between the mother and father, in the vast
majority of cases it is taken by the mother. Reasons for this include the breast-feeding
needs of the baby and the better economical outcome for the family when the lesserearning spouse (usually the mother) takes the parental part of the leave. The maternity,
paternity, and parental daily allowance is covered by the state and varied in 1999 from
60 FIM to 450 FIM (10-76 Euro) with an average near 250 FIM (42 Euro). It counts
as taxable income and is calculated according to the receiver’s earned income. A mother
who has not been employed is paid the minimum; permanently employed parents usually
receive their full salaries for the first three months, and the subsidy during this time goes
to their employer. The parental allowance is continued on the condition that the new
mother has a postnatal exam within 5 to 12 weeks of the birth of her baby. Because of
the long paid parental leave, which covers about 10 months after delivery, it is rare for
small babies to be placed in day care.
Maternity package, protective laws, and genetic counselling
A maternity package is given by the state to all pregnant women who undergo a medical
examination before the 17th week of their pregnancy. This package contains baby clothes
and items needed for the child’s first year of life. It is carefully prepared so that its
materials are of high quality, easy to care for, healthy, environmentally friendly, and
attractive. Instead of the package, new mothers can also choose a cash benefit of 760
FIM (128 Euro), about half the value of the package.
There are eight homes in Finland for unmarried new mothers or expectant mothers who
have nowhere else to go. These homes provide around the clock guidance for a variety
of problems, such as breast-feeding or colic babies. Some of these homes also give
antenatal classes for young families. The average stay in these homes is six months.
Two laws help to prevent hazards to a pregnant woman and foetus and also to the
fertility of both men and women. A law on occupational safety requires the employer to
ensure that working conditions are not likely to cause damage to the health of the fetus
or pregnant woman or to an individual’s fertility or genes. The employer is given a list
of products capable of causing such damage. The second law enacted in 1991 allows
women who have jobs which expose them or their prospective offspring to possible
health damages to have a job transfer or special maternity leave benefits. This possibility
63
is yearly used by 80-90 mothers (Dr. Helena Taskinen, Institute for Occupational Health,
personal communication).
All five university hospitals and the Family Federation of Finland support departments
of medical genetics. These departments provide genetic counselling to individuals interested
in learning about existing or suspected hereditary disease of their own or in their family.
The service cost to the clients are nil or low with the municipal payment contract, as for
other secondary care. The decision to seek genetic counselling or foetal diagnostics is
always made by the family. As part of standard maternity care, the new guideline for
screening (Stakes 1999) recommends ultrasound screening at either 13-14 weeks or
screening for chemical markers at 15-16 weeks of pregnancy
Miscarriage and Infertility
According to the national hospital register, an estimated 9% of pregnancies ended in
miscarriage in 1995. In a 1994 national survey (Hemminki et al, 1998), 15% of women
reported that they had experienced at least one miscarriage in their life. The vast majority
(97%) of these women had consulted a doctor after their miscarriage and 74% were
treated as inpatients; in most cases, an operative evacuation of the uterus had been
done. Hemminki et al. concluded that research regarding both the treatment and
prevention of miscarriage is needed, even though miscarriage rates in Finland are
comparable to those in other developed countries.
Infertility problems have increased in the last two decades. The average age of women
at the birth of their first child rose from 25.7 years in 1980 to 27.4 in 1994 and the
proportion of first pregnancies in the 30 to 39 age group has increased while the proportion
of mothers aged 20 to 24 has decreased (Miettinen 1997; Mikkola et al., 1995). The
older age of first pregnancy places new demands on maternity services for more infertility
problems and complications during pregnancy occur for older women. A 1989 study
(Nikander, 1992) indicated that 12% of women in the 40 to 44 age group had at some
time experienced infertility, while in 1994 the corresponding proportion was 16% (Malin, 1997). Notkola (1990) estimated that 35,000 couples are in need of fertility treatments
annually (Rehnström 1997).
Basic evaluation and treatment of infertility are provided at hospitals, some municipal
health centres and private gynaecologists. Advanced treatments including intracytoplasmic
sperm injection and frozen embryo transfers are available in all university hospitals and
many private clinics. Infertility treatments are accepted as part of normal health care,
but the scale of services, age limits, and number of treatments given to one couple vary
by municipality. At university clinics the fees are lower but waiting lists can be long,
whereas at private clinics waiting times are shorter but fees higher (currently reimbursed
at a rate of between 50 % to 75%). More than half of the high technology infertility
64
treatments are offered at private clinics. Three of the most popular infertility clinics are
operated by Family Federation of Finland (Väestöliitto) and are located in the major
cities of Helsinki, Turku and Oulu. They also provide special miscarriage and maternity
services. The clinic in Helsinki, for example, services 15000 clients and performs over
700 in vitro fertilisations annually. This clinic has its own sperm bank and receives
donated eggs.
Discussion
Some indicators of reproductive health are shown in Table 1. A comparison of these
with the corresponding indicators from other countries supports the view that maternal
health and health of the newborn in Finland are among the best in the world. Areas of
concern to health professionals concentrate on the experienced quality of the services,
cost-effectiveness, and equity issues. There are also changes in the needs of patients.
Changes since the early 1990s have given municipalities more control over decisions
affecting health services. This extended local autonomy may increase the risk for
inequitable service provision across municipalities. Also an increasing pool of couples
with infertility problems and the recent increase in immigrants who have higher fertility
rates than Finns present new challenges to the maternity health system.
Another concern among those who evaluate prenatal care is that hospital clinics may
expand their services to include regular monitoring of non-problematic pregnancies.
The local maternity centres have been known for their ability to provide a high degree
of emotional and social support and continuity of care at facilities close to the residence
of patients at lower costs and shorter waiting times than are characteristic of hospital
clinics. Finally, some are worried about the trend in local maternity units toward replacing
midwives, who have the most comprehensive specialised training in pregnancy, childbirth
and confinement, with public health nurses who are generalists and obtain much less
specialised knowledge and training in maternity care. Many attribute the past high quality
of maternity care in Finland to the role of primary care midwives and thus hope that
their important part in maternity care will continue. Nevertheless, close monitoring by
comprehensive statistics, evaluation systems involving patients, and collaboration
mechanisms among professionals at the local, regional and national levels offer important
safeguards helping to ensure that Finland will continue to offer high quality maternal
and infant care services to its citizens.
65
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Nikander, T. 1992. Naisen elämänkulku ja perheellistyminen. (The life and family
situation of women.) Tilastokeskus, Väestö 1992:1.
Notkola, I.L. 1996. Hedelmättömyyden yleisyys kolmesta näkökulmasta. (The
prevalence of infertility from three viewpoints.) In: Hedelmättömyyshoitoja koskevien lekiesitysten valmistelun kiirehtimiseksi. Stakes Aiheita 14/1996. Helsinki: Stakes.
Rehnström, Jaana. 1997. Reproductive Health and Health Care in Finland: An Overview.
Stakes: Themes 10/1997, Helsinki: Stakes.
Sihvo, Sinikka and Päivikki Koponen (Eds.). 1998. Perhesuunnittelusta
lisääntymisterveyteen: Palvelujen käyttö ja kehittämistarpeet (From Family Planning
to Reproductive Health: Use of Health Care Services and their Further Development).
Stakes Raportteja 220. Helsinki: Stakes.
Stakes (National Research and Development Center for Welfare and Health). 1996.
Screening and Collaboration in Maternity Care, Guidelines, 1995. Helsinki: Stakes.
Stakesin perhesuunnittelun ja äitiyshuollon asiantuntijaryhmä (Stakes expert group on
66
family planning and maternity care), editor Kirsi Viisainen. 1999. Seulontatutkimukset
ja yhteistyö äitiyshuollossa: suositukset 1999 (Screening and collaboration in maternity
care: guidelines 1999). Stakes Oppaita 34. Helsinki.
The Cochrane Library. 1999, Issue 1. Update Software, Oxford, England.
Taskinen, Sirpa. 1994. We Will Get a Baby. Helsinki: National Research and Development
Center for Welfare and Health.
67
Appendix: Table 1. Indicators of and factors relating to the quality of
reproductive health in Finland
Year
1991
1992
1993
1994
1995
1996
Number of deliveries
65 268
66 742
64 563
64 726
62 767
60 434
58 900
1)
Number of live births
65 395
66 731
65 219
65 477
63 391
60 940
59 329
1)
Number of live births
and stillbirths
65 701
67 019
65 496
65 730
63 694
61 426
59 540
1)
5 013 740
5 041 992
5 066 447
5 088 333
5 017 790
5 124 573
5 139 835
2)
13,0
13,2
12,7
12,7
12,5
11,8
11,5
2)
51,8
52,7
51,0
51,2
49,7
48,2
47,5
2)
3
3
2
7
1
2
2)
Maternal mortality
rate: Deaths/100 000
live births
4,6
4,5
3,1
10,7
1,6
3,3
2)
Perinatal deaths
532
490
438
441
439
381
341
1)
Perinatal mortality
rate: Deaths/1000
newborns
8,1
7,3
6,7
6,7
6,9
6,2
5,7
1)
Infant deaths
382
344
287
308
248
242
232
2)
Infant mortality rate
5,8
5,2
4,4
4,7
3,9
4,0
3,9
2)
26,9
27,0
27,2
27,4
27,6
27,7
27,7
1)
5,3
5,5
7,2
9,8
10,9
10,1
8,3
1)
% Cohabiting
mothers
21,3
22,9
22,9
21,8
21,6
23,2
26,6
1)
% Married mothers
71,6
70
68,5
67,3
66,2
63,3
62,9
1)
% Births outside
hospitals
0,11
0,12
0,10
0,11
0,12
0,10
0,13
1)
% Pregnant women
consulting before
16th Week
95,8
96,6
96,5
96,9
96,9
Mid-year population
Birth rate: Number of
births/1000
population
General fertility rate
per 1000 women of
fertility age
Maternal deaths
1997 Source
Mean age of mothers
at birth of first child
% Single mothers
68
1)
Year
1995
1996
9,8
9,7
15,4
16,0
16,4
16,5
1)
4,4
4,2
4,1
4,0
4,0
3)
3 547
3 540
3 546
3 538
3 522
3 536
1)
0,9
0,9
0,9
0,9
0,9
0,9
0,9
1)
% Low birth weight
babies (<2500 gr)
4
4
4
4,1
4,2
4,3
4,2
1)
% of Births to
women < 20 years
2,8
2,7
2,6
2,5
2,5
2,6
2,5
1)
30,4
30,5
30,7
30,8
30,8
30,9
30,9
1)
Mean pregnancy
week of first
antenatal visit
Mean number of
antenatal visits
Mean length of
hospital stay for
childbirth, days *
Mean birth weight
% Very low birth
weight babies
(<1500gr)
Average age of
women with
spontaneous
abortion **
1991
1992
1993
10,2
10,0
10,1
15,1
15,0
14,9
5,0
4,6
3 548
1994
1997 Source
1)
% of Mothers
breastfeeding for 3
months or more
a) Predominantly
68
4)
b) Of these,
exclusively
26
4)
% Caesarean
sections
14,4
% Fathers
attending birth
14,5
14,6
15,4
15,7
14,1
1)
70
5)
0,157
0,158
1)
4,5
..
61
Pelvic inflammatory
disease/1000
women aged 15-49
Cervical cancer
incidence
15,7
2,8
3,2
3,6
3,7
4,5
* Preliminary
Sources: 1) Medical Birth Register, 2) Statistics Finland, 3) Hospital Discharge Register, 4) Imeväisikäisten
ruokinta Suomessa, 5) Vallimies-Patomäki 1998, 6) Cancer Register
69
Elise Kosunen
5. Family Planning Services
Introduction
During the last thirty years, Finland has been more successful than many other western
countries in promoting sexual health in its population, at least with respect to rates of
unplanned pregnancies and abortions. After the renewed abortion law (1970) and the
Primary Health Care Act (1972), induced abortions decreased by more than half
compared to the early 1970s. Since the 1970’s, decreases in adolescents’ unwanted
pregnancies and abortions were exceptional compared to many other developed countries.
Low abortion rates or decreases in induced abortions in cannot be explained by differences
in sexual activity between Finland and other countries. In Finland, sexual behaviour
was studied using representative samples of the adult population, both in the early
1970s and in the early 1990s, the same period induced abortions sharply decreased.
Sexual activity increased rather than decreased during this period. When sexual activity
among Finnish people is compared to people in other European countries using frequency
of intercourse as a measure, Finnish people are a bit less active than the French, but
more active than the British (Bozon and Kontula 1998). However, differences among
countries are small. One crucial explanation for the decrease in induced abortions is
effective organisation of family planning services, and, therefore, wide use of
contraceptive methods in the population.
This chapter describes how the organisation of family planning services, contraceptive
counselling, delivery of contraceptive methods and access to induced abortion is organised
in Finland.
Contraception
Provision of contraceptive services
The enactment of the Primary Health Care Act in 1972 led to the current organisation
of health care in Finland. This law stipulated that every municipality must provide
(alone or with another municipality) a health centre for primary health care services to
its citizens. In addition, the act mandated that the municipalities provide a large variety
of preventive health care services. These include school, maternal, and child health
70
care, all of which already had a long tradition in the country. Modern contraceptive
methods had been introduced to Finnish markets only a few years earlier and, an
effective way was needed to allow all women easy access to contraception. Thus,
family planning services were added by the 1972 Act as a new field of preventative
heath care. This was also important because many had feared that the number of
abortions would increase because of the new abortion law; many thought this law
would lead women to use abortion as a means of birth control instead of the established
and recommended contraceptive methods.
Following the enactment of the Primary Health Care Act, family planning services were
carefully monitored. The National Board of Health issued detailed instructions for the
operation of family planning clinics and delivery of contraceptive methods. These
instructions were considered requirements and highly necessary to be followed by health
care personnel. Implementation of these new activities was effective. Within a few
years, more than 90% of municipalities had founded a family planning clinic or provided
these services in combination with maternal health care.
A public health nurse or a midwife with specific training in family planning, together
with a general practitioner, who was especially appointed for the task, gave contraceptive
counselling. This model of differentiated and specialised service-units was a common
model of working until the early 1990s (Kosunen and Rimpelä 1997). During the first
few years, the provision of services and number of visits were monitored by detailed
statistics. When declining abortion trends indicated the system was effective, instructions,
and follow-up were reduced.
All preventive services including visits to a family planning clinic were free of charge.
They have remained cost-free, although fees for visits were introduced during the
1990s in health centres for medical services. In 1982, a circular letter of the National
Board of Health advised that the first contraceptive method should be given free of
charge. Municipalities have applied these guidelines in many different ways. In most
cases, the first three months of oral contraceptives as well as the first intrauterine
device (IUD) were delivered free of charge.
Family planning services were also provided by private gynaecologists in cities and
villages, student health care clinics in towns with a university, as well as the Family
Federation of Finland (Väestöliitto), and in some municipalities, Folkhälsan. A study in
1994 indicated that one third of urban women used private services the last time they
needed contraceptive services, and in the capital area, the proportion was as high as
47%. Women living in rural areas mostly used health centre services (Sihvo et al. 1995).
71
Family planning services in change
In the primary health care organisation mandated by the Primary Health Care Act, a
health centre was responsible for providing health services to its citizens. When somebody
became ill, he/she went to his/her own health centre, not to his or her own doctor.
Then, the health centre organisation assigned any available doctor to care for the person. Consequently, the continuity of care was poor and the population was unsatisfied
with the frequent change of doctors (Aro and Liukko 1993). Problems similar to these
involving treatment were not seen in preventive services of health centres.
At the end of the 1980s, the population responsibility principle was suggested as a
solution to the problems of medical services in primary health care. From the viewpoint
of a health centre, this meant that a population living in a geographically defined area
was assigned to a doctor and a public health nurse. It was their duty to provide all
primary health care services to the population in their own area. From the viewpoint of
individual patients, this renovation meant that in an ideal situation all citizens in the
municipality had a doctor and a nurse of their own whose responsibility was to provide
them all necessary primary health care services.
Municipalities created many models in their application of the population responsibility
principle, the two extreme alternatives being the narrow-scale and the large-scale model.
The narrow-scale model meant that the population responsibility principle only concerned
medical services, and preventive services were provided similarly as before, that is, by
doctors and nurses who had specific training in these areas. The large-scale model
meant that a doctor and a nurse provided both medical and preventive services (including
family planning services) to their own population.
A study on the structure of public services carried out in 1995 showed that 27% of
municipalities had applied the large-scale model of the population responsibility principle
by including family planning services as one of the tasks of the small area units (Koponen et. al 1998). Thirty-one percent of the municipalities provided health services similarly
as before, based on differentiated and specialised tasks. The rest of the municipalities
used some kind of intermediary model, so that family planning services were partly
provided by the population-responsibility units. Altogether, a differentiated and specialised
model of work was still more common in family planning services than in maternal and
child health care or general medical care. The family planning study carried out by
STAKES in 1994 showed that 28% of women had a personal doctor and 20% had a
personal public health nurse in the health centre. One half of the respondents did not
have a doctor of their own.
72
In the 1994 study (Stakes), 43% of respondents preferred private doctors and 32%
preferred family planning clinics for contraceptive counselling. One fifth of the women
thought that the position of the service provider did not matter. Nearly half of the
respondents seemed to favour the large-scale model of work for 41% of the women
indicated they preferred to visit the same doctor, whether the reason for a visit was
contraception or another health problem. Most of the women thought the best ways of
organising family planning services were either to provide them completely on a specialised
basis or combine them with maternal health care. Only 12 % thought that the best
solution was to combine contraceptive counselling with the medical services provided
by a health centre doctor.
Women’s knowledge of reproduction and contraceptive
methods
The survey study in 1994 showed that women had good knowledge about topics
concerning pregnancy, but facts about fertility were not as generally known. One third
of the youngest respondents (18-19 year-olds) did not know which days during the
menstrual cycle when it is easiest to get pregnant and even in the 20 to 29 year old
group, this proportion was as high as one quarter (Sihvo and Koponen 1998). Knowing
the timing of the most fertile period is important not only when one wants to get
pregnant but also when coitus dependent methods of contraception are used. For example,
one has to evaluate the need of emergency contraception after breakage of a condom.
In the 1994 survey, adult women’s knowledge about contraceptive methods was
measured by supplying a list of seven contraceptive methods. They were asked if they
knew about these and how to use them. The widely used methods were well known,
but implants, emergency contraception, and diaphragms were less well known.
Knowledge about emergency contraception was high only among women under 25. On
the other hand, young women were less aware of the IUD than older respondents were.
(Table 1). Knowledge about the IUD was best among women who had been pregnant;
in other words, among those women who constitute the pool of potential users of that
method. Knowledge about other contraceptive methods by experience of pregnancy
showed no substantial variation (Sihvo and Koponen 1998).
Use of contraceptive methods
In Finland, modern contraceptive methods have been the most common in contraceptive
practices. This may be because their delivery was so effectively organised at the beginning
of the 1970s. The proportion of natural family planning methods was small in the
1970s, and they have not increased in popularity during the more recent years as in
Sweden, for instance, not even as a fashionable trend.
73
Table 1. Proportions (%) of positive responses to the question “Do you know
these contraceptive methods and how to use them?” by age. (Source: Kosunen
et al. 1997a)
18-24
year-old
25-34
year-old
35-44
year-old
All
Condom s
99
99
98
99
Oral contraceptiv es
97
99
95
97
IUD
76
85
92
86
Im plants
59
65
52
58
Em ergency contraception
79
53
36
52
Method
(Source: Kosunen et al. 1997a)
At the end of 1970s, the IUD was more widely used in Finland than in other Nordic
countries, but its popularity decreased during the 1980s when the use of oral
contraceptives increased among women, especially for those less than 30 (Makkonen
and Hemminki 1991). At the end of the decade the use of oral contraceptives started to
increase among women over 30 when new types of the pill more suitable for this age
group became available (Kosunen et al. 1997b).
Different studies give very different information on the use of condoms depending on
the age group and sexual activity of respondents in the sample. In general, figures
describing condom use among the Finnish population have been quite high compared to
many other countries. According to the population study in 1992, 27% of all women
and 40% of all men who needed contraception had used a condom at their most recent
intercourse. Among those who had sexual intercourse at least two or three times a
week, condom use was less frequent (20% in women and 25% in men). Instead of
condoms, they more often used oral contraceptives or IUDs (Erkkola and Kontula
1993). Another study in 1994 (Taloustutkimus) showed that 20% of women aged 1549 used a condom as their main method of contraception and 6% used it as an additional
method (Toivonen 1997). Similar percentages were found in the 1994 family planning
survey of Stakes (Table 2).
The revision of the Law of Sterilisation in 1985 greatly affected contraceptive practices
among those over 30. The revised law made it possible for women and men who were
at least 30 to be sterilised if they requested, regardless of the number of children they
had. The annual number of sterilisation’s more than doubled after the revision of the
law. Unlike other Nordic countries, sterilisation’s were performed almost exclusively
74
for women in Finland. The number of male sterilisation’s did not start to increase until
the late 1990s, when there was more active promotion of using this method. In 1998,
there were 9,593 female and 1,918 male sterilisation’s in Finland (unpublished information
from the national register).
Table 2. Distributions of current contraceptive method (%) by age among
sexually active women (regular need of contraception al least monthly or almost
monthly). Source: Sihvo and Koponen 1998
Age in years (n)
18-19
(65)
20-24
(250)
25-29
(304)
30-34
(312)
35-39
(294)
40-44
(239)
All
(1464)
Oral contraceptives
63
60
52
25
16
5
33
Double
contraception*
14
17
4
5
3
0
6
Condoms**
15
13
25
25
23
26
22
IUD
0
2
6
29
42
39
23
Sterilization
0
0
0
4
10
26
7
Implants
0
2
0
1
1
1
1
Spermicides
0
1
1
2
1
1
1
Do not use/
need at the moment
8
7
11
10
4
2
7
* a condom combined with oral contraceptives or IUD or implants
** a condom alone or combined with spermicides or a method of natural family planning
The most recent large surveys (in 1989, 1992 and 1994) on the use of contraceptive
methods suggest that current contraceptive practices with respect to age differences are
quite stable; no signs of major change have been found. The news of an association
between increased risk of venous thrombus embolism and the use of third generation
oral contraceptives, which was widely reported in mass media in 1995, did not have
any permanent effect on sales figures or proportions of oral contraceptive users in
Finland. (Kosunen et. al 1999).
Of women who participated in the family planning survey in 1994 (Stakes), 94% had at
sometime used contraception, and 75% of respondents were using some method at the
time of the study (Sihvo and Koponen 1998). About half of women under 30 were
currently using oral contraceptives or an IUD. For women over 30, this proportion was
smaller and the proportion who had been sterilised increased with age. Of sexually
active respondents, about 80% of women under 25 and 62 to 72% of women over 25
75
used highly effective methods like oral contraception, IUD, implants or sterilisation.
Almost all of the rest reported that they used condoms as their main contraceptive
method (Table 2).
Emergency contraception was introduced to Finnish markets in 1987. Sales figures of
the four-tablet package increased every year so that in 1998 about 44,000 packages
were sold (Schering Oy, unpublished information). The family planning survey in 1994
showed that most users were unmarried and nulliparous women under the age of 25.
Women over 25 were clearly less aware of this method and how it is used compared to
younger women. Knowledge of emergency contraception was less than that for other
methods (Kosunen et. al. 1997a). Adolescents receive information on emergency
contraception in sex education classes at school, and they know the method very well.
Thus, information directed to the adult population on more recent methods of
contraception needs to be increased.
The possibility of using the copper-IUD as a method of emergency contraception is not
well known among the population, and health centres do not frequently offer it for this
purpose, according to research in Central Finland (Kosunen and Poikajärvi 1998).
Copper-IUD can be used as emergency contraception when the time limit of 72 hours
for hormonal emergency contraception has been exceeded. The application of the copperIUD should be carried out within five or six days after an unprotected sexual intercourse,
and is even more effective than the hormonal method. The copper-IUD is a practical
option if a long-time contraceptive need exists and there are no contraindications for the
use of IUD. Thus, the copper-IUD can be left in the uterus to take care of contraception
in the future, as well as for the acute need of emergency contraception.
Induced Abortion
Legislation on induced abortion
The first Finnish abortion law in 1950 allowed termination of pregnancy almost exclusively
on medical grounds. Women did not have the right to have an induced abortion because
of their young age or for social reasons alone. Therefore, mental disorders like neurosis
were often used as a medical reason for an induced abortion during the 1960s.
The Abortion Law was thoroughly revised in 1970. Finland was among the first countries
in Western Europe that accepted more liberal abortion legislation. The most essential
revision in the new law was the allowance of termination of pregnancy on social grounds,
if two doctors provided a permission statement (2nd section, 2nd paragraph, see Table
3). The Law also specified limits on age and the number of children, so that in some
circumstances an abortion was permitted with a statement from only one doctor (the
76
performing physician). These circumstances applied if the woman was less than 17 or
older than 40 at the time of conception or if she had already given birth to at least four
children. Since the year 1970, only some minor revisions concerning time limits for
duration of pregnancy had been made to the Law, and the core elements of the law
have remained the same.
Most induced abortions are permitted on social grounds. The abortion statement form
that a doctor completes when referring a patient to a hospital for an abortion includes a
box where the social grounds must be defined in detail. In 1992 a sample of the grounds
were studied and the most frequently mentioned reasons were being an unmarried or a
single mother, economic concerns, unemployment, difficulties in the couple relationship,
and unfinished education (Rasimus 1993). Currently, an application for an induced
abortion due to social reasons is hardly ever denied. According to current interpretation,
a woman is the best expert of her life conditions and in knowing when childbirth and
child care would be a considerable strain for her and her family.
According to the law in 1970, an induced abortion had to be carried out by the 16th
week of pregnancy. In 1979, the limit was decreased to 12 weeks. For specific reasons,
termination may occur even up to 20 weeks. Since 1985, it has been possible to perform
an abortion up until the 24th week of pregnancy if a reliable examination shows that the
fetus has a serious disease or injury/handicap. Currently about two percentages of abortions
each year are performed on the grounds of a potential fetal injury (Gissler 1999).
An abortion can be granted to a woman asking for it when:
1)
Pregnancy or childbirth would risk her life or health
2)
Childbirth and child care would be a considerable strain on her and her family
economically and socially
3)
She is made pregnant againts her will
4)
She was not yet 17 years of age or was over 40 at the moment of conception or
already had four children
5)
There is a reason to expect the child to be mentally defective or to have a difficult
illness or physical defect
6)
Illness, disturbed psychological functioning, or a comparable factor of one or both
parents seriously limits their capacity to take care of the child
Source: Abortion Law 24.3.1970/239 in Finland
Source of translation: Rolston B, Eggert A (eds). Abortion in the New Europe. A Comparative Handbook.
Greenwood Press, W estport 1994.
The Main trends of abortion epidemiology in Finland
At the end of 1960s, during the last years of the old Abortion Law, the number of legal
abortions was about 8000 per year. It has been estimated that the number of illegal
abortions was 19,000 in 1966. Obviously, some of these illegal abortions led to serious
complications, even death.
77
The enactments of the new abortion legislation in 1970 stipulated that a doctor who
performed an abortion had to notify the abortion register (currently administered by
Stakes) within one month, using a specific notification form. According to a study in
1993, the time limit of one month is not often adhered to, but other than being late,
notifications are sent very reliably to the register. Only 1% of induced abortions was
missing from the register when data of the abortion register were compared with the
case reports from the operating hospitals (Ulander et al 1995).
After the revision of the law in 1970, the highest abortion rates were recorded in 1973
when more than 23,000 abortions were performed (19.6 abortions per 1000 women
aged 15-49 years). When the Primary Health Care Act became effective in 1972 and
the delivery of contraceptive methods was organised throughout the country, abortions
started to decrease. At the beginning of the 1980s, the figure fell under the limit of
15,000 abortions (Table 3). In the early 1990s, the number of abortions was down fifty
percent compared to twenty years earlier. In 1995, it was lower than 10,000 for the first
time. However, during the last few years decreases in abortions have levelled off, and
the latest figures suggest a slight increase. Age-specific abortion trends show that induced
abortions are most frequent among women aged 20-24, and this has been the case
throughout the current abortion law. The decrease in abortion rates was greatest among
women under 20 (see chapter 14). About one quarter of all abortions are performed for
married women and more than half for never-married women (Gissler 1999).
Table 3. Number of induced abortions and abortion rate (per 1000 women
aged 15-49 years). Source: Gissler 1999, Vikat et al. 1999.
Y ear
N u m b er
N u m b er
p er 1000 w o m en
1973
23 362
19,6
1975
21 547
17,9
1980
15 037
12,3
1985
13 833
11,0
1990
12 232
9,7
1995
9 884
7,8
1996
10 438
8,2
1997
10 274
8,2
1998
10 654
8,6
1999*
10 800
8,7
*prelim inary data in June 2000 (national abortion register)
78
One of the main goals of the Finnish health policy has been to ensure equal opportunities
for health care regardless of place of residence. However, the regional variation of
abortion rates has remained similar throughout the time the current Abortion Law has
been in effect. During the 1990s, the abortion rates have been highest either in Lapland
in the north or in Uusimaa (Helsinki metropolitan area and its surroundings in the
south). In addition, the island of Ahvenanmaa has been ranked high, but due to its small
population, the variation is great there. In 1998, the abortion rate for women aged 15 to
49 was highest in the hospital districts of Helsinki and Lapland (11.8 and 11.6 per 1000
women) and lowest (5.5/1000) in the hospital district of Keski-Pohjanmaa in the western
Finland (Vikat et al. 1999).
Eighty-seven percent of induced abortions were carried out on social grounds in 1997,
and 11% were for age or number of children in the family (Gissler 1999). The distribution
of the grounds for abortions has not changed during recent years. However, since the
early years of the law, the distribution of the grounds has changed to some extent so
that the proportion citing social grounds increased. This mainly reflects differences in
interpretations of the grounds in different areas. Ninety-four percent of abortions are
performed before the 12th week of pregnancy, and this proportion has remained fairly
constant for several years. In 1997, National Agency for Medicolegal Affairs (TEO)
permitted a termination for 568 pregnancies that had passed the limit of 12 weeks.
Seventy percent of all abortions are for women who have a termination of pregnancy
for the first time, 21% have it for the second time and 9% have had at least two
previous abortions. Compared to the early 1980s the proportion of repeated abortions
has increased somewhat steadily, but the changes were minor during the 1990s (Gissler
1999).
Abortion care
Different stages of abortion care typically constitute a series of events where primary
health care and hospital specialists each have their own role and where collaboration
between professionals of different levels of health care is supposed to proceed smoothly
without friction. Almost all clients wanting to terminate their pregnancy have to pass
through all the stages, because a referral is needed for hospital care and most clients
also need a doctor’s statement on their need and grounds for an abortion (see section
3.1 of this chapter). When a woman wants to have an induced abortion on social
grounds, she needs a permission statement from a primary health care doctor. If a
woman fulfils the criteria of age or number of children, a statement from another doctor
is not needed. Usually a woman makes an appointment with a doctor at either a health
centre or private clinic in order to get a referral to a hospital. Then the referral and the
statement (if needed) are sent to the hospital as soon as possible. The hospital clinic
informs the client about the timetable of the procedure which is carried out within one
week whenever possible.
79
Until recently hospitals usually followed the practice of two visits. First, a woman visits
an outpatient clinic of the hospital, where a gynecological examination is performed. In
addition, potential contraindications for general anesthesia are examined and then an
appointment for the procedure in a hospital inpatient clinic is made. Up to the 1990s a
major part of induced abortions were performed in inpatient wards. There are medical
arguments for this practice, because a general anesthesia has been widely used in abortion
care in Finland instead of local anesthesia. Therefore, a careful follow-up is needed
after the procedure.
After leaving the hospital a series of abortion care events continues in primary health
care. The patient is expected to visit her own doctor for a check-up a few weeks after
the procedure. The purpose of the visit is to check on not only physical but also
psychological recovery. In fact, the abortion legislation says that contraceptive counselling
should be provided for the client after the procedure.
Currently abortion care is changing and developing in Finland. As in operative care, in
general, abortion care is also adopting new practices of care by shortening the time
spent in the hospital. This means that the procedure is carried out in the outpatient clinic
of a hospital and the patient can go home during the same day, a few hours after a
follow-up to the procedure. A questionnaire study in 1994 showed that 86% of the
women who had experienced an induced abortion within the past year had had the
procedure in an outpatient clinic, while the proportion was only 12% for those women
who had had an abortion ten or more years ago (Sihvo et al 1998). One of the patients’
most crucial requests for development of future abortion care was to organise the care
so that only one visit to a hospital would be needed. Some hospitals have already tried
this practice with success.
In Finland, a major part of induced abortions are carried out before the end of the 12th
week of pregnancy and in 64% of all cases, the duration of pregnancy is less than eight
weeks (Gissler 1999). From a technical viewpoint this means that abortions are mainly
carried out by using a vacuum aspiration combined with curettage if needed. A medical
abortion, in other words, an abortion induced by an oral medicine such as mifepristone
will change practices of abortion care in the near future. This method was officially
adopted in Finland at the end of 1999.
The costs of abortion care include expenses in primary health care and expenses of
hospital care. Visits to a health centre (a family planning clinic or a general practitioner)
before and after the procedure are generally free of charge or the expenses are very
low. The costs are much higher if private services are used (about 40 or 50 dollars per
visit). The costs of hospital care used to be from 30 to 50 dollars, but the charges were
80
raised in 1999. Currently, the total costs of abortion care in a hospital are about 80 US
dollars (the first visit 20 dollars and the procedure 60 dollars in an outpatient clinic).
Women’s experiences of an induced abortion
An induced abortion is still somewhat taboo. It is an event that people would rather like
to hide and forget about as soon as it is over. Therefore, women who have experienced
an induced abortion seldom talk about their experiences, and this topic has not been
studied in Finland until recently.
Women’s experiences of an induced abortion were included as one of the topics of the
family planning questionnaire study of Stakes in 1994. A structured multi-choice question
was used to ask about the amount of discussions with a doctor and a nurse before and
after the abortion. An open-ended question was used to ask about topics that women
would have liked to include in these discussions. Altogether 34% of women who had
experienced an abortion would have liked more discussion with a doctor or a nurse
either before or after the procedure. Psychological effects of an abortion such as feelings
of guilt, sorrow and depression as well as justification of the decision were ranked
highest as topics of discussion. The second most requested topic to discuss centred
around abortion as a procedure. Women were concerned about health risks and possible
influences on post-abortion infertility (Sihvo et al. 1998). The same topics also emerged
in another study in which data were collected from women right after their abortion
using a narrative technique (Poikajärvi 1998). These studies indicate that many women
need more support and discussion in connection with abortion care. The discussions
should focus on a variety of topics including women’s groundless fear of infertility. This
specific issue should be automatically dealt with in counselling before a termination of
pregnancy to reduce unnecessary feelings of anxiety. Preparation of written material for
women seeking for an abortion is also necessary.
Future Challenges of Family Planning
The most crucial challenge of developing family planning services is to increase the
range of services. The aim of the work cannot only be contraception and effective
delivery of services, but comprehensive promotion of sexual health. When activities are
considered in this framework, services should include planning and timing of pregnancy,
prevention of sexually transmitted diseases, examination for infertility, and counselling
in sexual problems.
During the last decades, Finnish men have started to participate in the birth and care of
their children, but family planning has remained a female concern. However, men do
have a favourable attitude toward assuming part of the responsibility. In the family
planning survey in 1994, almost one hundred percent of 20 to 24 year-old men and
86% of 40-44 year-old men thought that the responsibility of contraception belongs
81
equally to men and women. In practice, participation in birth control was limited to use
of condoms; even sharing the expenses of contraception was rare (Sihvo and Koponen
1998). Increasing male participation and developing services tailored for men are
challenges of sexual health promotion. It would be easy to develop this new area of
services for boys often come to a waiting room of a family planning clinic with their girl
friends. It would be very natural to ask them to come in and join the discussion.
Money is an essential issue from an adolescents’ point of view. Although visits and
examinations are free of charge, the price of oral contraceptives is relatively high in
Finland compared to many other countries. Subsidising the price of pills for adolescent
clients in some way is extremely important. In the current situation, the Medicines Act
has prevented attempts at delivering oral contraceptives free of charge (except initial
prescriptions) from health centres, but certainly, a solution for this problem could be
found by changing current legislation. Arranging sales of condoms at a lower price
would probably increase use of double contraception (both condoms and pill) at the
beginning of new relationships or in cases of multiple partners.
Emergency contraception was introduced to Finnish markets more than ten years ago
and sales of these products have continued to increase steadily. However, when compared
to the number of abortions, the use of emergency contraception is still far too low. All
men and women, regardless of age, should have knowledge of emergency contraception,
its time limits, as well as how to get it. Access to emergency contraception would be
easier if delivery of the method was included as one of the duties of public health
nurses.
Recent studies have shown that young clients would like to discuss subjects other than
contraceptive methods when visiting a family planning clinic. Sexuality problems,
relationships, and sexually transmitted diseases are topics of great interest for young
clients. One crucial reason for neglecting these topics is insufficient education and training
in handling sexual concerns (Nurmi 2000). However, clients’ expectations have increased.
They are now capable and brave enough to ask for help, even about sexual problems.
Skills of counselling in sexuality are needed in preventive and medical care. Developing
these skills, as well as communication skills, is a challenge for undergraduate and
postgraduate education in health care. Improving communication and client-centred
skills are also challenges for professionals who work with abortion patients. Since an
abortion can occur in only one visit to a hospital outpatient clinic, a danger exists that
there is even less time for discussion than before. The new practice puts new demands
on staff of primary health care units before and after an induced abortion. A substantial
proportion of abortion clients would like more discussion about the abortion. They
need both practical information on the procedures as well as emotional support. It is
important for women to be able to honestly and openly discuss their feelings.
82
In 1993, Stakes appointed a working group to make a proposal for the development of
family planning services. After a long silence, this was the first time that family planning
services became a focus of a more comprehensive evaluation. The Committee gave
some recommendations of developing services on a general level, and many of the
recommendations have been, or will be, put into practice. (Stakes 1994, Rimpelä et al.
1996). Developing services has raised questions, which the working group Family Planning
2000 had not considered. One of these concerns the relationship of sexual health services
to the population responsibility principle in primary health care. Expectations of the
population and general trends of developing primary health care seem to be contradictory
here. Declining fertility during the 1990s also raises a question about the goals of Finnish population policy and its relation to developing services for family planning and
sexual health.
References
Aro, S., Liukko, M. (eds.). 1993. VPK –Väestövastuisen perusterveydenhuollon kokeilut 1989–1992. Mikä muuttui? (Experiments of population responsibility in primary
health care, 1989–1992. Did anything change?) Stakes. Raportteja 105/1993. Jyväskylä.
Bozon, M., Kontula, O.1998. Sexual initiation and gender in Europe: a cross-cultural
analysis of trends in the twentieth century. In M. Hubert, N. Bajos and T. Sandfort
(Eds.), Sexual Behaviour and HIV/AIDS in Europe. Comparisons of National
Surveys. Padstow. UCL Press.
Erkkola, R., Kontula, O. 1993. Syntyvyyden säännöstely. In Osmo Kontula and Elina
Haavio-Mannila (Eds.), Suomalainen seksi. Tietoa suomalaisten sukupuolielämän
muutoksesta (Birth control. Finnish Sex: Information on the Change in Sexual Life in
Finland). Juva: WSOY.
Gissler, M. (ed.). 1999. Induced Abortions in the Nordic Countries. Stakes. Statistical
Report 10/1999. Helsinki.
Koponen, P., Sihvo, S., Hemminki, E., Kosunen, E., Kokko, S. 1998. Raskauden
ehkäisyneuvonta ja väestövastuu - palvelujen järjestäminen terveyskeskuksissa ja
naisten toiveet (Family planning services in Finnish health centres – organization and
women’s opinions of services. Abstract in English). Sosiaalilääketieteellinen Aikakauslehti 1998; 35: 220-228.
Kosunen, E., Rimpelä, M. 1997. Perhesuunnittelun palvelujärjestelmä (Family planning
and health care organization). Duodecim 1997;113:1198-1202.
Kosunen, E., Sihvo, S., Hemminki, E. 1997. Knowledge and use of hormonal emergency
contraception in Finland. Contraception 55:153-157 (a).
Kosunen, E., Rimpelä, A., Kaprio, J., Berg, M-A. 1997. Oral contraceptives and smoking:
time trends for a risk behavior in Finland. European Journal of Public Health
7:29-33 (b).
Kosunen, E., Poikajärvi, K. 1998. Jälkiehkäisyn jakelu Keski-Suomessa (Delivery of
emergency contraception in Central Finland). Terveydenhoitaja 5/1998, pp. 10-12.
Kosunen, E., Rimpelä, M., Vikat, A., Rimpelä, A., Helakorpi, S. 1999. Ehkäisytablettien
käyttö Suomessa 1990-luvulla (Use of oral contraceptives in Finland in the 1990s).
Suomen Lääkärilehti 54:163-167.
83
Makkonen, K. and Hemminki, E. 1991. Different contraceptive practices: use of
contraceptives in Finland and other Nordic countries in the 1970s and 1980s. Scand
J Soc Med 19:32-38.
Nurmi, T. 2000. Seksuaaliterveys ja terveydenhoitaja. Seksuaaliterveyden edistäminen
ja terveydenhoitajiksi valmistuvien seksuaaliterveyden asiantuntijuus 1970-, 1980ja 1990-luvuilla ( Sexual health and public health nurse. Promotion of sexual health
and public health nurse graduatesí expertise in sexual health in 1970s, 1980s and
1990s. Abstract in English). Ministry of Social Affairs and Health. Publications 2000:13.
Helsinki: Edita.
Poikajärvi, K. 1998. Raskaudenkeskeytysprosessi asiakkaiden arvioimana (Clients’
evaluation of abortion care process). Lisensiaattityö. Kuopion yliopisto. Yhteiskuntatieteellinen tiedekunta. Kuopio.
Rasimus, A. 1993. Statistics on abortions. In H. Hämäläinen, A. Rasimus and M. Rimpelä
(Eds.), Induced abortions in Finland until 1991. Official Statistics of Finland. Health
1993:3. National Research and Development Centre for Welfare and Health, Helsinki.
Rimpelä, M., Rimpelä, A., Kosunen, E. 1996. From control policy to comprehensive
family planning: success stories from Finland. International Journal of Health
Promotion and Education 3:28-32.
Sihvo, S. and Koponen, P. (Eds.). 1998. Perhesuunnittelusta lisääntymisterveyteen.
Palvelujen käyttö ja kehittämistarpeet. (From family planning towards promotion of
reproductive health). Stakes. Raportteja 220.
Sihvo, S., Hemminki, E., Kosunen, E., Koponen, P. 1998. Quality of care in abortion
services in Finland. Acta obstetricia et gynaecologica Scandinavica 77:210-217.
Sihvo, S., Hemminki, E., Koponen, P., Kosunen, E., Malin-Silverio, M., Perälä, M-L.,
Räikkönen, O. 1995. Raskaudenehkäisy ja terveyspalveluiden käyttö. Tuloksia
väestöpohjaisesta tutkimuksesta 1994. (Contraception and use of health care services.
Results of a population based survey in 1994). Stakes. Aiheita 27/1995.
Stakes. 1994. The development of family planning services up to the year 2000. Report
of the working group. Stakes Themes 6/1994. National Research and Development
Centre for Welfare and Health, Helsinki.
Toivonen, J. 1997. Estemenetelmien mahdollisuudet (Possibilities of barrier methods
of contraception). Duodecim 113:1182-86.
Ulander, V-M., Gissler, M., Rasimus, A., Hemminki, E. 1995. Aborttirekisterin
luotettavuustutkimus (Reliability study of the register on induced abortions). In H.
Hämäläinen, A. Rasimus and M. Ritamo (Eds.), Aborttitilasto–Abortions 1993. Tilastotiedote 1995:14. Helsinki: Stakes.
Vikat, A., Kosunen, E., Rimpelä, M. 1999. Raskaudenkeskeytykset Suomessa–Induced
abortions in Finland 1987 - 1998. Tilastotiedote 39/1999. Helsinki: Stakes.
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Jukka Virtanen
6. Sexual Medicine in Finland
For a long time those in the medical profession have understood that sexuality is part of
health, but its significance at the clinical level is a new phenomenon. The traditional
approach has only considered problems related to reproduction, organic diseases of the
genitals, and sexually transmitted diseases. Sexual problems were viewed as psychiatric
abnormalities. Thus, traditionally the medical profession has been interested in sexuality
only when perceived as connected with organic disorders or mental problems. Treatment
of sexual problems has been divided among medical specialists in a variety of areas
including endocrinology, neurology, gynaecology, urology, psychiatry, and forensic
medicine. The interest in clinical sexology has been increasing in gynaecology because
of reproduction and infertility questions. The fast development of drug treatment and
surgery for erectile dysfunction has contributed to greater interest in clinical sexology
among urologists as well. A comprehensive understanding of human sexuality and sexual
problems has not been included in basic medical education of Finnish general practitioners
or in postgraduate education for medical specialists. Clinical sexology has not been a separate
speciality or subspecialty but has been integrated in the whole medical practice in Finland.
Service Providers in Sexual Medicine
Clinical services of sexual medicine have been offered in both public and private
healthcare without any integrated or coordinated national planning. The idea of nation
wide service groups providing clinical services in sexual medical has been under discussion
during the last two or three years. In the current national public healthcare system,
general practitioners and specialists already diagnose and provide basic treatments for
the most common sexological diseases. The more complicated cases are treated in five
university central hospitals and their clinics. But these clinics usually do not have an
integrated system of services for clinical sexology. Patients seek help from a variety of
specialists and clinics. Jyväskylä Central Hospital is the first public healthcare unit in
Finland planning to offer a Clinic for Sexual Medicine.
Patients can also choose private medical services. Some patients do so because of the
belief that the quality of private healthcare is better than the quality of public service, or
they worry about their privacy at municipal health centres where they are well known.
Some private medical centres have gynaecologists and urologists who have special
training to provide clinical services for sexual healthcare. National organisations such as
the Family Federation of Finland and SEXPO (Finnish Foundation for Sex Education
85
and Therapy) have private clinics and therapy centres for sexual health. The lack of a
national register of sexual healthcare professionals creates problems for patients in finding
service providers and clinical practitioners.
Both public and private sexual healthcare service are available to patients. The choice
of public or private depends on many factors including education, economical resources,
and local public services. Economical factors are a major determinant in many cases.
The annual service fee for local municipal healthcare in Finland is about 20 to 40 dollars
per patient. This includes all basic medical services and laboratory and radiological
examinations. Private medical services cost about 40 to 80 dollars per visit, and the
basic laboratory examinations cost between 80 and 2000 dollars, depending on the test.
When long term psychotherapy or demanding surgery is needed, the difference in cost
between public and private sexual healthcare is significant, often thousands of dollars.
For example, surgery for cavernosal leakage in erectile dysfunction costs a few hundred
dollars in the public sector and a couple thousand dollars in the private sector.
The choice between municipal and private medical service also depends on the patient’s
knowledge of human sexuality and its problems. The more a patient knows about the
background and pathological mechanisms of his or her sexual problem, the more likely
he or she is to choose a specialist in the private sector. In this case the patient can
choose his or her physician or therapist, an option not possible in municipal or public
health service. Patients who recognise their sexual problems based on simple symptoms
like “I have no erection” or “I have no desire” tend to choose public or occupational
healthcare, but patients with complicated multilevel disorders more often use a private
service, especially when the problem includes serious psychological components or
relationship concerns. The choice of a private specialist from medical specialities (e.g.,
endocrinology, gynaecology, urology, or psychiatry) seems to depend on the patient’s
health behaviour, medical history, and his or her earlier contacts with medical practitioners.
Some national patient organisation and rehabilitation centres have well organised,
integrated sexual healthcare services. The service group typically consists of two to
four healthcare professionals co-operating with each other at the same unit. An effective
service group is, for example, a four-member team including nurse, physiotherapist, sex
counsellor and physician who work in co-operation or a three-member team of nurse,
physician, sex therapist. However, this kind of clinical practice is available only in a
few special units such as the Family Federation of Finland, some private hospitals, and
patient organisations.
86
Clinical Sexology and Sexual Medicine
Clinical sexology diagnoses and treats sexological health problems and diseases by using
methods from health sciences and psychology. Sexual medicine is a part of clinical
sexology and a speciality branch of the general medical profession.
The fast development of modern sexual medicine in Finland started in the 1980s. In
that decade, new pharmacotherapies (intracavernous injections) and penile implant surgery
for erectile dysfunction became available. These treatments increased the awareness of
the general public and the media to sexual health and sexual medicine. Reproductive
medicine and new diagnostic and therapeutic methods like insemination and in vitro
fertilisation were also introduced during this period. Consequently, problems of biomedical ethics in reproductive medicine appeared in public and official discussions.
The rapid progress of sexual medicine has produced an increasing number of sexological
articles in Finnish medical journals. Members of the Finnish medical organisation Duodecim wrote many of these articles as well as the Textbook of Sexuality (Hovatta et al.,
1995) for basic medical education. Medical schools only offer one to two credit units of
voluntary sexology courses for medical students, and sexology is not included in the
official medical degree programs. Education in clinical sexology has been offered only
at Helsinki Polytechnic and the Jyväskylä Polytechnic where students can take a short
10 credit unit program for sex counselling, a 40 credit unit continuing education program
for basic clinical sexology, and an 80 credit unit clinical sexology degree program.
The first guidebook of sexuality for the general public, written by a Finnish physician,
was published only recently (Palo et al. 1999). Professor Risto Pelkonen, an
internationally known and highly respected physician, is an endocrinologist who has
been a pioneer of sexual medicine in Finland; his efforts have greatly promoted this new
medical speciality. Sildenafil citrate or Viagra became available in Finland in 1998.
When Viagra was introduced, it attracted tremendous publicity in the media and opened
public discussion of sexual medicine and the possibilities of modern pharmacology.
Specialists in clinical sexology are trained to provide treatments for male and female
sexual dysfunctions, problems in variations of sexual desire, and reproductive problems.
Functional disorders involving a patient’s sexual identity, structure of personality, and
sexual desire require a different type of treatment than disorders associated with some
kind of anatomical, physiological or pharmacochemical factor that disturbs erection,
ejaculation, orgasm, or vaginal lubrication.
Exhibitionism, voyeurism, fetishism, sadomasochism and paedophilia are examples of
forms of sexual behaviour which were traditionally labelled as perversions or disorders
but are being redefined in the latest psychiatric handbooks as paraphilias or variations
of sexual desire.
87
Functional Disorders
Gynaecologists treat patients with fertility functional disorders. Public and private clinics
as well as some organisations offer infertility diagnostics and therapies. Gynaecologists
treat female infertility by using hormonal induction of ovulation, microsurgery,
insemination and in vitro fertilisation (IVF). Male infertility is treated by urologists or
gynaecologists with a male sexual problems subspecialty. Treatments include
endocrinological pharmacotherapy, induction of ejaculation, urological surgery,
insemination, and IVF. Usually a general practitioner or a couple’s family doctor is part
of the infertility team of specialists. Couples often experience infertility as a crisis, and
this contributes to problems in a couple’s relationship.
Vaginal lubrication disorders are treated by general practitioners in public healthcare,
but female orgasmic disorders such as painful intercourse (dyspareunia) and arousal
and desire disorders require gynaecologists and in some cases the attention of psychiatrists.
Psychiatry mainly offers consultations for diagnostics and supportive psychotherapies.
Patients can also go directly to a sex counsellor or sex therapist without first visiting a
physician, especially when the symptoms include problems with sexual identity or a
relationship. Sex counsellors and sex therapists have professional skills to work
independently with a patient or in co-operation with a physician.
Male Functional Disorders
Diagnosis and treatment of male erectile dysfunction (ED) have changed quite radically
during the 1990s. About 15 years ago most cases were treated by testosterone
supplementation, and the more complicated erectile dysfunctions were referred to
endocrinologists or psychiatrists. Andrology (the treatment of men’s sexual problems) is
not an independent speciality in Finland, but some endocrinologists and gynaecologists
have practised it as an unofficial subspecialty. Rapid developments in clinical sexology
in urology have changed treatment methods. Penile implants and vascular surgery for
erectile dysfunction became available in the 1980s. Urologists offer implant surgery and
some manufacturers require that only specially trained and licensed urologists are allowed
to implant their prostheses. But today most manufacturers are more lenient in this
regard.
Erectile dysfunctions are quite often caused by problems of blood circulation. There is
a high incidence of common cardiovascular diseases in the Finnish population. Surgery
of the blood vessels of the penis was supposed to increase arterial inflow and help many
patients, but the long-term results of the procedure have not been satisfactory. Arterial
surgery for erectile dysfunction is a demanding operation with many risks and currently
is no longer a treatment choice. Surgical closure of penile cavernosal leakage has a
88
better record of effective treatment, at least in many cases; it is also possible to close the
pathological outflow from cavernous bodies by using operative procedures in the veins.
Today, most cases of erectile dysfunction are treated by pharmacotherapy.
Intracavernous penile injections (e.g. papaverine, phentolamine, alprostadil) became
available for patients about a decade ago. They were the first new generation of
pharmacotherapy for ED and are still in use. The drug of choice for ED is oral sildenafil
citrate (Viagra) which has turned out to be a very effective treatment with a low incidence
of side effects. But sometimes giving a prescription for sildenafil citrate may be
inappropriate and even considered medical malpractice. A physician may consider
sexological patients too demanding and time consuming and therefore avoid or even
neglect to take a careful sexual history or perform a thorough examination. Prescription
of drugs is so easy and time saving that it will be difficult for some physicians to consider
other treatment options.
The most demanding and difficult male sexual problems are premature ejaculation,
delayed ejaculation, hypoactive sexual desire disorder, and orgasmic disorders. Sexual
medicine has not yet found effective treatments for them. In most cases, these disorders
have complex and multilevel etiologies. Therefore, their diagnosis is often difficult and
time consuming. Co-operation with a sex counsellor, sex therapist, or psychiatrist may
help a general practitioner in treating men with these problems. The incidence of male
desire disorders seems to have increased in the Finnish population, but this is only a
clinical observation without any survey-based evidence.
Problems in Variations of Sexual Desire
Problems in variations of sexual desires, previously called disorders of sexual preference
and sexual identity make up a minority of cases of clinical sexology in Finland, but they
still require attention. Undergraduate degree program curricula at Finnish medical schools
do not include education in variations of sexual desire. In postgraduate programs only
psychiatry and forensic medicine offer medical education in this very complex field of
sexology.
Variations of sexual desires or paraphilias were only considered perversions in certain
psychoanalytic revisions of Freud’s original writings. Recent psychoanalytic researchers
argue that Freud came close to what would be the accepted enlightened language today:
in ‘variations’ we have not perversions but simply versions (May 1995, 161). The new
version of the international psychiatric standard, Kaplan and Sadock’s Comprehensive
Textbook of Psychiatry reminds that throughout the late-nineteenth and twentieth century
the terms inversion, perversion and deviance were used by mental health professionals
89
to denote the paraphilias but that these term are now officially out of favour because
they no longer connote acceptable standards of objectivity and they have been generically
applied to any unconventional aspect of sexual identity – cross-dressing, homosexual
orientation, or sexual sadism (Levine 2000, 1634).
One of the main problems is to establish a diagnostic border between normal but
slightly atypical sexual behaviour and real psychopathological states. Most normal people
engage in behaviour that traditionally was defined as a disorder of sexual behaviour,
such as sucking, biting, and light bondage, for example. Erotic fantasies may include
even more extreme portrayals of such behaviours without any intention by the one
having such fantasies to actually engage in these unconventional acts. Sexual violence,
rape and pedophilia are topics of public debate but more as ethical and criminal problems
than as medical phenomena.
The first question when planning treatment strategies for problems in sexual variations
is to determine if the patient really requires therapy. What kind of therapy is needed is
the second question, and what will be its likely effects is the third. Municipal healthcare
centres do not have resources to offer this kind of service in Finland. Patients with
problems in sexual variations are referred to university clinics with psychiatrists and
clinical psychologists who have experience in clinical sexology. Private sexual healthcare
offers specialist level medical service and sex therapy in a few special units. Use of a
private or public health service is up to the individual and depends on factors discussed
earlier. Kuopio Central Prison in north east Finland has started a voluntary 6-month
therapy program for men convicted of rape or pedophilia.
Problems in variations of sexual desire can be treated in municipal mental health centres,
public local hospitals, and central hospitals. However, it is usually difficult to find a
private physician who is familiar with these sexual problems. In many variations such
as transgenderism, transvestism, and fetishism, a patient feels fine and does not see any
need for medical help. The demand for therapy usually comes from relatives, friends,
or the authorities. Sometimes it is difficult to determine if the primary problem is
sociological (caused by societal attitudes) or medical (so severe it needs professional
attention).
Special Questions
Sexual medicine also deals with issues involving sexuality during childhood and
adolescence and with sexual problems of specific patient groups, such as the disabled
and people from different cultures and religions. In the 1990s politicians have reduced
the funding for sex education in schools. Thus, sexual problems among young people
and the incidence of adolescent pregnancies have increased in Finland during recent years.
90
The significant increase of older people in the population has created a situation where
sexual healthcare professionals encounter more and more ageing patients every year.
This phenomenon has also been noticed in undergraduate and postgraduate medical
education. Globalisation has changed Finnish society, and healthcare professionals need
to understand the sexuality of different cultures and religions.
There are also special questions that involve a minority of individuals such as transsexuals,
those having problems with variations of sexual desire, those dealing or suffering from
HIV or AIDS, and sex workers. Only a few physicians have experience in diagnosing
and treating transsexualism. Treatment involving plastic surgery for transgendered
persons is offered only at Tampere University Hospital in Central Finland. Finnish
transsexuals were forced to find their medical help abroad for many years, but the
activity of the Finnish National Organisation for Sexual Equality (SETA) has improved
services for those with identity problems in Finland. SETA offers counselling for
transsexuals and other sexual minorities. HIV diagnostics is carried out nationally in
municipal basic healthcare, treatment services are concentrated in special infectious
disease units, and a national AIDS support centre network helps people with HIV. The
Pro Support Centre and few private projects offer preventive healthcare and medical
services for sex workers.
References
Duodecim (Seksologia (Sexology) 15/1988.
Hovatta, Outi, Ojanlatva, Ansa, Pelkonen, Risto, Salmimies, Pekka. 1995. Seksuaalisuus (Sexuality) Helsinki: Duodecim.
May, Robert. 1995. Re-reading Freud on homosexuality. In Domenici, Thomas &
Lesser, Ronnie C. (Eds.) Disorienting sexuality. Psychoanalytic reappraisals of sexual
identities. New York: Routledge.
Levine, Stephen. 2000. Paraphilias. In Sadock, Benjamin and Sadock, Virginia (Eds.)
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Baltimore: Lippincott
Williams & Wilkins.
Palo, Jorma and Palo, Leena-Maija. 1999. Rakkaudesta seksiin (For the love of
sexuality). Porvoo: WSOY.
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Pia Brandt, Raisa Cacciatore, Marketta Ritamies, Dan Apter
7. Väestöliitto and Sexual Health
The welfare of families and improvement of sexual health have been important aims of
Väestöliitto (The Family Federation of Finland) since its founding in 1941. The structure
of Finnish society and its attitudes and values have shaped how Väestöliitto’s activities
have developed.
After the Second World War there were major family and population problems in
Finland at both individual and national levels. A positive solution to the population
question was thought to be absolutely necessary for the nation. Population goals are still
part of Väestöliitto’s program, but they have been adjusted to the course of social
change in Finland, and currently attention is focused on improving families’ financial,
psychosocial, and sexual welfare.
Sexual health was considered an important part of family welfare. Central areas of
Väestöliitto’s activities – public health work, improving families’ financial status,
improving living conditions, and enhancing children’s welfare – also increase people’s
opportunities for expressing their sexuality independently, satisfactorily, and safely. In
the 1990s, a sexual health concept was adopted that had a broader scope than the one
in the first decades. Väestöliitto’s research, publication, and information activities have
promoted sexual health not only in direct and obvious ways but also from the new
broader perspective advanced by international organisations.
Väestöliitto’s first program addressed maternity protection. At a time when maternity
protection did not yet exist, it was radical for Väestöliitto to demand that a working
mother’s situation should be secure, and that she would not lose her job because of
marriage or pregnancy. Väestöliitto also demanded that a woman giving birth should
have a paid and sufficiently long maternity leave before and after the baby’s birth.
Väestöliitto worked to improve the midwife institution, and founded maternity counselling
centres in every municipality. In addition, Väestöliitto wanted women’s hospitals and
delivery hospitals with specialist doctors to be established in different parts of Finland
so people suffering from infertility could be treated.
Since the beginning, prevention of abortion was an important part of policy. The
consequences, health-related impediments, and even sterility produced by illegal abortions
were emphasised. An abortion law was passed, and Väestöliitto actively participated in
its preparation. When the law came into effect in 1950, Väestöliitto cooperated with the
National Board of Health to prepare a plan for preventing abortion. In 1951, abortion
prevention was entrusted to Väestöliitto. The social clinic of Helsinki became the leading
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clinic. Based on the Helsinki experience, Väestöliitto’s nine other clinics began to
specialise in this form of work.
When the Public Health Law came into effect in 1972, the work of Väestöliitto’s social
clinics was gradually transferred to be primarily the responsibility of local municipalities
and their health care centres. Väestöliitto’s task was mainly to provide pregnancy tests.
Väestöliitto still closely follows the development of the abortion situation, taking active
part in public discussion and producing instructional manuals and educational material
related to abortion. Väestöliitto has tried to reduce the number of abortions in many
ways: lobbying for improved sexual health services, delivering research information,
increasing knowledge of contraception, and testing new contraceptive methods.
Väestöliitto can be considered a pioneer in sex education in Finland. As early as the
1940s, there were public lectures about contraceptive techniques. Physicians from the
public health office lectured in several secondary and vocational schools, and courses
were organised for young physicians to familiarise them with the new diaphragms Väestöliitto had imported. Demands were made for more effective family education in
schools and for appropriate sex education for every age group. In 1947, a marriage
clinic was founded in Helsinki, and by the 1950s eight more towns had their own
clinics. Clinics gave contraceptive counselling to people who intended to get married or
were recently married.
Väestöliitto was the first to start mail order sales of condoms in Finland, and later
started the VL-Marketing company to take care of contraceptive devices’ sales. Due to
effective press campaigns as well as outside advertising, everyone became aware of
condoms. Väestöliitto proposed to the National Medical Council that condoms should
be manufactured using quality control procedures. In association with the mail order
sale of condoms, Väestöliitto prepared and delivered educational materials about family
planning. Even after oral contraceptives and IUDs became common in family planning,
condoms continued to be important in young people’s contraception. Therefore,
campaigning and publicity have been directed especially to the young. In the 1980s,
condoms assumed new importance for preventing AIDS and other venereal diseases.
School campaigns conducted by Väestöliitto have emphasised both men’s and women’s
responsibility for contraception.
Settling marital conflicts and resolving questions about sexuality have been central parts
of marriage counselling at Väestöliitto clinics (called “family counselling” since the late
1970s). For example, clinic professionals try to assist married couples who have problems
in their sex lives, when they cannot have children, and when a couple wants to divorce.
Because marriage and family clinics deal with so many problems in an individual’s life,
clinics are sometimes the pioneer organisations to confront particular social problems.
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When the Public Health Law came into effect in 1972, the tasks of marriage clinics –
such as counselling about contraception and abortion – were transferred to the public
sector. The law did not apply to arbitration of marital crises, family therapy, genetic
counselling, infertility, or research work. In spite of financial problems, clinical work on
these issues continued.
Arbitration programs for marital crises were developed, and sex therapy and therapy
for individuals, families, and groups were started. International connections guaranteed
that the latest international information could be adapted to this work. A special genetic
counselling clinic was established in 1971. Since then, the genetics clinic has surveyed
and researched unusual diseases, educated doctors and the population, and provided
genetic counselling for clients.
The importance and lack of family education was noticed especially in the late 1970s.
Väestöliitto, which had traditionally provided these services in association with the
church and some municipalities, undertook efforts to develop and provide family
education and training for professionals. Teaching materials for instructors of family
education and education institutions were also produced. Over the years, hundreds of
thousands of family education material such as pamphlets and books have been distributed
throughout Finland. A course centre for family education was founded in the early
1980s and was called Väestöliitto’s training centre.
In the 1980s, Väestöliitto once again sought new material for its clinical work and
infertility treatment, and research became a new focus. Väestöliitto’s Infertility Clinic in
Helsinki was started in 1986 and is now the largest in Finland. The larger meaning of
fatherhood was emphasised in this work, because artificial insemination demanded that
the meaning of “fatherhood” be clearly understood. In the 1980s, an important part of
Väestöliitto’s activities was to encourage men to participate in family planning. Väestöliitto also operates infertility clinics in Turku and Oulu.
Research has always played an important role in Väestöliitto’s activities. Over the decades
since its founding in 1946, the Population Research Institute of Väestöliitto has conducted
population, family, and fertility research. In 1951, Armas Nieminen, who worked in the
institute, published his pioneering dissertation Fight about Sex Morals, which summarised
Finnish discussions of sexuality in the 19th and 20th centuries. In the early 1970s with
the support of the Academy of Finland, the Population Research Institute offered a
place to work for sexual scientists Kai Sievers, Osmo Koskelainen, and Kimmo Leppo,
who undertook a large-scale survey of Finnish sex life.
In the late 1990s, research on sexual health and sexology became an important part of
the Population Research Institute’s activities. In 1997, FINSEX-research, which studies
Finnish sexuality and sex culture, became part of the work of the institute. In some of
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this research comparisons are made among sexuality research in Finland, other European
countries, and developing countries, as well as and with sexuality research done by
international organisations. Young people’s sexual issues are a major research subject of
the institute.
International Activities
Väestöliitto has been represented in the official delegation of Finland at all UN population
conferences (Bucharest to Cairo). It was especially actively involved in the UN
International Conference on Population and Development (1994) and its follow-up
meeting (1999) and the Fourth World Conference on Women (1995) and its follow-up
meeting (2000). It has been an advocate for the implementation of the commitments
made in these conferences.
Väestöliitto is a member of the International Planned Parenthood Federation (IPPF),
the Confederation of Family Organisations in the European Community (COFACE),
and the International Union of Family Organisations (IUFO). In addition, researchers
of Väestöliitto are members of the International Union of the Scientific Study of Population
(IUSSP) and the European Association for Population Studies (EAPS). The Sexual
Health Clinic of Väestöliitto has close contacts with The International Federation of
Pediatric and Adolescent Gynecology (FIGIJ). Through these organisations and others,
Väestöliitto has extensive international contacts both in industrialised and developing
countries. Väestöliitto’s expertise has been used in the evaluation of family planning
projects in developing countries (Bangladesh, Mexico, Vietnam) and in starting the
marketing of condoms in Hungary. It has had close cooperation with the UN Population
Fund (UNFPA) since 1986.
Väestöliitto has recently expanded its activities in cooperating internationally for improving
sexual health. The main aim has been to include sexual health components as part of
ongoing projects.
Since 1985 Väestöliitto has been involved in overseas development projects in the field
of sexual and reproductive health. The first project was in Mexico working together
with Mexfam (Mexican Family Planning Foundation). The collaboration with Mexfam
has continued. In 1998 the Finnish Foreign Ministry funded a new project “HIV/AIDS
prevention with a gender perspective”. Its goals are to prevent HIV/AIDS in Mexico by
considering gender issues, providing information, and distributing condoms and
Information, Education and Communication (IEC) materials.
In 1998 in rural Malawi, a pilot project funded by the William and Flora Hewlett
Foundation was started. The goals of this project are to help primary health care
professionals strengthen their family planning services and increase their efforts to offer
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programs designed to prevent AIDS and other STDs. A cooperation agreement was
made between Väestöliitto and Finland’s Mannerheim League for Child Welfare (MLCW)
to integrate a sexual health component in their ongoing project in Malawi. The MLCW
had established a training health centre in 1993 in the Lungwena area. This Malawian
government operated health centre offers primary health care services including family
planning, maternal and child health care, delivery care, and STD-prevention and
treatment.
Väestöliitto participated in a Contraceptive Social Marketing Project in Vietnam in 1997
and 1998. The local co-operating partner for the project, funded by the Department of
International Development Co-operation of Finland, was DKT International/Vietnam,
which has specialised in the design and implementation of contraceptive social marketing
projects. Contraceptive social marketing uses commercial marketing techniques and the
resources of the local private sector to make contraceptives affordable and accessible to
target populations.
A South African-Finnish joint cooperation to improve maternal care through training of
nurses in KwaZulu-Natal Province started in 1999. It is also funded by Finland’s
Department of International Development Co-operation. The aim of the project is to
decrease maternal mortality by improving midwife training and adolescent sexual health.
It is a joint project of Finnish Midwife Teachers, the Finnish Midwife Association,
Väestöliitto and Polytechnics of Helsinki, Pirkanmaa and Jyväskylä. Väestöliitto’s
emphasis area in this project is the prevention and decrease of teenage pregnancies and
HIV infections.
In 2000, Väestöliitto became involved in another project, “Support to Namibian fight
against HIV/AIDS among children and adolescents”, also funded by the Department of
International Development Co-operation. Several Finnish NGOs support the Namibian
national AIDS program and the AIDS work of local officials and non-governmental
organisations. The main beneficiary group of the project are 4-15 year old children.
The goal is to reduce the spread of HIV by changing risky behaviour and improving life
skills to help people avoid risky behaviour in the future. Providing information about
HIV and sexual health to children and adolescents and decreasing child prostitution and
substance abuse should reduce behaviour that increases risks of getting a STD.
Väestöliitto in Finland
Väestöliitto works in several rather independent units: 3 clinics (Infertility, Medical
Genetics, and Sexual Health Clinic), the Population Research Institute, a Child Care
Unit, and Central Office. Väestöliitto has 110 full-time employees.
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The Sexual Health Clinic
In 1991, Väestöliitto Family Planning Clinic in Helsinki started its services, and in 1996
its name was changed to the Sexual Health Clinic. The change of name reflects the
broadened view of sexual health emphasised at the 1994 Cairo International Conference
on Population and Development. In 1998, the Family Clinic (which originated from the
Marriage Clinic) became part of the Sexual Health Clinic. A Family Clinic of Väestöliitto
also operates in Tampere.
Väestöliitto’s Sexual Health Clinic is the only broad sexology unit in Finland. Its programs
are in a continual state of development and involve the cooperation of a multidisciplinary
professional group. The Clinic’s personnel consist of health care providers with many
different specialities: psychologists, professional nurses, midwives, physicians, social
workers, and students of different professions. Highly educated personnel work in the
sexuality research and treatment unit. In the multidisciplinary group, consultation is
convenient. Therefore, the group’s knowledge and professional skills can be used
effectively. The aim is to improve sexual health in Finland in many different ways. The
human sexuality field is continuously changing, and is holistic, individual, and
multifaceted. Sexual health is related to people’s ability to experience their own sexuality
as an inseparable and natural part of their humanity. The expression of sexuality is a
unique, valuable, private, and continuously developing resource belonging to every
stage of life. Having a well-fulfilled and healthy sex life contributes to the development
of healthy self-esteem and gives security and pleasure.
Services, Functions and Characteristics of the
Sexual Health Clinic
1. Creating new ways to work
Creating new effective ways to work has been the basic principle of the Sexual Health
Clinic. Needs for sexual health services in society have been identified, and new methods
for dealing with them have been developed. With the support of the Slot Machine
Association (RAY), the Open House youth project was founded in 1988 in Helsinki.
Today the project is a major source of sexual health care for people under 18. The Full
Life-project concerned the sexuality of aging people; it operated from 1996 to 1998,
and later became a part of the clinic’s activities. In 1998, the Family Network project
was begun with three years of financial support from the Slot Machine Association.
This project works to improve the welfare of families with small children. People can
also contact the Family Network if they have questions about parenting or sexual health.
In daily clinical work, old methods are improved, and new ones created. New treatments
– for example, better contraceptive alternatives – are developed through research.
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2. Education and training
The clinic’s educational and training efforts focus on three groups: clients, professionals
in the health and education fields, and students. These are explained next.
Client education
Open House personnel provide sexuality education for schoolchildren and students.
Sex education is given in schools, but groups can also visit the clinic. Over the past
several years, it was hoped that education would be provided to younger age groups,
because children in preschool and lower grades are interested in some aspects of human
sexuality. When children receive information at a young age about sexual health and
about the human body and how it changes as they get older, they are much better
prepared as adolescents to make independent and responsible decisions about their own
sexuality. Information given at the right age helps form sexual identity, supports selfesteem, and reduces risky behaviour.
The purpose of articles and public lectures is to increase people’s knowledge of sexuality
and related topics of current interest. As a result of these lectures and articles, people’s
attitudes toward sexual health can change. The intent is to help people understand the
value and meaning of sexual health, discard myths and taboos, and adopt healthy and
responsible sexual attitudes.
Continuing training offered to health care and education
professionals
Health professionals are regularly invited to training sessions and seminars designed
especially for them. Midwives and nurses participate in their own training sessions, for
example. Phone consultations provide information to different professional groups. The
clinic also offers professionals an opportunity to practice new skills, such as the technique
of non-scalpel vasectomy. The Sexual Health Clinic’s personnel provide training in the
workplace when it is considered appropriate. The basic principle is sharing know-how
and skills.
Education offered to students
The Sexual Health Clinic also participates in the education of health care students by
offering training and teaching in the clinic. In addition, the Clinic has provided sexology
education during the past several years as part of university medical education.
3. Publishing
Publishing is an important part of the clinic’s activity. Over the years, Väestöliitto has
created broad-based sexology education materials that are well known nationally. The
aim is to keep the prices of the publications low, so that circulation to health care
centres, schools, clinics, hospitals, and private individuals can be as wide as possible.
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Publications are evaluated and updated regularly. Väestöliitto also has a website that
includes articles about sexual health, particularly for boys, including discussions about
the structure and function of the penis, masturbation, relationships, and contraception.
The Sexual Health Clinic’s personnel have written several health care publications.
4. Advocacy
As an independent special-interest group supporting the welfare of families, Väestöliitto
works is to influence the development of society, so that the family’s interests and
people’s sexual and reproduce health and sexual rights are always considered in political
decision-making. Sexual development involves a long and vulnerable chain of events in
an individual’s life. In society today, benefits provided to people are central for their
well being. The requirements for adequate parenthood can never be emphasised too
much. The needs of parents and their children must be taken into consideration by
makers of social policy, so that parents have the opportunity to work in the community
without endangering their families. The importance of an individual’s sexual rights and
integrity must also be emphasised.
Finland is one of the leading nations in the world regarding the general level of sexual
health of its citizens and the implementation of sexual rights. Väestöliitto works in close
cooperation with members of the Finnish Parliament, the media, NGOs, and public
sector organisations that implement health policy. During the past few years, Väestöliitto has increased the knowledge of members of parliament about sexual rights, sexual
issues in general, and possibilities for maintaining and improving a high Finnish standard
of sexual health for the population.
Väestöliitto’s international unit has been an important part of the Sexual Health Clinic,
and in 1999 it became a separate unit. International advocacy takes place at several
levels. First, it is important that sexual health care at the national level be of high quality
and be implemented as planned. Improved knowledge among members of parliament
and among citizens has brought more prestige and influence to international work.
Väestöliitto has been represented in official Finnish delegations to numerous international
meetings. In addition, professionals from Väestöliitto have independently participated
in several international forums. Striving to implement sexual rights globally is a huge
challenge. The Nordic countries including Finland are pioneers in this effort. Danish,
Finnish, Icelandic, Norwegian, and Swedish associations working in the field of sexual
health and rights together prepared “The Nordic Resolution on Adolescent Sexual Health
and Rights” for the follow-up meeting to the International Conference on Population
and Development in Cairo. The Nordic experience shows that with persistent and
committed action, many problems can be prevented or reduced in magnitude. It seems
likely that the Nordic approach to sexual health problems of adolescents can be applied
to programs and legislation for young people in other parts of the world.
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Advocacy work includes publishing articles, participating in public discussion, acting as
a professional, and giving interviews to the media. Professionals of Väestöliitto actively
participate in discussions of problems and political issues that affect sexual health.
5. Clinical work
In the Sexual Health Clinic, the client is examined and treated in a holistic fashion.
Important components of client care are support for individual sexual development and
functioning and reinforcement of sexual identity. The focus is always on individualised
counselling and not only about diseases or problems.
Gynecological clinical reception
Women of all ages come to the gynecology clinic. Gynecological examination and
counselling, questions about different life situations, and choosing contraception always
involve unique situations, in which medical and personal matters are considered. The
physician works as a counsellor and specialist, while the woman makes her own decisions
about treatment and contraception. Clients with contraception problems are often referred
to the clinic from their health care centres.
Perimenopausal women are a large client group. Hormonal replacement therapy and
facts and beliefs linked to it have recently created much public discussion. The clinic’s
personnel give professional information about different alternatives and their effects,
and try to make it easier for the client to make her own decision. Decision-making often
takes time, and written material can then be of great value.
Treatment of sexual problems in the clinic is steadily increasing because it is easier to
talk about problems to a reliable gynecologist and also because clients have not found
help elsewhere.
Nurse’s appointment
The clinic’s specially trained nurses do physical examinations, take pap smears, and
give guidance. Nurses also provide emergency contraception to clients. These different
services make it easier for clients to obtain the care they need. During the past decade
some health care services have decreased in Finland. The availability of contraception
has decreased and prices of contraception have increased. Therefore, it is important to
develop alternative approaches to guarantee that services are available.
Open House for adolescents
The Open House for adolescents under 18 was founded in 1988. It provides free-ofcharge counselling, sexuality-related services, and support for building an individual’s
identity. Adolescents can come to the clinic without an appointment or can telephone to
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make a future appointment. Appointment with physicians and psychologists need to be
made in advance, but a nurse is available for walk in appointments when a young
person needs help, support, or conversation with an adult. Subjects discussed in the
clinic include growing up, maturation, dating, sex, sexually transmitted infections, and
pregnancy.
Young women have used this service regularly for several years. They trust the clinic’s
personnel and share with them the joys and sorrows of growing into womanhood.
There is no minimum age. If a young person is old enough to need our help, she/he is
old enough to get it. If the client is very young, she/he is encouraged to discuss problems
with the parents too. The Open House is meant for girls and boys. However, the
majority of clients have been girls. In the spring of 1998 we opened a Service for Young
Men with male employees. The intention was to increase boys’ sexual knowledge and
help them know their bodies. Questions about relationships and problems connected
with sexuality are different for boys and girls. Väestöliitto’s websites include articles
about sexual health that are targeted especially for boys. In addition, conversation can
take place through email. Professionals from the Open House also participate in
community events for young people.
Treatment for people experiencing sexual violence
Women who have experienced sexual violence usually obtain acute treatment at a local
health care centre or in a hospital. These places usually have time and resources for
treating acute injuries, but nothing more. Long term effects of trauma and violence
might not receive attention. If a woman does not need acute care for injuries, she may
not seek health care help at all, nor even tell anyone about the incident. At the Sexual
Health Clinic, treatment of people who have experienced sexual violence is integrated
with the clinic’s other activities. Thus, a person can come without fear of being labelled.
The goal is to help women who do not get help anywhere else. The gynecological
examination can be therapeutic and can support the healing process. Often treatment in
the clinic is limited to discussing feelings and thoughts that the violence has caused:
hurt, guilt, impurity, and the view that sexuality is no longer a positive part of life.
Erectile dysfunction
The clinic examines and treats factors that influence men’s erection problems. New
treatments, developed in the past several years, have brought remarkable help and have
opened up the discussion of men’s sexual problems. Counselling that considers the
whole life situation and men’s relationships is an important part of the clinic’s work.
Men’s sterilisation
Non-scalpel vasectomy is done at the Sexual Health Clinic under local anesthesia.
Väestöliitto’s Sexual Health Clinic was the first to introduce this technique to Finland.
The new technique causes notably fewer complications and less pain. Sick leave is not
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needed, and recovery is very quick. If the man wishes, before the operation he can
save a semen sample in Väestöliitto’s sperm bank for later possible artificial insemination.
Psychologists
There are four psychologists and psychotherapists in the clinic. They have specialised
in family dynamics, relationships, and sexuality. The goal is to develop and test new
ways and approaches for improving people’s abilities to survive difficult situations,
independently or with professional help.
Family counselling tries to improve the welfare of those with problems in relationships
or in family crises. The types of counselling offered include psychotherapy for individuals,
couples, and families. Psychologists also offer counselling, education, consultation, and
advanced training.
Sexual counselling
Sexual counselling is an essential service of the Sexual Health Clinic. The clinic’s phone
service is free of charge and operates four days a week. Counselling is also given by email. Often it is easier for the client to make first contact by telephone. Much of the
time, phone discussions provide sufficient treatment, because permission and information
can often solve a sexual problem. Calls come from all over Finland.
Sexual therapy
Sexual therapy helps clients with functional sexual disorders. At the moment, there are
three clinical employees educated in sexual therapy. In the course of therapy, it is
important that different types of professionals work in the same place so that their
consultations are facilitated. It is easier for the client to have sexual therapy in the unit
of the physician who suggests it, rather than changing the place of treatment.
Research
Scientific research has always been an important part of the work at the Sexual Health
Clinic. The first research about contraception was done at the beginning of 1980. Results
of Finnish development work that have reached the market include Nova-T-IUD,
Norplant-implants, and the Levonova/Mirena-hormone releasing IUD. Väestöliitto has
served as a research centre in clinical studies of these new contraceptives.
Research work has been done in cooperation with the medical industry, the Population
Council, and WHO. Intensive research into hormonal contraception for men and new
delivery systems are continuing. Research into women’s functional sexual disorders
and the development of adolescent sexuality are new and interesting research themes.
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Summary
Väestöliitto serves as a broad and continuously developing centre of expertise on sexuality,
with the important task of increasing the appreciation of sexuality. Väestöliitto’s goals
include accepting the diversity of sexuality, improving sexual health, and respecting
sexual rights at individual, national, and international levels. Väestöliitto’s work at the
individual level is also important in order to increase the credibility of its advocacy
work. The national work provides a justifiable basis for international tasks. Väestöliitto’s
Sexual Health Clinic illustrates models showing how sexual health care can be integrated
into primary care. There are no sexology research and development units in Finnish
universities. Thus, Väestöliitto attempts to participate in sexology research and
development along with its other duties.
References
Auvinen, Riitta. 1991. Äitiyssuojelusta perhekasvatukseen. (From maternal protection
to family education) In Taskinen Ritva (ed.). Perheen puolesta Väestöliitto 19411991(On behalf of the family: Väestöliitto 1941-1991). Väestöliitto, Otava, pp. 205242.
Avain Väestöliiton toimintaan (A key to Väestöliitto’s activities) 1999.
Väestöliiton vuosikertomukset (Annual Reports of the Family Federation of Finland)
1987-1997.
Väestöliiton toimintasuunnitelma (The Action Plan of action of the Family Federation
of Finland) 1999-2001.
Ohjelma - säännöt (Programme - statutes). Väestöliiton julkaisuja N:o 2. Väestöliitto,
the Family Federation of Finland 1941.
Väestöliitto RY:n säännöt (statutes of the Family Federation of Finland) 1969.
Rauttamo, Mari. 1980. Valistusjärjestöstä toimeenpanevaksi väestöpoliittiseksi elimeksi.
Väestöliiton syntyhistoriaa ja liiton toimintaa vuosina 1941-1960 (From a counselling
organisation to an active organ of population policy. The early history and work of
the Family Federation of Finland 1941 to 1960). Helsinki: Väestöliitto, the Family
Federation of Finland.
Report to the Rockefeller Foundation on Educational work on Population/Reproductive
Health Issues by Väestöliitto, Finland, 1998.
Täyttä Elämää - Ehkäisy (Full Life - Contraception). Helsinki: Väestöliitto, the Family
Federation of Finland 1996.
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Tuisku Ilmonen
8.The Sexpo Foundation Promotes
Sexual Health
The winds of peace and love
“A balanced sexual life is a central pre-condition for the welfare of both the individual
and the society. However, in Finland there is still a sex-negative atmosphere and the
general level of information in sexual matters is very poor.“ (From the charter of the
SEXPO Foundation, the Finnish Association for Sexual Policy, SEXPO, 1970).
The history of SEXPO is a significant part of the Finnish history of sexuality. SEXPO
has reflected societal changes and has influenced these changes. Those who were later
called “the generation of the sexual revolution“ of the 1960s challenged in many ways
the traditional values of the previous generations and started social activities aiming at
reform and renewal. The events of the world such as the French student revolts, the
occupation of Czechoslovakia, and the Vietnam War also had effects on Finnish society.
The occupation of the Old Student house by the students in Helsinki in November 1968
was one of the visible signs of the student movement. The young adults also demanded
the right to get more information about sexuality and to make decisions concerning their
own sexuality. Neither did they want their children to grow up as uninformed as they
had been themselves.
The spring of 1965 in Finland was called “the sex spring“. At that time students from
various fields started a wide public debate, which was part of a general European
phenomenon and not specifically Finnish. An important starting point for the debate
was the study on human sexuality carried out by Alfred Kinsey in the United States. A
collection of Finnish articles smashing old taboos was published as a book with the
name Sexless Finland – Matter-of-Fact Information about Sexual Questions (Tammi
1966).
The student movement created a number of single-issue movements for peace, equal
civil rights, and cultural change. One of them was the Association 9, which fought for
equality between genders and gave birth to SEXPO in 1969. With regard to sexual
issues the founders of SEXPO stated: “The existing national organisations – cannot act
efficiently because of their ideological burdens but only support the prevailing trends“.
One model for SEXPO was the Swedish RFSU (Swedish Association for Sex Education)
with which co-operation was immediately started.
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One of the goals of SEXPO was formulated in the following way: “…that people would
generally learn to relate to sexuality as a positive part of life, as a value in itself and
simultaneously as an important factor in human relationships“. The charter of SEXPO
emphasises sexuality as a resource in human relationships and its importance as part of
human health, welfare and the quality of life in all stages of the life cycle. To emphasise
this in 1989 SEXPO created the prize of the “Valentino of the year“ or the “Valentina of
the year“ to be given to individuals or organisations who have promoted a positive
attitude towards sexuality.
Practical sexual policy
The new organisation’s name included the phrase “sexual policy“ to reflect the general
belief in the 1960s in political action and improvement of legislation as the moving force
behind reforms. It also reflected the definition of sexuality as a larger societal question.
In SEXPO sexual politics has been seen as part of socio-political systems, as a large
entity which includes laws and other behavioural norms through which the society tries
to regulate the sexuality of its members. It also includes the services and support functions
of society that enhance the possibilities of people to fully enjoy their lives. Thus, sexual
politics covers all sectors of society from social and health policy to criminal, educational
and housing policy.
Sexuality is always a current issue requiring constant sexual discourse. The role of
SEXPO has, however, all the time been a general sexual political one. That means that
is has tackled challenging or new phenomena in Finnish society and tried to perform
tasks connected with these as part of the general social and welfare services, educational
institutions and even, for instance, prison administration. A number of organisations
and service centres, such as the Organisation for Sexual Equality (SETA), the Finnish
AIDS Council/HIV Foundation, the rape crisis centre, and the Pro Support Centre for
sex workers have originated around specific issues. These have not, however, narrowed
the mission of SEXPO. They have collected information and special knowledge and
advocated their own important sexual political goals in their own sectors.
In the beginning SEXPO’s emphasis was on the then current issues of reproductive
health. Problems connected with contraception, abortion and sexually transmitted diseases
were seen in a larger context; they had ramifications for mental health and the realisation
of sexual rights. In the 1960s fear of pregnancy was common; there was hardly any
counselling on contraception and in order to get an abortion it was necessary to obtain a
psychiatric statement of “some sort of psychiatric disorder“. As a result the future
plans of many people were destroyed by compulsory marriages, and the number of
illegal abortions was high. A sort of guild of abortionists without medical education was
created. In addition to health risks, this led to legal action against those who had undergone
abortion, against those who had provided the addresses of abortion providers and against
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those who had performed the actual abortions. SEXPO was also worried about the
“multi-pregnancy women of rural areas“ whose exhaustion had been discussed as early
as during its foundation meeting.
One of the first practical projects of the new organisation was the founding of a sexual
counselling clinic in Helsinki for the demand for services was high. In the beginning
counselling was given by nurses because information was especially needed on
contraception, abortion, and sexually transmitted diseases. Counselling service by a
psychologist and a physician were started soon. Also legal advice was given to clients.
SEXPO argued that it is the duty of society to take care of sexual education and
counselling as part of preventive public health work. Pilot programmes for young people
were developed in the 1970s and various lectures were held in schools, youth clubs,
and student organisations. The National Board of Education founded a working group
at the initiative of SEXPO to plan the integration of sex education in the curricula of the
comprehensive school. The work of many years led to the definition of sex education
as an integrative subject. That means that information about sexuality must be
disseminated in various different subjects in suitable connections. A problem that remained
was the capability of the teachers to provide sex education.
Many of SEXPO’s original goals began to be realised in the 1970s. The term “sexual
politics“ was no longer widely used in public debates on themes concerning sexuality.
That was replaced by discussion about single themes, such as the position of gays and
lesbians in Finland and the threat posed by AIDS. A book published by SEXPO,
Awareness raising – information and views on sexual politics (Gaudeamus 1988)
defines as its goal to remove the fallacy that the only current sexual political problems
involve AIDS.
In the beginning of 1997 the Association for Sexual Policy (SEXPO) founded the
Sexpo Foundation (Finnish Foundation for Sex Education and Therapy) and transferred
all professional activities to it. All the work has been made possible by state funding
from the National Lottery Machine Association and by selling its own services. Additional
funding has been obtained from health education funds and the City of Helsinki.
Health and rights
A central background factor in defining the principles of sexual health and sexual rights
is a person’s conception of the basic nature of human beings. This conception guides all
activities, and it defines the way one treats oneself and others and the way situations
and solutions to problems are perceived. This perception is culturally defined and it also
strongly influences views about sexuality. If the human being is perceived as basically
evil, then feelings and sexuality are often perceived as dangerous and the purpose of
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education is to repress feelings and needs. This may lead to perceiving sexuality in a
very narrow way so that attitudes, values and norms are associated with sexuality in a
negative way. In turn this negativity affects the whole sexual culture and thus also
sexual politics.
A fundamental principle in the sexual political activities of SEXPO throughout the years
is the intention to promote sexual health and the fulfilment of sexual rights and thus
increase the opportunities to enjoy sexuality. The definition of sexual health and sexual
rights is in a constant state of flux, and it often takes a long time to put principles into
practice. In the following I shall combine aspects of the charter of sexual and reproductive
rights of the International Planned Parenthood Federation (IPPF 1995) and the declaration
of sexual rights given by the World Association for Sexology (WAS 1983 and WAS
1998-1999).
The right to enjoy sexuality and control one’s own sex life
•
•
•
•
•
The right to all sexual thoughts, fantasies and desires
The right to sexual enjoyment and pleasure, the right to sexually
stimulating material
The right to participate in all sexual activities which take place with mutual
consent and without violence, pressure or deceit
The right to refuse to participate in any sexual activities
The right to get neutral and understanding professional help and
support in problems related to sexuality
Many clients of sexual counselling only need a verbal or non-verbal assurance that their
activities, thoughts, feelings, desires and fantasies are permitted or common. Giving
permission means the normalisation of them. For many it is important to hear that they
are not alone with their worries; many others may have similar hopes or fears. The
counsellor, however, cannot give permission to just anything; laws are one source of
norms. It is equally important to consider what is socially acceptable behaviour. However,
to what permission can be given depends to a great degree on the knowledge and values
of the counsellor. An attempt to transfer one’s own values to the client is unprofessional
behaviour. The more information the counsellor has about the variations of sexual
behaviour in his or her own culture and other cultures, the more naturally he or she can
give permission to various forms of sexual behaviour.
Getting permission can help clients get rid of false beliefs and myths about gender roles,
distortion of models, and simplistic dichotomous right-wrong judgements. It can help
them find an individual way to function sexually and accept their sexuality in a way
suitable to their life situation. Sexual self-determination is part of finding oneself.
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Everybody has to identify what he or she likes, and it is not necessary to like everything.
Everybody also has the right to refrain from sexual activities.
The goal of SEXPO is to ensure that everybody has the right and possibility to get
support and help with concerns and problems related to sexuality. This requires that the
personnel working in the fields of social work and health care, youth work, and education
have sufficient information and preparation for sex education and counselling.
The right to equality and freedom from discrimination
•
•
•
•
The right to equality between the genders
The right to express one’s sexual preference, gender identity and
variations of sexual pleasure
The right to self-chosen sexual behaviour without prosecution,
condemnation or discrimination
The right to get help and assistance to realise sexual desires when
restricted by a disability or disease
In its first charter SEXPO stated: “Marital status, gender, age or other such property
must not be an impediment to the realisation of basic sexual rights. Education about
attitudes must emphasise the individual’s responsibility for his or her own deeds,
respecting the rights of others, and the sexual equality of all people“. Gender equality
means that laws, customs, and cultural models are not based on the superiority of either
gender or stereotypical perception of gender roles. Although problems still exist, one
may consider the Nordic model internationally quite progressive. The fact that equality
became an official principle in Finnish legislature required years of hard work, strongly
influenced by the human rights fight of gays and lesbians and the issues raised by the
women’s movement. At the same time the pioneers of health care and social policy
formulated new principles in the field of family policy, and women’s and men’s studies
produced new information and views, the effect of which on attitudes has been slow
but clearly evident. Also women’s magazines have introduced themes related to sexuality
and equality into public discussion. The greatest credit for the fact that the Finnish man
today participates in childbirth and child care, however, should be given to the men
themselves.
The first charter of SEXPO stated that “the societal position of sexually discriminated
groups of people must be improved by changing general attitudes into a more tolerant
direction“ and by decriminalising homosexuality, which took place in 1971. SEXPO
noted the position of transsexuals at the end of the 1980s and pointed out the difficulties
transsexuals have had to get proper treatment, causing this group to suffer from serious
social and mental health problems. Seminars were arranged dealing with this question, and
in the beginning of the 1990s groups for transsexuals and transvestites were also organised.
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SEXPO argues that everybody ought to have a possibility to get support in efforts to
clarify one’s gender and sexual identity and the right to live according to this identity.
However, people in the fields of social work and welfare and education still do not have
sufficient information about sexual and gender minorities and variations of sexual pleasure.
This lack of information contributes to discrimination against members of such minorities
who need to use these services.
The sexology course in the United Nations year of the disabled people in 1976 demanded
equal opportunities for the handicapped to use public services and the right to human
relationships and sexual life. The first guide book called Disability and sex life was
published jointly by the National Association of the Disabled in Finland, the Association
of Psychologists in Health Care and SEXPO. The training courses of SEXPO continually
address the needs of physically challenged individuals or people with a long-term illness.
Issues connected with physically challenged people, people with intellectual disabilities
or long-term illness are also the most frequently requested in tailored supplementary
training. However, sex education and counselling does not always reach those who
need it. Also family members of disabled people need support, counselling and help
with problems. Equality also requires the development of both supervision and training
of personnel.
The realisation of the sexual health and sexual rights of ageing people and especially
persons living in institutions, such as prisoners, also requires both empirical information
and training of personnel.
The right to self-determination in founding a relationship or family
and in ending a relationship
•
•
•
The right to choose a partner without outside pressure
The right to decide about legalisation of a partnership, founding a
family and having children
The right to a good divorce
Couples who intend to begin or terminate a relationship should have the right and
possibility to discuss problems related to the partnership. “Marriage schools“ could be
organised to prevent various problems connected with the partnership and sexuality.
Groups for the divorced could help in dealing with the process of divorce and healing
painful experiences. In the case of a separation professional help may be especially
needed to organise agreements on alimony and to ensure that the resolution is as
advantageous as possible for any children involved. Thus, attempts should be made to
protect children from conflicts.
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SEXPO argues that heterosexual and same-gender partnerships ought to be treated
equally under the law. Practices similar to those in heterosexual partnerships should be
created in order to formalise same-gender partnerships. The right to adoption in samegender partnerships also needs to be included for the realisation of equality.
The right to life and the right to family planning
•
•
•
No woman’s life ought to be put at risk or endangered because of
pregnancy
Nobody must be forced to pregnancy, sterilisation or abortion
Everybody has the right to independent choice of contraception
and family planning
The first charter of SEXPO stipulated the right of every child to be born as a desired
child. In the new law on abortion (1970) social reasons were added as grounds for
abortions, and one of SEXPO’s goals had thus been realised. SEXPO’s proposal to
distribute contraceptives free of charge has not been realised with the exception of
some given to the youngest age groups.
Forced sterilisation and castration had been used in the 1950s for reasons of racial
hygiene and as a “treatment“ for sexual criminals. In the proposal for a new law on
sterilisation SEXPO considered it a progressive step to increase the rights of the individual
to make decisions about his or her sterilisation. SEXPO also stated that unfortunately,
at least so far, sterilisation had been used almost solely for women. It was thought that
the low rate of sterilisation of men was caused by the misunderstanding that sterilisation
would adversely affect sexual capability.
SEXPO considers it important to provide more therapeutic counselling for women
before and after abortion. The experience of abortion may raise controversial feelings
that may return even years after an abortion. When members of the couple don’t agree
with the decision on abortion or sterilisation, there ought to be ways to clarify and
resolve the situation. In the case of people with intellectual disabilities, it is important
that they understand the implication and meaning of an abortion or sterilisation procedure.
The right to privacy, sexual health care and protection of health
•
•
•
All services connected with sexual and reproductive health
must be confidential.
All clients have access to information and services, alternatives,
dignity, comfort, continuity and the right to express their own opinions
All clients have the right to access the latest, safe and acceptable methods
developed by reproductive technologies.
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It has been possible to come anonymously to the counselling clinic of SEXPO from the
beginning and information about the clients has not been given to outsiders. This has
made it easier for many to come to the clinic. Clients appreciate the sensitivity of the
counsellors who talk with them about their problems related to sexuality. Many have
come from far away. SEXPO also considers it extremely important to create a system
that would facilitate the treatment of persons who are guilty of sexual crimes.
One of SEXPO’s goals is to guarantee the right to treatment childlessness for lesbian
couples and couples becoming a same-gender female couple through a gender
reassignment process. This is part of the realisation of equality and the prevention of
discrimination.
The right to freedom of thought
•
•
All human beings have the right to be free from the restrictive
interpretations of religious texts, philosophies, and customs as
tools to curtail the freedom of thought on sexual and reproductive
health care and other issues.
All human beings must have the right to seek to influence
governments to place a priority on matters of sexual and
reproductive health and rights.
The effect of beliefs connected with sexuality may be imperceptible, and it is difficult to
see the myths internalised by one’s own culture. Myths and beliefs control sexual
behaviour by informing what is permissible and what is forbidden, and they provide
models on how to behave as women or men. Myths simplify matters, situations and
human relationships and easily produce situations of right/wrong and either/or, which
are easier to handle than actual reality. Recognising one’s own beliefs is an important
starting point for the reassessment of attitudes and also for interacting with people
coming from other cultures.
In today’s Finland there are more immigrants and refugees than earlier. However, workers
in the fields of social work and welfare, education, and justice are often inadequately
prepared to sensitively consider the background of people coming from different cultures.
Finns need information and practical experience from countries where effective
multicultural methods have been developed for providing sex education and sexual
health services. Goals are to enhance interaction by acquiring information about beliefs,
habits, and norms connected with sexuality in different cultures and to develop skills in
dealing with these issues.
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The right to information and education
The lack of information and unchecked beliefs may have a devastating effect on the
sexuality of both the individual and the couple. The dissemination of information is an
important part of both sex education and sex counselling.
Sexuality information and education for children
The sexuality education for children is expected to take place in connection with sexual
socialisation. Goal-oriented sex education and systematic guidance for parents have not
been realised in Finland, and the contents and methods of sex education have not been
developed and tested. The Children’s Self Protection Programme is one of the few
methods tested in practice. The sex education of children has not really been researched;
for instance, the importance of the Finnish sauna culture in sexual socialisation and
education would be worth examining. In some cultures merely seeing one’s own parents
naked is classified as incest, which is important to bear in mind when interpreting, for
instance, American studies.
One problem with material that has been available for children in Finland is that it has
often been based on adult sexuality, especially reproduction. Although this theme also
interests children, the experience of and response to the sexual world are different for
children and adults. In addition, it is difficult to discuss matters associated with the great
mysteries of life only on the basis of factual information. Fairy tales are especially
important when a child integrates his or her sexuality and associated feelings. Already
small children are thinking about the basic questions of existence that do not have
scientific answers.
A goal of the project for sexual growth (1996-1999) was to produce material needed for
the sex education of children. The book Children and sexuality (Kirjayhtymä 1999) by
Gertrude Aigner and Erik Centerwall, translated from Swedish into Finnish, provides
information about the sexual behaviour of children and discusses problems of multicultural backgrounds in, for instance, day-care centres. The first publication of the
project Critical Views on the Evaluation of Sexual Abuse of Children (Edita 1997)
was seen as necessary and important. Findings from this project indicated that there are
unduly sensationalised aspects about the issue of child sexual abuse which may have a
harmful effect on the environment of children and, more generally, on the reasonably
healthy and open Finnish sexual culture. When adults fear showing affection for children
or the young or when children’s normal sex play or drawings of naked people are
labelled as evidence of sexual abuse, sex educators are also forced to think what can be
said about sexuality without the possibility of misinterpretations.
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Sexuality information and education for young people
The different capabilities of providing sex education of various teachers are still visible,
and there are great differences in the content and quality of school sex education. The
overall responsibility for development has not been assigned to the teacher of any
subject, and many teachers feel their knowledge and skills are inadequate. At the same
time the number of hours assigned to physical education and home economics have
decreased, and family education and health education have been changed from
compulsory subjects to optional subjects.
SEXPO collected views and experiences on sex education for the young for the book
About sex – how to talk to the young? (Otava 1991). SEXPO also participated in the
production of an information database labelled “Love and sex“ for the Finnish Centre
for Civic Education in the beginning of the 1990s. The fact that this package proved to
be the most popular of all packages published by the organisation indicates the great
need and demand for this type of information
According to SEXPO the goals of sex education for the young include improving the
quality of dating and sexual relationships, encouraging growth as a man or a woman,
and providing a wide range of information about many sexual concerns. Adolescents
need factual information about contraception and sexually transmitted diseases as well
as discussions about more personal issues involving relationships. There is a special
need to develop educational materials and teaching methods for children, young people,
and adults who are physically challenged or have intellectual disabilities. More attention
should be paid to the kinds of representations of sexuality that are constructed by sex
education instruction and materials.
The right to be free from all exploitation
•
•
•
All human beings have the right to protection against rape, sexual assault,
abuse and harassment.
Nobody should be forced into prostitution and existing legislation must be
developed to prevent the traffic in human beings.
Children especially have the right to be protected against sexual
exploitation and abuse.
Perceiving sexuality also as a means of power, both on a cultural and an individual
level, provided an opportunity for dealing with sexual abuse. In the field of sexuality
there are, however, still strong taboos which make it difficult to discuss these matters
from different points of view. There is often a panic reaction to sexual abuse when it is
first acknowledged and revealed. Sexual abuse, especially when the victim is assumed
to be a child, combines three taboo areas: sexuality, a child’s innocence and violence.
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This often causes strong emotional reactions and demands for a strict control policy. In
these cases there is a danger that the effects of various actions remain unanalysed, and
even good intentions may have bad consequences.
SEXPO has emphasised the importance of sexual self-determination. Already in
connection with the reform of the Criminal Code on Sexuality in 1971 it was suggested
that rape within marriage ought to be criminalised, but this reform occurred only recently,
in 1995. Also in the recommendations of SEXPO to the committee report of The
Council for Equality between Men and Women on violence against women in 1992 the
starting point was the right to self-determination. At the same time SEXPO criticised
the view in which, for instance, pornography and prostitution were seen only as questions
of women’s position and rights. The view conceals the many dimensions of these
phenomena. Therefore, the need for thorough and versatile research was emphasised.
Additionally, SEXPO suggested the founding of support centres for victims of sexual
abuse and offering therapy for people sentenced for sex crimes.
SEXPO considers the safety education of children an important part of sex education.
Although it can not prevent abuse, it would prepare the child to describe what has
happened and to ask for help.
Crimes connected with abuse ought to be investigated by the police in the same way as
other crimes are investigated, and legal authorities ought to use experts in forensic
psychology in order to examine the reliability of the narratives of different parties.
Experts in forensic psychiatry, however, are not generally used in child abuse cases in
Finland. Knowledge of the basic principles of the Western legal system should also be
included in the basic training of professionals in social and welfare and educational fields.
In the early 1990s, immigrants from Africa came to Finland and Finnish society had to
face a new phenomenon, the “circumcision“ of women, about which there was hardly
any information available. SEXPO suggested the criminalisation of this kind of mutilation,
and this was accomplished rather soon. In addition, the importance of education for
health care workers was emphasised. SEXPO translated a publication of the international
organisation against women’s mutilation and produced an educational video. Also today
information materials and meetings are needed for immigrants coming from societies
which still have the tradition of genital mutilation. The material and activities ought to
be jointly planned together with the immigrants themselves.
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Information and skills
“Of course it is absolutely necessary to change the school textbooks in such a way
that, for instance, in describing human anatomy it no longer is necessary to leave out
the genitals. Today the atmosphere in many teacher training institutes is so conservative
that the students can be satisfied if their own genitals are not removed“(Miettinen
1965).
SEXPO has been a pioneer in producing sexological literature. Members of SEXPO
participated in producing the book Sexology (Tammi 1974), which was the only basic
book in Finnish for a long time. The publication project produced several books in the
beginning of the 1990s in fields where they were needed. Of these books Sexual Pleasure
(Kirjayhtymä 1990) was honourably mentioned in the national competition of textbooks.
An important accomplishment was the bibliography of Finnish sexological literature,
published in 1991 in co-operation with the Kellokoski mental hospital comprising the
references in literature and articles in Finnish from 1549 to 1989.
SEXPO was for a long time the only organisation to provide training in sexology.
Sexuality courses of one week started in early 1970s. Also shorter thematic courses
started to be organised. The first training period of one year in sexual counselling and
therapy began in 1980. The British National Marriage Guidance Council offered their
training expertise to a Finnish group who had to pay only travel costs and daily allowances.
This training was organised and planned by the Family Federation of Finland, the
family counselling service of the Lutheran state church, and SEXPO. Two similar
training periods were organised with Finnish resources in the 1980s, and thereafter
these have been organised at intervals of a couple years. Various organisations have
been responsible for the training, but SEXPO has always been one of the organisers.
The basic contents of the one-year-long training programmes of SEXPO’s courses
have been quite similar, but the emphasis changes depending on whether they are sex
education and counselling courses, sex therapy training or sexual counselling training
focused on working with physically challenged people or people with intellectual
disabilities. The themes which the courses have dealt with have included the following:
myths, taboos and fantasies, sexuality in various age periods, the many forms of sexuality,
treatment possibilities of sexual problems, sex toys, and disability and sexuality. In
addition to practical training seminars students get acquainted with literature, work in
self-regulating job supervision groups, and write a final thesis. Participants in these
courses are mostly professionals in social and welfare fields, youth work and education.
Others taking the programme are students.
An important starting point for these courses is the sexual attitude reappraisal and
modification of attitudes of those in the training programme. This requires the
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normalisation of many phenomena, such as masturbation and sexual fantasies as well
as the problematisation of, for instance, gender, heterosexuality and various myths.
In addition to long training periods (4-10 credit weeks) short courses are organised,
such as Basic Sexology (5 days), Sexual Issues in Mother and Baby Clinics (4 days),
Sexually Transmitted Diseases (3 days) and Evaluating Sexual Abuse (3 days).
Supplementary education has also been provided for various organisations. Those who
provide services for people with intellectual disabilities have been active clients of SEXPO.
A pioneer among the educational institutes has been the Kätilöopisto Maternal Hospital,
whose students were offered a 20-hour long basic course in sexology. Further educational
programmes designed to meet the needs of clients are frequently organised.
From problems to solutions
The majority of the clients in sexual counselling throughout the years have been young
adults or adults: the age group of 20 to 40 comprises about 60% of the clients. In the
beginning of the clinic the majority of the clients were women, whereas today the
majority of callers are men. Women tend to more often prefer a personal visit in addition
to the phone conversation. The number of calls coming to the counselling service varies
depending on the length of the hours on duty of the phone service. The number of calls
has steadily increased as resources permit the time of the phone service to increase. In
1998 about 1000 phone calls were received during the counselling hours.
The problems of the callers have remained similar throughout the years. The largest
category of problems is simply the need for information. The next largest category of
problems concerns sexual dysfunctions, men’s problems related to erection or too rapid
or retarded ejaculation, and women’s problems related to orgasm, dyspareunia or
vaginismus. Common problems also include the lack of sexual desire and various
relationship crises. In some years a large number of problems are called in by gender
and sexual minorities or by people who ask about variations in sexual pleasure experiences.
In other years, problems of callers more often involve sexual abuse.
In the 1970s therapy was based on the psychoanalytic framework. Therapy was mainly
psychodynamic, focused psychotherapy or crisis therapy. The treatment model of the
American sexual therapists Masters and Johnson was used in the 1980s. In the 1990s
the main therapeutical methods have been solution-oriented brief therapy and Gestalt
therapy. Typical therapy clients are men suffering from rapid ejaculation and women
suffering from problems related to orgasm. Couple therapy is requested because of a
lack of desire by a person or his/her partner or because of conflicts in the couple
relationship. The number of clients who have undergone individual or couple therapy
has remained rather stable during the past years, around 300 clients per year.
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The goal of the treatment project of sex criminals and victims (1992-1995) was to
develop treatment methods for special groups for whom there were no suitable methods
available in Finland. The sexual counselling clinic of SEXPO was the first one in
Finland to organise groups intended for the victims of sexual abuse. This project also
organised individual and group therapy for persons sentenced for sex crimes in prisons
or after their release. Negotiations were started to organise treatment and also the
training of the personnel. The project contributed to the establishment of a treatment
unit intended for sex criminals founded by the prison authorities.
Important principles of SEXPO’s counselling work
The words we use. The language used in counselling influences the way the client
perceives his or her situation. The expression “foreplay“ leads to patterns of thought
where coitus is the goal and a certain path is followed to attain it. Terms like “impotence“
and “frigidity“ are very emotionally loaded terms. It would be better to talk about a
sensitive erection or ejaculation and everybody’s personal way to react to stimuli.
Giving permission. We try to move from symptom and problem-centred to neutral or
positive definitions which normalise the situation and give permission. Often questions
of insecurity arise as well as questions of whether certain fantasies and variations in
sexual pleasure are “right“ or “perverse“ or, for instance, am I gay because I get excited
when I think of people of my own gender. Simply getting permission for individual
sexuality and arousal is a relief for many clients.
The importance of relaxation. Trying hard blocks enjoyment and coitus-centred sexuality
leads to performing, not enjoyment. Stress may become evident in the holding of breath
or hyperventilation. It is important to learn various relaxation techniques so that one can
concentrate on enjoying one’s feelings and not turn love making into a performance.
The most important form of play of an adult. Sexual communication by enjoying all
sensations is the adult’s form of play. There are no standards dictating how much and
what kind of sexual communication should take place in a partnership. Often the partners
compare themselves with an imagined “mean value“ or believe that the sex lives of
others are much more active and satisfactory than their own.
I would desire to desire. When one partner lacks desire, he or she would often desire to
desire and feels guilty because he or she has to disappoint the partner. The other one
experiences the situation as stressful and thinks he or she is a poor lover or thinks that
the other one does not love him or her because there is a lack of desire. This problem is
often treated by prohibiting coitus and with touching exercises to treat this “sex allergy“.
It is surprising how often it helps that one does not have to think about love making as
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a responsibility. Quite often the couples report that they spent a wonderful night together
after the consultation.
Hooray for masturbation! Masturbation is important in learning to recognise the feelings
and enjoyment of one’s own body. It is not a substitute for coitus but something that
can be valued and seen as an important source of pleasure in itself. It is important to
make this clear, especially if a temporary ban on coitus is recommended to the couple.
A problem in the head or the body? It is important for women, who have lost their
interest in sexual interaction or who react to the surroundings so sensitively they cannot
reach an orgasm, to visit a physiotherapist trained in this area. The problems may be
due to diminished sensitivity caused by physiological reasons or dysfunctions of the
pelvic floor muscles that can be treated with various exercise methods.
The telephone counselling service and appointment reservation of SEXPO are available
by telephone for the price of a normal phone call for 3 to 4 hours during working days.
Consultation is also given via SEXPO’s home page. In addition, SEXPO gives consultation
and job advice for a consultation fee to individuals, couples, or groups of professionals
in various fields.
SEXPO’s office, counselling and training: Malminkatu 22 E, 00100 Helsinki, Finland.
Telephone: (+358-0) 6866 450, telefax: (+358-0) 6866 4544. Email: [email protected].
Home page: http://www.health.fi/sexpo. The home page also includes SEXPO’s library
listing.
References:
Annual Reports, Annual Plans and Charters from 1969 to 1999. Sexpo Foundation.
International Planned Parenthood Federation (IPPF). 1996. Charter on Sexual and
Reproductive Rights. London: IPPF.
Kontula, Osmo (Ed.) .1988. Tietoiseksi. Tietoa ja näkemyksiä seksuaalipolitiikasta (To
become aware. Knowledge and views on sexual policy). Helsinki: Gaudeamus.
Seksuaaliraportti (Sex Report). 1970. Helsinki: Association 9 and Sexpo
Taipale, Ilkka (Ed.) .1966. Sukupuoleton Suomi (Sexless and genderless Finland). Helsinki: Tammi.
World Association for Sexology (WAS). 1983. Fundamental Sexual Human Rights.
World Association for Sexology (WAS) .1998 and 1999. Declarations on Sexual Rights.
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Olli Stålström and Jussi Nissinen
9. Seta: Finnish Gay and Lesbian
Movement´s Fight for Sexual
and Human Rights
Background
Finland traditionally has shared enlightened and egalitarian views in matters concerning
sexuality with its Scandinavian sister democracies. However, due to its geographically,
culturally and linguistically isolated position, Finland has been a backwoods society in
the Nordic context, with harsh attitudes and laws toward homosexuality. Homosexuality
was punishable by imprisonment until 1971. For most of the 20th century, public attitudes
about homosexuality in Finland were influenced by psychoanalytic theories accepted in
psychiatry and psychotherapy. According to these theories (West 1968/1955, Bergler
1958, Bieber et al. 1962, Socarides 1978), gays and lesbians were sick, disturbed,
perverts, injustice collectors, unreliable and a threat to children. This traditional psychiatric
view contributed to mental health problems and suicides of homosexuals.
Homosexuality was decriminalised in 1971, but nevertheless, the state church demanded
a censorship law criminalising “public encouragement of homosexuality“. This law
which severely limited freedom of speech about homosexual issues remained in force
until 1999. Because of sanctions and invisibility it was difficult for homosexuals to find
a partner. Every fourth gay man growing up before decriminalisation had been beaten
up by youth gangs who hunted gay men in their meeting places. Society was not able to
protect the sexual or physical health of lesbians and gays and transgendered people.
After the mid-20th century, events in the United States and Europe began to impact the
situation of homosexuals in Finland. In the 1950’s fresh scientific literature from America
reached Finland, including the Kinsey male report and female report (1948, 1953), the
latter of which was immediately translated. The comparative studies of Evelyn Hooker
(1957) and the cross-cultural studies of Ford and Beach (1951) entered university
textbooks. The general relaxation of sexual morality was launched in the 1960’s by
contraceptives, antibiotics and baby-boomers entering universities and demanding social
change. A new radical youth culture protested against old structures and the double
standards of society. Radical students in the United States and all over Europe occupied
their universities in 1968. Various anti-authoritarian protest groups around the world
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sprang up (black civil rights movement, new feminist movements, anti-Vietnam war
protest groups) providing a model for Finnish movements, such as the radical feminist
Group 9, the movement to defend mental patients, homeless alcoholics and sexual
minorities (the November movement), as well as SEXPO, the general sexual policy and
education organisation. The first homophile organisation was founded in the heydays of
the 1960’s with a radical charter but it soon relapsed to an underground secret mode of
work. Time was not yet ripe.
New ideas were brought to Finland by women who had been in touch with French
feminism (de Beauvoir) and Swedish left-wing feminism and by men who had participated
in the radical events of Stonewall (New York), Copenhagen or Amsterdam in the late
1960’s. Another important event was the radicalisation of the homophile movements,
which finally lead to the deletion of the sickness label by the American Psychiatric
Association in 1974.
Organisation for Sexual Equality: SETA
Founding and charter
In 1974 a new gay and lesbian liberation organisation SETA (SETA is an abbreviation
for the Finnish words meaning sexual equality) was founded. From the beginning it was
an open societal pressure group and became involved in political lobbying, demonstrations,
and disseminating information.
The main philosophical principles of SETA are equality, inclusiveness, integration and
confrontation. Thus, SETA is open to anyone who supports the principle of equality
between the genders and between people of various sexual preferences. In practice this
has meant, for instance, gender parity. The number of chairpersons in SETA’s history
has been equal in terms of gender (6-6). Inclusiveness means that individuals with
various sexual orientations and gender identities are welcome. Transgendered people
have been part of SETA from the very beginning. Integration is the principle originating
from the experiences during the second world war of the Dutch gay and lesbian
movement. Gays, lesbians and transgendered people would be too isolated without
having as friends and supporters a large number of those, who value the equality of all
humans. Confrontation means that sexual minorities must proudly come out of the
closet and publicly demand their rights, through demonstrations, if necessary.
The question of inclusiveness has led to frequent discussions of the categories of “sexual
minorities“. Several members of the Finnish religious right have protested against the
idea of sexual equality by warning that homosexuals always exaggerate their numbers
and that if homosexuality is accepted, it may lead to other deviations like paedophilia,
even necrophilia. These fears are irrational and unfounded. A thorough literature review
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was done by the American Supreme Court before its Colorado Amendment 2 decision
in 1996 to grant complete legal equality to gays and lesbians. The Court concluded that
there is no connection between being gay or lesbian and paedophilia (see Stålström 1997).
The principle of integration led to the establishment of several contacts and allies such
as the Finnish Mental Health Association, the sexual political organisation SEXPO, and
leading scientists in the field of sociology, public health and social policy. Practical cooperation with the Department of Sociology started on a very intensive level in the first
few years. SETA also recruited both ordinary and famous parents of its members. All
political parties were contacted bringing several supporters. Several straight human
rights lawyers were recruited to SETA’s work. For example, human rights lawyer Tarja
Halonen, has given unrelenting support to the cause of sexual equality. When SETA
was founded in 1974 she participated in the first ever public panel discussion on sexual
equality, and in 1980-81 she served as chairwoman for SETA. As the Foreign Secretary
of Finland she has publicly criticised countries that still formally oppress sexual minorities.
Tarja Halonen was elected as the president of Finland in the spring of 2000.
SETA’s main demand was total legal and social equality for lesbians, gays and
transgendered people. It was understood that many of the social, mental and sexual
health problems of sexual minorities were mainly caused by societal oppression and the
necessity to hide. This shame and fear of discovery led to a double life and contributed
to the so-called stigma signs characteristic of other oppressed minority groups. SETA
articulated this oppression in its charter based on the United Nations Declaration of
Human Rights, according to which all human beings are equal and share the same
fundamental human rights.
Fight for the freedom of speech and anti-discrimination
reform
When homosexuality was decriminalised in 1971, a law setting a higher age of consent
for homosexual relations compared to heterosexual relations and a censorship law were
introduced in the Sexual Offences Code because of requirements of the religious right.
The bishops of the State Church of Finland warned in their formal statement that
homosexuality is a disease and a sin and can quickly spread by seduction unless a
censorship law is enacted against it. The Church and its psychiatric expert demanded a
paragraph criminalising “public encouragement of sexual relations between members of
the same sex”. Complaints were made against the Finnish Broadcasting Company from
the early 1970’s about allegedly violating this paragraph. Although nobody was ever
convicted of “encouraging homosexuality”, the public threats from the religious right
led to censorship on homosexuality in the electronic media in the 1970’s and 1980’s.
Many excellent programs were shelved.
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SETA took the censorship issue of Finland to the United Nations Human Rights
Committee in 1978, who discussed the matter for three years. The decision of the
Human Rights Committee was a landmark case, because it revealed a weakness in the
United Nations’ rules. If nobody has been punished in a court because of a censorship
law, there is nothing the UN Human Rights Committee can do. The UN mandate is to
protect individuals from violation of human rights but it cannot oppose a law such as
the censorship law of Finland as long as nobody has been convicted on the basis of the
law.. For several years SETA members tried to get themselves arrested by holding
street demonstrations in Helsinki and publicly encouraging love between members of
the same sex. The police always collected the placards as evidence but no one was ever
convicted. The state knew that the UN Human Rights Committee would be able to act
as soon as the first Finn had been convicted of ‘encouragement’.
SETA’s representative was invited to a large symposium on homosexuality at the Madrid World Psychiatric Association annual conference in 1996. There Finland’s case was
discussed and received further visibility. Several leading figures in psychiatry criticised
the undemocratic practices in Finland. The Director of Foreign Affairs of the American
Psychiatric Association sent letters to the Finnish Ministry of Justice and the Chairperson
of the Finnish Psychiatric Association.
The fight for freedom of speech and anti-discrimination reform took a quarter of a
century because of the opposition and lack of support from politicians. Very few politicians
wanted to be regarded as working for gays and lesbians. Reform measures were
incorporated in a major revision of the Sexual Offences Code. Because of the large
number of topics considered in this code, homosexuality issues received less attention.
The large General Revision of the Sexual Offences Code finally equalised the age limits
for sexual relations for homosexuals and heterosexuals and deleted the censorship
paragraph, when it became a law on January 1, 1999.
In its charter SETA also demanded that all anti-discrimination laws be extended to also
cover homosexuality in the same way that characteristics such as sex, age, race, language
and religion were grounds for non-discrimination. A large (N=1051) sociological lifestyle
study conducted at the University of Helsinki in 1982 (Sievers et al. 1984) revealed
widespread discrimination against gays and lesbians. Although it has been very common
to hide one’s sexual preference, 21% of men and 12% of women had been targets of
name-calling because of actual or suspected homosexuality. Three-fourths of respondents
had heard the word “homo“ used as a common slur. A minority of men and women also
reported discrimination against them in hiring for jobs, by employers and work colleagues,
and from officials and courts. It was also rather common for doormen to refuse entrance
to those they thought looked like they were homosexuals. Homosexuals were also
prevented from congregating in certain restaurants. The lack of safe meeting places
exposed gay men to harsh violence.
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SETA lobbied hard together with human rights lawyers, Ministers of Justice,
Parliamentarians and trade unions to bring all indirect and direct job discrimination to
an end. This was achieved in the over-all reform of all existing anti-discrimination laws
in 1995 by adding the words “sexual orientation” to the list of other protected qualities
such as age, gender, religion, language and ethnicity. These anti-discrimination laws (i)
prohibit libel, insult or agitation against a group of people, (ii) prohibit discrimination in
the exercising of a trade or profession, serving the general public, exercising official
authority or other public function, or arranging public events or meetings, and (iii)
prohibit discrimination against a job-seeker or an employee.
SETA’s main legal demand was fulfilled when the Finnish Constitution was amended in
1995 in such a way that the text accompanying the Government bill explicitly mentions
“sexual orientation” as an example of “other reason related to the person”. This puts
Finland among the first nations in history to grant constitutional equality to gays and
lesbians.
These legal changes, together with increased media visibility and support have removed
a large number of social problems. Discrimination in restaurants, which used to be a
problem, has practically ceased and is not tolerated by law. For example, a restaurant
doorman who violently removed two men for kissing each other in 1998, was ordered
to pay a fine because of discrimination.
SETA’s charter of 1976 demanded that same gender partnerships be granted equal
status with heterosexual partnerships in the law. Lesbians, gay men and bisexuals need
formal recognition of their partnership status and legal protection similar to that of
heterosexual couples. SETA has lobbied for legal recognition of their relationships for
this would improve their societal position and confirm the importance and significance
of these love relationships for gays and lesbians. SETA has also requested that partners
of gay and lesbian parents be recognised as legal parents. In the 1990’s SETA has
increasingly focused on various forms of partnership and parenting. An organisation
called “The Rainbow Families” was founded in the 1990s to support lesbian, gay,
bisexual and transgendered families. It also provides new information and discussion on
various family forms and the needs and rights of children of these couples. In addition it
acts as a support network for these new “alternative families” or “families of choice”.
The “family committee” of the Finnish Ministry of Justice acknowledged in its report of
1992 that same-gender couples ought to be included in the legal system of marriage.
The Centre for Family Affairs of the Lutheran State Church voiced a dissenting opinion.
The matter was presented to the Parliament in a Private Member’s Bill introduced by
Member of Parliament, Outi Ojala, MEP, in 1993. This created a lively discussion in
the Parliament and the media. The Legal Committee of the Parliament did not introduce
the draft Bill to the Parliament, because the general assumption at that time was that it
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would not be passed, especially if it included the right to adoption. At the same time a
public opinion poll was carried out indicating that 45% of the Finns were for the legal
recognition of same-gender couples and 35% were against it, with the rest undecided
(Hiltunen 1996). The Ministry of Justice set up a committee with SETA representation
in 1997 to prepare a legislative initiative for the formal recognition of gay and lesbian
relationships. The committee submitted its report in 1999. The committee’s legislative
initiative did not include the right to internal adoption. At the present the law reform is
being blocked by the resistance of the state church of Finland.
Artificial fertilisation has been possible in Finland for individual women or lesbian couples.
However, a parliamentary committee submitted its report on legislating artificial fertilisation
in 1998 in which lesbian couples and single women were excluded from fertilisation
treatments. This created a public debate and the final reading in the Parliament was
postponed.
Media in Finland
SETA’s charter holds the media responsible for information on and attitudes towards
sexual minorities. From its inception SETA has provided information and news to the
media, monitored it closely, and corrected misrepresentations.
During the 1950’s and early 1960’s homosexuality was under a blanket of silence. The
silence was only broken by the rare scandal or a crime involving a victim who was
homosexual. An important example occurred in the mid-1960’s when one of the
sensation-seeking tabloid newspapers infiltrated an ordinary gay man’s home in order
to make a provocative lead story of homosexual life in Helsinki. After the story’s release,
the man was immediately recognised and endured unnecessary suffering and harassment.
The police, for instance, refused to give him a driver’s licence. This piece of sensationalist
journalism raised a lot of protests in the general public and nearly one hundred journalists,
artists and culture personalities, including the next archbishop, signed a written protest
against gay hunting in the tabloid press.
In the 1960’s and 1970’s the laws on pornography were relaxed. This created a large
market for pornographic, sensation-seeking journals which started to use homosexuality
as a bait to get readers interested in “abnormality”. This made the media image of a
homosexual even worse, from total silence to exaggeration and sensationalism.
SETA demanded that the media stop publishing false, libellous or misleading statements
about sexual minorities and that the National Press Opinion Board criticise media
members who publish unethical texts about sexual minorities. SETA reminded the
state-controlled Finnish Broadcasting Company that, according to its own charter, it has
the responsibility to promote tolerance toward minorities, and thus it should also promote
tolerance toward sexual minorities. Board members of SETA made several visits to the
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lawyer and Director General of The Finnish Broadcasting company, after a program on
homosexuality had been censored.
During the first years SETA was frequently attacked by the conservative and the Christian press. The National Press Opinion Board handled three formal complaints by
SETA against this sector of the press. In the first case a conservative newspaper accused
gay liberation of harming children. A Christian newspaper compared homosexuals to
criminals and terrorists. Another Christian newspaper accused homosexuals of child
abuse. All these complaints were thoroughly examined by the Board, which found them
to violate the ethical norms of journalism in Finland. Each paper had to publish the
decision of the Board on its own pages.
SETA was gradually able to recruit a number of leading journalists to its ranks and
started to make an impact on the media. SETA also collected, translated and disseminated
scientific information to journalists and experts. Members of SETA have written dozens
of articles for the general and scientific press, entries for medical encyclopaedias as well
as other educational material and appeared in radio and television interviews. SETA cooperated in the beginning of the 1980’s with a sociological research group to carry out a
large lifestyle study, which made it possible to publish a textbook of homosexuality for
the general public (Sievers et al 1984).
One of the demands of SETA’s 1976 charter was that public and scientific libraries
should acquire new and relevant literature. Several university libraries co-operated and
the Helsinki University Social Sciences Library ordered almost 200 volumes on
homosexuality in the 1990’s. Members of lesbian and gay research groups have collected
a 78-page bibliography of gay and lesbian literature in Finland, available in the internet
(Stålström 2000), which is continually updated. General and scientific information about
homosexuality is now generally and widely available in libraries, bookstores and
organisations. The way the nonsensational media handles homosexuality has been almost
normalised in Finland. Gays and lesbians are generally portrayed as ordinary people.
Nevertheless, some fringe organisations, influenced by the American religious right,
occasionally cause problems with their unrelenting war against homosexuality.
School education
SETA’s charter notes that school education in Finland about sexuality has traditionally
been one-sided, even faulty. All school books in the 1970’s, if they mentioned anything
at all about same gender attraction, considered homosexuality a psychological deviation.
SETA demanded that human relations and sexuality must be integrated in all subjects
and considered from a societal perspective. Sex education must not only be the inculcation
of existing norms but the school must give information about different normative systems
and the possibility of changing norms. Homosexuality must not be taught as a deviant
form of behaviour but as a form of sexuality and love equal in value to heterosexuality.
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The principle of integration of sexual minorities into general education on human relations
and sexuality was accepted by the National Board of Education in the 1970’s. There
have been great difficulties, however, in updating the schoolbooks. In the beginning of
the 1990’s most high-school books still either totally omitted homosexuality or presented
it as some kind of psychological or medical problem (Heikkinen 1991). SETA has
constantly been in touch with writers of school books and in many cases they have
stopped the pathologisation of homosexuality. SETA has also sent members of its
information group to schools to give educational talks and to tell what it is like to live as
a lesbian or gay person. Finnish sexology has been developing, but old attitudes defining
same-sex love as an inferior substitute for heterosexual relationships or as deviant
behaviour still need to be critically examined. A recently published textbook written by
lesbian and gay scientists (Lehtonen, Nissinen, Socada 1997) is now available for
educational, health, and social work professionals.
Scientific research
SETA’s charter of 1976 notes that research on homosexuality has traditionally been
directed towards finding the cause of homosexuality and developing prevention
mechanisms or cure for homosexuality. It claims that all research at that time was
unreliable and methodologically flawed in making generalisations from a small number
of mental patients to the whole gay and lesbian population. In addition, research had
neglected to consider the effect of societal attitudes, laws and other norms on the
mental health of homosexuals.
SETA demanded that the state and organisations responsible for the funding of scientific
research concentrate on funding studies which look at the causes of prejudice and
discrimination against racial, religious and sexual minorities. Research must chart the
social problems caused by discrimination and plan ways of overcoming them. Several
research projects have been carried out by universities, some of them with the support
of SETA.
The largest lifestyle study was published in 1984 (Sievers et al. 1984) in which 1051
lesbians and gay men from all around Finland responded to questions taken from the
large Kinsey-institute study (Bell & Weinberg 1978). According to the results the majority
of men and women had realised their sexual orientation before the age of 15 and more
than a third said they had realised it as long as they could remember. The majority of
men hid their homosexuality from their workmates and family members, including
mother and father. Women were more open. The majority of lesbians lived in a couple
relationship and about one half of men replied they also have a steady couple relationship.
Twelve percent of men and 16% of women responded that they had very rare or no
sexual contacts.
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In 1997 the European Union and the Finnish Ministry of Social Affairs and Health
started to fund a research project looking at men who have sex with men. The findings
from this quantitative and qualitative study were published Huotari and Lehtonen
(1999). The results of the survey, carried out at the HIV Foundation with the practical
help of SETA, comprising 750 replies indicate that the sex life of Finnish gay and
bisexual men is relatively reserved and safer sex practices very common. The majority
of the responding men had a regular partner, although the modal pattern was having one
regular partner and casual sex on the side. The favourite sexual techniques cited by
most respondents were kissing and caressing, full body contact, mutual masturbation,
fellating and being fellated. About two thirds of respondents included anal sex as a
favourite sexual activity and the majority reported condom use with casual partners.
The non-use of condoms was mainly attributed to alcohol and its effect on lowering
judgement but also to the intensity of the situation and infatuation. Condom availability
is low in gay bars and sex saunas. There are technical problems with their use as well as
condom slippage and breakage. Respondents reported a high level of knowledge about
HIV/AIDS. Yet, risk of infection from a steady partner was not fully acknowledged.
Similar findings of high STD transmission rates from regular partners were also reported
in a recent Finnish study involving heterosexuals. Regular partners often have unprotected
sex even though one or both may have had unprotected sex with others. In addition to
adherence to condom use in casual sex, clearly a new ethic of openness about sex is
necessary in all sexual relationships, including those with a regular partner. Nearly two
thirds of the gay men in this sample reported never having had an STD (including HIV).
Psychiatry and mental health services
SETA’s charter of 1976 notes that homosexuality was still classified as a “disorder of
sexual behaviour” in the Finnish classification of diseases. The prevailing psychiatric
views of that time came from American psychoanalysts, mainly Irving Bieber. The
leading psychiatric textbook (Achté et al. 1976) classified homosexuality as a deviance
and disorder. Homosexuals were described as incapable of human relationships and
victims of pathological parenting, prone to various psychiatric illnesses. In his earlier
psychoanalytic texts Achté recommended electric shocks as “punishment” for
homosexuality. Based on rat observations he concluded that homosexuality is a
“substitute”.
SETA demanded that homosexuality be deleted from the national classification of diseases
and that psychiatric textbooks be updated to include information other than that obtained
from psychoanalytic patient samples (Bieber et al. 1962, Socarides 1978). SETA noted
that although sexual minority behaviour is not a disorder, discrimination and societal
pressure can lead to mental problems and suicidal thoughts unless proper help is available.
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SETA urged a total revision of texts about homosexuality in psychiatric and medical
textbooks and in the field of mental health education and suicide prevention.
The confrontation between SETA and the old-school psychiatrists led to a deadlock
lasting for a quarter of a century. The main protagonist of the sickness label, professor
Achté, publicly stated that the books he values most are the Bible and Kaplan-Sadock’s
Textbook of Psychiatry. That text follows the “adaptational” psychoanalytic views of
Sandor Rado (1940), who revised Freudian theory of homosexuality. Rado held that
Freud was mistaken in assuming a basic bisexual potential in all human beings. Rado
and his followers also tried to refute Freud’s claim that homosexuals can be quite
healthy mentally. A change of international significance is that the Gadpaille text on
homosexuality has been accurately updated by professor Terry Stein whereas most
earlier editions of the (Kaplan-)Sadock textbook spread the psychoanalytic sickness
classification for decades. The newest edition refrains from psychoanalytic stereotypes
and now defines homosexuality as a normal variation of sexuality (Stein 2000).
SETA strongly lobbied the National Board of Health, which finally declassified
homosexuality from the national classification of diseases in 1981. The old school
psychoanalysts never changed their attitudes and the sickness perspective of
homosexuality spread to medicine and curricula for high-schools. Fortunately, a new
generation of psychiatrists has recently published a new version (Lönnqvist et al. 1999)
of the psychiatric textbook (Psykiatria). This edition closely follows the new American
DSM-IV classification in which homosexuality has been totally deleted but where
transvestism still is classified as a disorder. The new Finnish psychiatric textbook
emphasises that homosexuality has been erroneously classified as a disorder for decades.
This textbook makes it clear that homosexuality is not a clinical entity and corrects
some of the most widespread psychoanalytic prejudices. Practically all university and
high-school textbooks published in Finland in the year 2000 consider homosexuality a
normal expression of sexuality. The demise of the pathologising perspective on
homosexuality is described in a doctoral thesis in sociology called “The end of the
sickness label of homosexuality” (Stålström 1997), which received widespread publicity.
The state church
According to SETA’s charter the Lutheran state church carries a heavy responsibility
for the continuous discrimination of homosexuality by having traditionally labelled it as
a sin, mental disorder and contagious vice. SETA demanded that the state church
refrain from discrimination on the basis of sexual orientation and consider new scientific
research.
There has been a lively discussion about homosexuality within the church and it has
practically stopped labelling homosexuality a contagious mental disorder. According to
the latest official statement of the bishops, dated 1984, acting on one’s homosexuality is
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still a sin. Since then two archbishops and several highly-placed theologians and ethicists
have actually been in the forefront defending the human rights of homosexuals and
people with AIDS. However, a person openly living as gay or lesbian will not be ordained
a priest in the Finnish state church.
International co-operation
SETA’s charter of 1976 states that homosexuals are being discriminated against in
societies with a variety of political systems. SETA sees its work in Finland as part of the
universal fight for equality and human rights, for ethnic, religious and sexual minorities.
SETA demands that the Finnish government together with other Nordic countries works
to ensure the equality of sexual minorities in the United Nations and other international
bodies. Two members of SETA serve as part of a human rights group in the Finnish
Ministry of Foreign Affairs. The group proposes recommendations for Finnish foreign
policy on issues related to human rights of lesbians and gays.
SETA has been active internationally lobbying the Nordic countries through the Nordic
Council for Homosexuals and the European Union through the International Lesbian
and Gay Association. SETA was among the founding members of the International
Council of AIDS Service Organisation founded in co-operation with the World Health
Organisation SETA has assisted its Baltic and Russian sister organisations even during
the time when organising for sexual equality was illegal in those countries. SETA has
received continuous support from the American Psychiatric Association, American
Psychological Association and the American Psychoanalytical Association. Members of
SETA have participated in various international conferences.
Social and Welfare Services of SETA
Counselling and social work
SETA’s counselling services focus on the prevention of mental health problems. Sexuality
and gender are such important dimensions of personality that the degree of self-acceptance
and adjustment in these issues influences general well-being and mental health. Lesbian,
gay, bisexual and transgendered people need a place where they are welcomed and
where they can express their feelings and get positive feedback. SETA provides this
environment and works particularly on self-esteem and self acceptance. SETA’s work
complements the formal counselling services. Professionals in official social work and
health care do not always know how to interact with sexual minorities in an accepting
and relaxed way. These professionals often lack expertise about problems of minority
identity formation processes, coming-out, openness and self-discrimination.
SETA’s counselling services include social work, telephone counselling and small group
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activities. SETA has 19 member organisations, of which 12 are regional groups and the
rest theme-oriented or professional groups, such as the alternative family group “Rainbow Families” and the Association of Lesbian and Gay Professionals within Social
Work and Health Care. The national organisation of SETA has employed one social
worker, one instructor and one secretary for education working in the Transgender Support
Centre. Three of the regional organisations have part-time social workers and instructors.
SETA’s counselling services are greatly dependent on volunteer work. There are 50
small groups all around Finland in the regional organisations serving the needs of
individuals of different ages. There are special groups for adolescents, women living in
same gender relationships, Christian gays, lesbians and bisexuals, people who mainly
identify as bisexual, gay and bisexual men who are or have been living in a heterosexual
marriage, the parents of gay and bisexual youth, and mature women planning retirement.
One group offers action-oriented and camping activities for families with children, and
another acts as a support group for people who have problems with substance use.
Some of the groups offer unstructured discussion and activities and some involve
discussions guided by a social work professional. These groups are especially valuable
for participants when they are forming their own identity or are in the coming-out
process. The Christian group is also important because the State Church does not yet
encourage sexual minorities to accept themselves as people who have the right to engage
in sexual relations with someone of their gender.
SETA currently also offers peer-group telephone counselling in eight Finnish cities.
Telephone counsellors are volunteers, who receive special training for this job as well
as updated training and supervision. This helps to ensure the quality and ethical level of
counselling work. Phone calls deal with questions about homosexuality, bisexuality,
transsexuality, transvestism, relationships, and problems of everyday life. Social work
professionals guide the voluntary and training work of the organisations. They work to
offer gay, lesbian, bisexual and transgendered people a peer group and means of
participation in their communities, and to assure that the counselling work is based on
up-to-date research and information.
Training and information
SETA and its member organisations arrange a rich variety of training and teaching
services for the general population. SETA provides between 200 and 300 training or
educational lectures every year. Lectures for high-school classes are often requested
and are one of SETA’s most popular forms of information provision. They are given by
lesbians, gay or transgendered people themselves and include lots of interaction and
dialogue with the audience. SETA’s peer educators discuss questions of sexuality and
gender, as well as everyday problems and gay/lesbian/transgender subcultures. The
goals are to provide information to students that promotes their ability to deal positively
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and responsibly with their own sexuality and gender and to help them relate to people in
various minorities. SETA also sends its peer educators to give talks and presentations
for school theme days, lecture series and seminars. Most of the peer educators are
volunteer workers who have received instructions in training techniques and counselling
from SETA. SETA co-operates closely with the Association of Lesbian and Gay
Professionals within Social Work and Health Care (STEAM), the Finnish Foundation
for Sex Education and Therapy (SEXPO) and various educational institutes in order to
provide training about sexuality, gender and minority problems for professionals and
students in the fields of social work and health care. An important part of SETA’s
clientele consists of social workers and counselling professionals who need advice and
supervision to help them in their jobs.
Finnish AIDS council (HIV Council)
SETA started its comprehensive preventive work in 1982, even before the first AIDS
diagnosis in Finland. The organisation was concerned that, in addition to the spread of
the disease itself, discrimination against gays would increase and attempts might be
made to register the names of infected people and to forcibly quarantine them. SETA
founded a health group in 1983 after the first Finnish AIDS diagnoses. The group was
responsible for the production and dissemination of preventative information, personal
counselling and providing referrals for those worried about a possible infection. The
health group also trained the personnel in SETA’s counselling services and co-operated
with the medical personnel and the authorities of the National Board of Health. In
practice, this meant psychological and medical counselling in SETA’s office, and SETA’s
members became involved in producing and distributing leaflets, arranging training
sessions and information campaigns in gay discos, giving information to the press and
liaising with the medical team investigating AIDS.
In the beginning the National Board of Health did not consider AIDS a serious
epidemiological problem. The public health care system was reluctant to provide
anonymous medical services. SETA demanded free and anonymous HIV antibody
testing with pre- and post-test counselling available in the whole country. This was
deemed extremely important because of the great social risks associated with the infection
becoming known to outsiders. SETA made several visits to the Minister of Health and
the Director of the National Board of Health to demand appropriate and confidential
testing and medical care.
The medical authorities took the situation seriously only after it became evident in 1984
that HIV could spread to the “general population”. In 1985 the National Board of
Health appointed an AIDS commission which took into account the demands of SETA
and which was in accordance with the WHO General Program on AIDS. The
commission took a thoughtful stand emphasising voluntary measures and information
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provision. Its objective was to facilitate testing and to ensure that accurate information
was provided to the general public. The commission rejected the demands by some
medical researchers for large-scale testing and declaring HIV infection as a “dangerous
communicable disease” instead of a “notifiable disease1 “. It was felt that compulsory
reporting of names would impede the general willingness to be tested and thus contribute
to the further spreading of HIV. In 1985 the National Board of Health began training
health care personnel together with SETA’s health group to promote their abilities to
deal with HIV/AIDS situations. SETA and the National Board of Health edited a booklet
for medical personnel about homo- and bisexuality (Nissinen 1985).
SETA took great care to maintain a positive attitude towards sex and reduce panic
reactions. Information campaigns were specially tailored for each target group and
considerations were made for the wide variation of human sexual behaviour. However,
others chose a scare tactic. There were large signs attached to trains and buses warning
that “AIDS IS A DEADLY SOUVENIR”. In literature distributed to high school students
and teachers homosexuality was falsely identified with risky practices. The booklets
simply warned against “promiscuous” and “homosexual” relations. At this time, in the
mid-1980’s, SETA’s simple brochure “Safer Sex” was the only source of information in
which different forms of sexuality and sexual practices were discussed explicitly and
honestly. This brochure also included practical and explicit advice on prevention. Tens
of thousands of copies of this booklet were distributed by SETA to medical centres for
distribution to their clients.
In 1986 the National Public Health Institute started co-operation with SETA to organise
anonymous antibody-testing. This led to the founding of the Finnish AIDS Council.
The steering group of the Finnish AIDS Council was enlarged to include not only
members of the National Public Health Institute but also members of the Finnish Association for Mental Health. The AIDS Council network was extended to include six cities
in Finland and was formally operated by SETA until the end of 1997 when it was
restructured as an independent foundation, the HIV Foundation, to which SETA still
elects board members.
Currently the activities of the Finnish HIV Foundation are directed toward the worried
well and infected people and their significant others, irrespective of their sexual orientation
1. The classification “dangerous communicable disease” involves diseases which are easily communicable
and may, under some circumstances justify involuntary detention of the infected person having diseases
such as diphtheria, cholera and syphilis. SETA fought very hard against this alternative, as some conservative
representatives of the medical profession initially suggested the internment of HIV positives to the deserted
Seili Island, which is an old leper colony (Halonen, 1985).However, at the moment HIV infection is only
classified as a “notifiable disease”. This means that all HIV infections must be reported to medical authorities
with or without personal identification. Diseases belonging to this category do not justify quarantine or
involuntary detention per se. However, strict legal action is taken if an infected person threatens or is
perceived to threaten other people with the infection. A legal precedent in Finland has classified “intentional
spread of HIV” as equivalent to “manslaughter”. (see Law on Communicable Diseases TTL 786/1986).
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or mode of transmission. The organisation offers telephone counselling, free and
anonymous antibody-testing, and referrals to support persons or support groups. It also
provides re-adjustment courses for infected persons and the services of a medical doctor,
psychologist and social worker. This foundation distributes information about HIV,
prevention and services. The foundation continues to support the guiding principles of
The Finnish AIDS Council, a positive attitude towards sexuality, prevention of
discrimination and defence of social safety and human rights. The HIV Foundation has
grown into a recognised national institution (see Halinen 2000).
The number of registered HIV infections in Finland remained the lowest in Western
Europe until 1999, partly due to the early information campaigns started by SETA
already in 1982 and the traditional lack of large-scale sex saunas, backrooms and
incoming sex tourism. The proportion of newly diagnosed infections obtained in
male-to-male sex has steadily decreased in the last five years and they represented one
third of all newly diagnosed sexually transmitted HIV infections in 2000. The proportion
of new infections transmitted by needle-sharing intravenous drug use increased sharply
during of 1999. (The Department of Epidemiology, National Public Health Institute,
epidemiologist Pekka Holmström , August 2000).
Transgender Support Centre
From the beginning SETA has co-operated with transsexuals, whose physical appearance
and biological sex does not correspond with their gender identity, and transvestites, men
who occasionally express their feminine side in various ways, for example, by
cross-dressing. Even within SETA these transgendered people have been a minority.
Therefore the transsexuals formed their own organisation (Trasek) in 1984 and the
organisation of transvestites (“Dreamware Club”) was registered in 1996. Both organisations
act as interest groups, arrange peer-group activities and work closely with SETA.
Transsexuals need sustained medical care and strong social support structures to enable
them to live according to their gender identity. Their risks of marginalisation, depression
and suicide would be considerable without care and support. Currently it is still difficult
to obtain systematic supportive treatment for transsexuals in Finland. In the 1980’s
some transsexuals went abroad for operative treatment. Others received hormonal
treatment in Finland without any other support. Many lost hope of a tolerable future
and attempted or completed suicide.
Transsexuals who are genetically male still need a formal castration permit before sex
correction surgery. Obtaining this permit is a long and arduous process and some requests
are denied. As part of this process, a transsexual has to take a difficult examination, that
many regard as invalid and unreliable. Transsexuals have problems finding social workers,
therapists, psychologists, psychiatrists and medical doctors with sufficient expertise in
transgender issues to provide them with services they need.
133
Since the 1980’s SETA and Trasek have tried to get social and welfare authorities to
improve the health care system so that competent professionals are available to
transsexuals. Finally, the National Research and Development Centre for Welfare and
Health (STAKES) established a committee, to consider this matter and as a result a
report was published in 1994 on the development of care and support services for
transsexuals. This enabled SETA to establish the Transgender Support Centre as part of
a three year project. This project, as well as many health-related projects in Finland has
been funded by the Finnish Slot Machine Association. This association channels money
from slot machine operations and lotteries to public health projects. The Finnish Ministry
of Social Affairs and Health controls and directs these funds and also funds from the
state budget to public health organisations (such as SETA, Trasek, the Finnish HIV
Foundation and SEXPO).
The Transgender Support Centre has provided support services for transsexuals and
transvestites and their significant others as well as consultant services for health care
professionals and administrators. It has collected research findings and material about
the needs of several client groups and produced information for health providers. Workers
for the Centre defined and described the terminology and important concepts connected
with issues that concern transgendered people. The Transgender Support Centre has
identified and analysed problem areas and organised seminars, which have functioned as a
forum for dialogue among transgendered people, health care authorities and professional
helpers. In 1998 The Finnish Ministry of Social Affairs and Health organised a working
group, with one transgendered individual, to clarify the societal position of transsexuals.
A social worker has been employed by the Transgender Support Centre to provide
personal counselling and psycho-social support for the clients, to co-ordinate information,
training and support work and to arrange training and consultations for professionals in
the health care field. In addition, the Centre has organised peer support in the forms of
telephone counselling, support persons, and small groups. So far all training has been
free of charge with the exception of some courses.
In self-help groups of the Centre, the participants have been able to get to know and
learn from others in a similar life situation in an emotionally safe environment and to get
support for learning about and feeling compatible with their gender identity. There have
been small groups for female-to-male transsexuals, transvestites, transsexuals under
treatment, post-operative transsexuals, the significant others of transsexuals and
transsexuals living in couple relationships. The Centre has prepared re-adjustment courses
for those who have undergone surgery. Nevertheless the Centre cannot compensate for the
great need for more transsexuals to receive proper care within the health care system.
The Transgender Support Centre has primarily served transsexuals and their significant
others but the services can also be used by transvestites and other people going through
a gender definition process. It is sometimes impossible to distinguish between transvestism
134
and transsexualism. Some people living the life of a transvestite may have a gender
identity close to that of a transsexual, but can manage without sex correction surgery.
The degree of difficulty in adjustment and self-acceptance varies greatly among
transgendered people. The Centre has provided care and support to many transgender
people, so that they can better live with and handle the contradiction between their
physical body and perceived gender identity without medical help.
Transvestites also need support to develop a positive identity and work through
self-discrimination. They often need encouragement and unconditional acceptance of
their transvestism to help them accept themselves and develop a life of openness and
acceptance. They frequently need help with problems involving their partner and
parental role, especially if their spouse is unaccepting of their transvestism.
The Finnish organisation for transvestites started a project in 1999 to gather and
disseminate information about the life situation of transvestites for professionals in the
field of social work and health care. The steering group of this project, that is funded by
the Finnish Department of Health, consists of members of the Transgender Support
Centre, the Finnish Association for Mental Health and the SEXPO Foundation. Such
co-operation among sexuality and health organisations in Finland has been an effective
commonly used strategy in working for shared goals.
The development of meeting institutions and subcultures
From the beginning SETA has tried to arrange safe meeting places for gays, lesbians,
bisexuals and transgendered people. The most popular of these have been dance evenings
and discos organised from the early 1970’s a couple times a month in the largest cities.
These social activities have had an important impact on liberation, development, identity
and friendship formation for participants. Such social events have also been a source of
funds for the social work and magazine of SETA and its associates. In 1984 SETA
opened the first gay/lesbian disco in Helsinki. Discos and other meeting institutions
operated by SETA are also based on the principle of integration, i.e., mixing gay, bi,
transgender and straight populations and encouraging people to get acquainted with
each other. The present disco operated by SETA foundation, called “Don’t Tell Mama”,
is among the most popular discos of any kind in Helsinki. Today there are also several
purely commercially operated bars and discos in the largest cities - Helsinki, Tampere
and Turku - for gay/lesbian/straight/bi/trans populations. Once a year SETA arranges
with its local membership organisations a “pride week” to join international organisations
in commemorating the Stonewall-uprising in 1969, the symbolic birth of the modern
gay liberation movements.
135
Lesbian and gay mental health professionals organise
Until recently lesbian and gay professionals in the fields of social work and welfare
have hidden their sexual orientation for fear of being stigmatised in professional contexts.
To remedy the situation, a group of lesbians and gay people formed a professional
network in the early 1990’s. The goal of the network is to offer mutual professional
support and training. This new organisation, founded in 1996 and called the Finnish
Association of Lesbian and Gay Professionals within Social Work and Health Care
(STEAM), has organised conferences and seminars on issues such as identity, openness,
same-gender relationships, and alternative forms of parenting. STEAM has also founded
a network of therapists, to whom SETA can refer clients needing supportive therapy.
STEAM closely monitors issues concerning gay and lesbian professionals in Europe
and the United States and co-operates with the European Association of Lesbian and
Gay Psychologists, the American Association of Gay and Lesbian Psychiatrists and the
American Psychiatric Association.
The gay, lesbian and transgender movements within SETA have worked hard and
productively to end formal inequalities. SETA celebrated its 25th anniversary on May
29, 1999. Most of the basic demands of the 1976 charter have been met and a new
charter has to be written for the new millennium, when Finland may be finally achieving
an international leadership position, not only in gender equality, but also in the protection
of equal rights and sexual health of sexual and gender minorities. As early as 1980 an
American social anthropologist in his study of the Finnish gay and lesbian movement
summarised the moral effect of the movement:
“When a self-help organisation takes on primarily a political role, it in effect becomes
the ombudsman for the minority in question... The gay self-help groups have
made positive and tangible contributions to gay people, as well as, I believe to the
societies in which they occur. Not only in terms of personal growth and change
(providing more social alternatives, community and identity) but also as a vehicle
of change. Ultimately such grass-roots activity is what participatory democracy is
all about - people in action on their own behalf” (Fitzgerald 1980, 199).
A whole post-Stonewall generation has matured from street activists and demonstrators
into experts in their own fields, where many of the activists continue their work for
sexual equality and health. They have realised in their own lives the famous motto of
Mahatma Gandhi: “You must be the change you want to see in the world”.
The authors thank SETA’s social worker Kaija Kurkela for her critical comments and
information about SETA’s counselling work, the Secretary General of SETA, Rainer
Hiltunen, for his lawyer’s point of view, Maarit Huuska, the social worker of the
Transgender Support Centre, Markopekka Vauramo, the counsellor of SETA’s
136
Transgender Support Centre, Gus Nasmith, chairperson of the American organisation
AIDS, Medicine and Miracles for his long experience in comparative comments on
the American and Finnish situations, professor Pauli Leinikki of the National Public
Health Institute for the latest information on the HIV situation in Finland, and Tauno
Matikainen and Tom Heikkinen for their support and constructive critique.
.
References
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Bergler, Edmund. 1958. Counterfeit sex. New York NY: Grune and Stratton.
Bieber, Irving et al. 1962. Homosexuality. A psychoanalytic study. New York NY: Basic
Books.
Fitzgerald, Thomas. 1980. Gay self-help groups in Sweden and Finland. International
Review of Sociology, 10, July-December, 15-24.
Halinen, Isto. 2000. Ruohonjuuritasolta dynaamiseen imagoon? AIDS-tukikekuksen
kehitysvaiheet kolmannen sektorin näkökulmasta. (From grass roots level to a dynamic
imago? The developmental stages of the Finnish AIDS Council). PD thesis, Tampere University.
Heikkinen, Teppo. 1991. Homoseksuaalisuus oppikirjoissa (Homosexuality in school
textbooks). Nuorisotutkimus, 9, 2, 27-32.
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Huotari, Kari and Lehtonen, Jukka. 1999. Miesten välinen seksi (Sex between men). In
Lehtonen, Jukka (Ed.) Homo Fennicus. Miesten homo- ja biseksuaalisuus muutoksessa (The homo- ja bisexuality of men in change). Helsinki: Sosiaali- ja terveysministeriö.
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being and society). Facsimile edition of volume 1-2, 1968. Helsinki: Kustannusvastuu.
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Lehtonen, Jukka, Nissinen, Jussi, Socada, Maria (Eds.). 1997. Hetero-olettamuksesta
moninaisuuteen (From the hetero-assumption to pluriformity). Helsinki: Edita.
Lönnqvist, Jouko, Heikkinen, Martti, Henriksson, Markus, Marttunen, Mauri, Partonen,
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Recommended new finnish sexological and sociological literature
on lesbians, gays, bisexuals and transgendered people
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Uusin silmin – lesbinen katse kulttuuriin (With new eyes –a lesbian gaze on culture).
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(Positive life. How HIV positives cope in everyday life). Helsinki: Helsinki University. [PhD Dissertation in Social Work]
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identiteettikehitys (From confusion to integration. Identity development of gay men).
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Sirpa Tukiainen and Pentti Soramäki
10. Sex Therapy in Finland
How Did It All Begin?
The training of sex therapists in Finland began in the autumn of 1980. Forty family
counsellors, theologians, physicians, psychologists, and social workers from all parts of
the country were invited to the training centre of the Evangelic-Lutheran congregations
of Tampere to study sexual therapy skills. Almost all participants were educators employed
in the field of family work. The organisers had managed to obtain as the main trainers
Alison and David Glegg from the British National Marriage Guidance Council. Their
training framework was based on a modification of the Masters and Johnson sex therapy
method. The organisations then supporting the training project were the Family Affairs
Office of the state church, the Family Federation of Finland (Väestöliitto) and SEXPO.
In later training periods, the organisers have also included the A-Clinic Foundation
(which provides and develops services for people who have problems with alcohol and
other addictions), Helsinki University Central Hospital, the Finnish Family Therapy
Association, and the former National Board of Health as well as various individual
therapists.
The first training of sex therapists in Finland some 20 years ago started with an intensive
period of one week in the fall, supplemented by a three-day course in January and a
one-week course later in the spring. Between these courses, trainees met in peer groups
to continue their studies.
Many participants in the Alison and David Glegg courses experienced quite a shock
when they could not evade matters but had to talk about sexual behaviour and parts of
the body directly using real names. It was still more anxiety provoking to encounter
one’s own sexuality. The learning process began with film and video material on various
aspects of sexuality, with group discussions. The films and videos, in addition to ordinary
couple situations, dealt with the sexuality of pregnant women, disabled people and
minorities as well as with masturbation. Alison and David Glegg considered it necessary
that the teachers be able to face their own sexuality if they were to treat sexual problems
of client couples and train other professionals. The Gleggs considered sexuality and its
associated feelings and activities a central component of a relationship, believing that
sexual feelings and activities ought to be handled in the same way as other aspects of
the relationship. Therefore the sex therapist must have sufficient training in couple
therapy and family therapy.
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Participants in these early training sessions remember them as quite serious and dramatic.
The same reactions surfaced again and again later when these new therapists began
client work and began teaching people in the field. A sex therapist does not succeed
without being totally familiar with his/her own sexuality. Although clients and students
may blush and be unable to utter a word, the sex therapist must guide the conversation
along unconstrained and reliable channels. The question always exists of how to create
a confidential relationship when the topic is sexuality or the most intimate concerns of
fellow human beings. Alison and David Glegg encouraged their students to acquaint
themselves as broadly as possible with the entire field of eroticism and sexuality, including
the commercial side of sexuality, porno stores and sex toys.
The training started in the early 1980s continued in 1984-1985 and 1987-1988. During
this period, sex educators, including many of the same people who were in the 19801981 initial session, used skills obtained in their early courses to apply their knowledge
for the first time in a sex therapy course organised totally with Finnish resources. Since
1980, considerably more than 100 sex therapists have been trained in Finland, and
almost 300 people working in basic health care have received training as sex counsellors.
The Jyväskylä Polytechnic has started to give specialised training in sexology for sex
counsellors in the fields of social work and health care. The personnel working in basic
health care are relatively well prepared for counselling work. Actual therapeutic training
has so far been organised in various projects.
The demand for trained sex therapists has been much larger than the supply. One
problem is that the couple relationship must be treated as an entity of which sexuality is
only one part. Comprehensive therapy often requires expertise in traditional problem
areas as well as in sexual problems. The traditional helpers for sexual problems —
physicians, psychologists, and theologians — have indicated a need for further education
in couple and family therapy, because these topics are treated very superficially in the
basic education period. If a physician or theologian seeks family therapy training, he or
she does not obtain sufficient knowledge and skills about sex therapy. The road to
becoming a sex therapist usually involves (1) being trained as a professional social
worker, psychologist, physician, theologian, and so on, (2) obtaining professional
experience, and (3) then followed by three weeks of family therapy training and one
week of training in sex therapy.
What Kind of Training?
The training in the pioneering phase during 1980-1981 consisted of three seminars (see
above). The first seminar started by bringing trainees face-to-face with sexuality by
compiling glossaries of sex words, viewing films and videos, and participating in small
group work. The various levels of sex counselling were illustrated using the PLISSIT
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model. The term PLISSIT comes from the initials of Permission, Limited Information,
Special Suggestions and Intensive Therapy.
Permission means that client or patient obtains permission from the therapist to have
sexual thoughts, fantasies, feelings, and needs. The client or patient is also assured that
having such thoughts is permissible and common. Client questions may deal with
masturbation, various forms of stimulation or sexual positions, sex toys, or sexually
arousing material. A problem may also be that the client considers herself or himself to
be deviant because of his or her activities or fantasies. It is also important to give the
client permission to have feelings of anxiety, fear, shame, or guilt that may be connected
with the activities or fantasies. Giving permission means the normalisation of the client’s
sexual thinking. This is sufficient for most clients. Asking for permission can be connected
with various stages of life. Many young people may directly or indirectly ask for
permission for their first sexual intercourse, and older people for continuing their sex
lives. Permission must be given in relation to the client’s readiness, not according to
what the counsellor considers desirable. In conflict situations, permission cannot be
given to one partner only.
Limited Information means giving information about matters that puzzle the client.
These issues can be connected with genital anatomy, physiological reactions, pregnancy,
childbirth, diseases, and medication related to sexually transmitted diseases and sexual
disturbances, among others. Lack of knowledge often seems to be associated with
anxiety and resulting sexual disturbance. Giving information may be greatly anxietyrelieving, especially for mild disturbances.
Problems related to sexuality very deeply concern the body. One’s perception of one’s
own body, or one’s masculinity or femininity may be problematic. One may feel one’s
own genitals are deviant, ugly, or dirty. It may be a relief for the client to see pictures of
different genitals; for example, self-examination of her own genitals may be the first
step a woman takes to accept her own sexuality. In men, the small size of the penis may
be a problem.
Myths and disturbing beliefs concerning sexuality may be inadvertently internalised,
and a clear source of these is not always obvious. They are promoted by the social
climate or atmosphere, or from negative or controversial attitudes of parents or others.
These influences are not always necessarily verbalised. A myth could be produced from
a double message like “Sex is dirty, so save it for marriage when it will be clean” or
“Sex is beautiful but don’t talk about it in the presence of the children.” Some sexual
beliefs are used for making sex less dangerous and for trying to find a balance when
one’s own helplessness, fears, and disappointments are too difficult to handle. The
purpose of these beliefs is to protect delicate areas in one’s mind, to help avoid anxietyproducing closeness, and to keep threatening situations at a distance.
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Special Suggestions (the SS in the PLISSIT model) refer to advice given to a client for
improving his or her sex life, for instance, changing one’s lifestyle, increasing interaction
with one’s partner, or carrying out exercises designed to reduce performance pressures.
To give relevant advice requires therapists to understand the client’s problems adequately
and have detailed information about the client’s sex life, life situation, and desires for
change. In exercises aimed at reducing performance pressures, attention is focused on
feelings instead of performance. One issue behind erection problems may be the fear of
failure. If one is afraid that the erection may not last, anxiety connected with the fear
may block the erection. Exercises can be given to the couple involving a prohibition on
intercourse and on touching the genitals and breasts. The clients do not move from
possibly arousing sexual feelings to sexual performing, but can instead enjoy their own
feelings without pressure.
Intensive Therapy refers to a phase where the client or couple has decided together
with the counsellor that counselling is not sufficient but that actual sex therapy is needed.
This includes various exercises, homework and its follow-up, and analysis aimed at
removing various disturbances.
In the training period from 1980 to 1981 training was based on cognitive therapy. The
actual sex therapy training concentrated only on treating functional disturbances with
the help of a solid theoretical basis, exercises, and supporting material (films, videos,
pictures, sex toys). The two subsequent training periods (1984-1985, 1987-1988) were
similar in structure to the first seminar. The goal was to acquaint trainees with short
therapy models with an emphasis on problem solving according to behavioural and
systemic approaches.
What Is Sex Therapy In Finland?
Sex therapy can be defined as short therapy, the goal of which is solving the sexual
problem or problems regardless of the therapeutic model or combination of models.
Very often the basis is the short therapy method developed by William Masters and
Virginia Johnson for the treatment of functional disorders. Before Masters and Johnson’s
model was developed, all sexual problems, including functional disorders, were
approached using psychoanalytic frames of reference. Psychoanalysis usually means
long-term work requiring several years. After psychoanalytic treatment, the client may
understand the background of his or her functional disorder(s), but the symptom remains
unchanged.
Sex therapy is considered to be one application of behavioural therapy. Although sex
therapy has been developed for the treatment of functional disorders in clients’ sex
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lives, its exercises can also be used diagnostically, as part of other couple or familytherapy,
and for enriching a couple’s relationship. The exercises easily bring to the surface the
couple’s internalised feelings, concepts, and beliefs, and help focus on problem areas.
Sex therapy is primarily couple therapy, but attempts have been made to treat various
functional disorders in group settings. A Finnish version of the developmental model of
the sexual relationship called SEX-IMM has been created and has been carried out in
group therapies, although relatively little thus far.
The sex therapy includes:
1) Treating functional disorders of sexual behaviour through structured
behaviour-guiding exercises;
2) Giving information;
3) Helping both partners realise that the couple’s functional problem is a
“shared problem” and that both people are responsible for its treatment;
4) Creating an atmosphere where the client’s attitudes can change from
negative to positive;
5) Helping clients eliminate performance pressures;
6) Developing the client’s interaction skills;
7) Lifestyle guidance.
Sex therapy based on the Masters and Johnson model combines psychodynamic
understanding of sexual problems with behavioural guidance. Although therapy proceeds
in a structured way, therapy does not apply the model in a mechanical way. Instead,
throughout the whole therapy, there is open discussion of sexuality and its associated
feelings and attitudes. Because the therapist encourages the expression of these feelings,
an atmosphere is created in which change is possible. Therapy can be augmented
according to client needs or the counsellor’s training, for instance, by contact and
relaxation exercises, massage, music therapy, or visualisation with the help of Gestalt
therapy or the new form of short therapy gaining popularity in Finland, NLP (neurolinguistic programming).
The sexual response sequence can be divided into three separate phases: 1) desire, 2)
arousal, and 3) orgasm. Possible disturbances can therefore be placed within one of
these three phases. Disturbances at different levels of intensity can occur in each stage,
and treatment should be selected according to the quality and difficulty of the disturbance.
Usually the first stage is most difficult from the perspective of treatment and the last is
the easiest. Sex therapy can be used in the treatment of disturbances in all three phases.
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However, this three-phase classification does not apply to involuntary spasms in the
genital area, such as vaginismus in women. Such symptoms do not block desire or
orgasm but can make intercourse painful or impossible. These symptoms also are very
suitable for treatment with sex therapy. About 15% of problems connected with a lack
of desire can be treated by means of sex therapy.
Sexual counselling provided by the basic social and welfare services concentrates on
giving permission and limited information according to the PLISSIT scheme. The
special suggestions part of PLISSIT belongs partially to sexual counsellors. Intensive
therapy is, as its name indicates, expressly sex therapy.
What qualities are needed of a sexual
therapist?
Sex counselling and sex therapy require that professionals being trained should have
adequate knowledge of sexuality and have an attitude that prepares them for facing
sexual matters.
PLISSIT
P (permission)
basic health care/
sexual counselling
LI (limited information)
SS (special
suggestions)
special instructions/
sex therapy
IT (intensive therapy)
Figure 1. The distribution of client cases to the different levels of sexual work
The basis of a sex therapist’s work includes his or her life experience, training, and a
professional frame of reference as well as his or her view of the human being. It is
difficult to measure results when working in human relations, but the essential concern
is always with change. The therapist’s attitude towards change affects his or her work,
interpretations, and intervention methods. One may approach problems in a broadbased manner or in a focused way by opening up the bundle of problems layer by layer.
The decisive issues are how the therapist defines the problem, what kind of a therapeutic
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Figure 2. The subjective prerequisites of a worker
Facing one’s own sexuality,
Attitudes,empathy
Professional
treatment
practices
The
atmosphere
of the
workplace,
values,
attitudes,
norms
Facing the
client’s
sexuality
Sexological know-how
method the therapist finds possible, and whether the therapist approaches the problem
from the perspective of the individual client and his/her personality structure and patterns
of social interaction.
In working with sexual problems, the therapist’s basic attitude is important: if the therapist
him or herself is open and positive, he or she may use this positive attitude to build a
new, positive model and give permission to experiment with new activities. The first
step towards success centres on one’s relation to one’s own sexuality. After this, it is
good to broaden one’s own perspective and understand that what one feels is sexually
significant for oneself is not necessarily the same as what another person considers
significant.
A sex therapist is required to be neutral and objective as an educator and client worker.
He or she should be prepared to deal with problems of gender and sexual identity, and
with variations of sexual desire such as transvestism, fetishism, or sadomasochism. If
the client has committed sex crimes, a larger network of authorities is often needed to
deal with the situation.
Therapists and clients both have their own social and emotional background and
surroundings that contain myths, taboos, values, and prejudices. Clarifying and
understanding these myths in the context of problematic sexual situations is as important
as clarifying the backgrounds of disturbances arising from functional factors, diseases,
or medications.
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Who Seeks Sex Therapy?
The couple seeking sex therapy is expected to have a basically stable relationship.
Therapy can help those who do not have any organic reason for their sexual disturbances.
The disturbances are classified in Finland mainly according to the Masters and Johnson
schema. According to this, the functional disturbances in men include problems with
erection or are connected with premature ejaculation or an inability to ejaculate. About
20% of men of ages 40-70 in Finland quite often have problems with erection. Only 510% seek treatment, although most could be helped with therapy and/or medication.
Smoking is the most common lifestyle reason for problems with erection. The next
most common reason is being overweight, and the third most common is excessive use
of alcohol. The reason behind erection problems is most often a disturbance of blood
circulation (70%). The proportion due to psychological reasons is 10%, and the proportion
due to hormonal problems is half that. Erection problems are being treated at various
potency clinics throughout the country. Urologists also help. The best treatment results
are achieved through co-operation between sex therapists and physicians. Physicians
are seeking training in sex therapy more actively than earlier.
According to the Masters and Johnson classification, women’s problems include
vaginismus, painful intercourse, and disturbances in achieving orgasm in intercourse or
while masturbating. According to an American study (Hite) 70% of women are bothered
by a lack of orgasm. According to Finnish results, 5% of women never achieve an
orgasm, one third have difficulties of some degree in achieving orgasm, and almost two
thirds achieve orgasm fairly regularly. Lack of desire is a common disturbance of sex
life for both women and men.
The most common questions from couples seeking help deal with “How, When and
How Often?”. It has been noticed that routines make sexual relationships stale. Foreplay,
intercourse and afterplay, if repeated according to the same pattern, may disturb the
functioning of one’s sex life. Men tend to be more straightforward in their approach
than women. In deciding on the frequency of intercourse, problems could be solved,
for instance, in such a way that the partner desiring more frequent sex can decide on
two days per week and the partner wanting less frequent sex on, for instance, five days
per week. A different daily rhythm of the partners can produce other difficulties besides
stress. People living in a couple partnership must get the courage to demand privacy
and time for themselves in spite of work, children, or grandparents possibly living in the
same household. It is very common that either one of the partners is still dependent on
his/her parents and does not have the courage to demand an independent and stable sex
life. The attitudes of the childhood home, inhibitions, and secrecy can have a long-term
effect. Sexuality can also be used to dominate, blackmail, reward, and humiliate. Both
partners of couples entering therapy are required to want change and to be motivated to
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work toward it. They also have to be motivated to seek therapy by reserving enough
time for the treatment (therapy visits and home exercises). Starting therapy also requires
that both partners refrain from outside sex relationships and avoid excessive alcohol use
during the treatment.
In sex therapy, the therapist first attempts to create a positive atmosphere in which it is
possible to change attitudes. The responsibility for treatment is divided between both
partners. The goal of treatment is to abolish pressures to perform and to increase
interactive skills. A central part of treatment consists of exercises carried out at home
and their analysis in therapeutic sessions. The preconditions for beginning sex therapy
are clearly delineated.
The criteria for beginning the treatment are the following:
1.The couple relationship is basically stable. Both partners want to continue the
relationship, and both partners obtain some kind of satisfaction from it. This can be
checked by asking clients about the following:
• Opinions about positive and negative aspects of the relationship;
• Information about the use of common leisure time and satisfaction with how
that time is used;
• Opinions about the ability of both partners to act independently;
•The frequency of quarrels and the method of settling them;
•To what extent each partner considers the other partner as physically attractive,
i.e., approves of the other one’s physical appearance.
2. The disturbance can be classified according to the Masters and Johnson classification
(with the addition of dysfunctions in the arousal phase of the female partner).
3. No organic cause underlies the disturbance. The therapist must clarify effects of
possible illnesses and of medications, disabilities, or surgical operations. Furthermore, it
is important to clarify the use of alcohol and other intoxicating drugs. If there is even the
slightest reason, it is necessary to consult a physician or refer the client to one for a
more detailed examination. Such referrals are always needed in cases of painful
intercourse (dyspareunia) and vaginismus or other cramps of the perivaginal muscles.
4. Neither partner is deeply depressed. The problem is not the type of depression but
whether or not enough energy remains for the treatment.
5. Both partners want change and are motivated to work. This is the most important of
all criteria. Additionally, it is important that one partner does not bring the other one to
treatment but that both are able to perceive the problem as a common one and affecting
both.
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6. Both consider the problem as sexual. If partners disagree about what their problem
is, it is necessary to help the partners to reach an agreement or to choose the problems
they want to work on first.
7. Both are ready to reserve the required time. It is very important to clarify with clients
the extent of their commitment. Sometimes it is necessary to clarify in detail the home
conditions of partners and help them find the time for the exercises (3 times per week).
8. Secrets between the partners must not become too great an obstacle for the therapist
to treat the client couple. Individual interviews may reveal facts that the other partner
does not know. It is important to ask the client for information about these kinds of
secrets, and encourage the client to discuss them with the partner.
9. Neither one has an outside sexual relationship during the treatment. This point is
important to emphasise because as the treatment progresses step by step, an external
sexual contact may destroy the progress made.
10. Neither partner uses too much alcohol. Too heavy drinking may block all sexual
response and directly affect erection and the ability to reach an orgasm.
Several different modes of work have been created, from therapy sessions on the
Internet, to weekly meetings, to open care based on exercises. We will next explain the
method of working in open care.
In the beginning, the couple and the therapist become acquainted with each other, and
the couple defines the problem as accurately as possible in a common session. Next,
both come to give their sexual histories in a meeting of about one and a half to two
hours. These sexual histories can be taken also while both partners are present with the
so-called focusing technique. In this, the starting point is the problem presented by the
client couple, which is subsequently illuminated by the sexual histories.
After the initial discussions the therapist and couple discuss together their most important
goals: what questions will be focused on, will an agreement be signed about the beginning
of sex therapy, and what kind of exercises will be used to begin the treatment. Now
almost without exception the sessions start with showering exercises, which help the
partners become comfortable with nakedness and intimacy. A series of pictures about
sexual reactions and anatomy are shown. Caressing exercises (Sensate focus I and II)
are carried out at home afterwards according to the instructions and the results are
analysed weekly in meetings. Sensate focus III is an exercise in caressing the genitals
with an orgasm as its goal. It has proven to be a useful additional exercise for partners
who are extremely anxious or who require slower progress. At the end, a decision is
made about the start of symptomatic treatment if it is seen as necessary. There is a
specific treatment for each type of sexual problem.
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An example of the treatment of a symptomatic
disturbance
One of the most common and most easily treated functional problems is premature
ejaculation by the man. A man suffers from premature ejaculation when he would like
to continue longer with intercourse but for various reasons is unable to do so. Therapists
have rejected definitions based on the length of time between intromission and orgasm,
or the frequency of orgasm. The disturbance can be treated with the squeeze technique
and many other ways, but also by using masturbation. Marilyn Hahn and Jay Mann
(University of California, Medical School) have developed an eight-point masturbation
program that is also used in Finland.
In the first phase the man has to masturbate with a dry hand until he is able to continue
for 15 minutes. After that, he masturbates using a moisturiser, again aiming at continuing
for 15 minutes. In the next phase, the partner masturbates the man in a similar way.
The partners proceed from genital caressing to intercourse and the woman takes a
position above the man. The man is allowed to move only as much as is needed to
maintain his erection for 15 minutes. When this goal has been reached, the man lies
motionless under the woman and she moves gently until the 15-minute goal is achieved.
If necessary, the squeeze technique can be taught to the couple.
In the penultimate phase, the same positions are maintained and both move gently until
the man lasts 15 minutes. In the last phase, the couple attempts full sexual intercourse
with the goal of lasting at least 15 minutes. The couple carries out the exercises according
to their own time schedule and receives instructions from the therapist in sessions that
are analysed together.
Where to obtain sex therapy
Sex therapists in Finland work in family health centres, church family counselling centres,
A-clinics, rehabilitation institutions, and public mental health clinics as well as in prisons
and prison mental hospitals. Private practitioners also offer sex therapy. A register of
sex therapists is maintained by SEXPO, the Family Federation of Finland, and the
Finnish Association for Sexology. The Finnish Association for Family Therapy also has
a register of members with training in sex therapy.
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What Does The Future Hold?
More and more physicians seek training in sex therapy, mainly gynaecologists,
psychiatrists, and especially midwives from among the nurses. In other ways, too, cooperation between midwives and sex therapists has increased lately in a promising
fashion. Through the Finnish program in sex therapy education, midwives achieve
readiness for sex counselling and training in how to provide health services, and
information in matters related to pregnancy, birth and child care. This sexual therapy
and counselling seem to fit naturally with the other duties of midwives. The teachers of
Polytechnics in the fields of social work and health care have also paid more attention
to obtaining training in sex counselling. Through them, knowledge and attitudes about
sexual questions are widely disseminated among practitioners providing basic health
care in Finland. Some people with sex therapy training have organised additional training
in various parts of Finland, thereby further increasing the availability of sex counselling.
There is a need to organise more sex therapy education for family and couple therapists
who already have a degree in another field. Workers in mental health and psychiatric
clinics as well as couple therapists in family counselling clinics (psychologists and social
workers) have noticed how common sexual problems are. Thus far it has been usual to
refer couples to professional helpers, but the need is quickly increasing for helpers in all
these different areas to gain knowledge themselves about sex counselling and therapy.
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Riitta Raijas
11. Sexual Violence in Finland:
Legislation, Prevalence,
Public Discussion,
and Services
Introduction
Sexual violence creates serious risks to an individual’s psychological, physical, social,
and sexual health. However, sexual violence is still largely a hidden phenomenon. The
majority of victims of sexual violence do not report their experience to the police and do
not seek professional help. Some victims keep silent, and tell no one about their attack.
The purpose of this chapter is to describe how attention in Finland has been directed to
violations of the right of sexual autonomy. My aim is to review discussions held in
Finland, amendments in the legislation, and the prevalence of sexual violence. Work
done in Finland to acknowledge and prevent sexual violence is also described. I discuss
opportunities for victims and offenders to get help at the end of the chapter.
Most commonly, the victim of sexual violence is a woman and the offender a man.
Sexual violence is often seen as a part of structural violence against women that cannot
be separated from other forms of male to female violence. However, the emphasis
here is on those authorities and organisations that concentrate particularly on recognising,
preventing, and treating sexual violence. Many projects dealing with violence against
women, domestic violence, in particular, will not be discussed, even though physical
violence in intimate relationships is closely linked to sexual violence.
In this chapter I concentrate on work done with adults who have experienced sexual
violence at some point in their life. I do not discuss the treatment of children nor
research about them. Accounts of child sexual abuse and treatment of abused children
in Finland has been organised primarily by local family health centres and departments
of child psychiatry. The major organisations participating in research and development
of service activities for abused children are the National Research and Development
Centre for Welfare and Health (STAKES), the Central Union for Child Welfare, and
the Mannerheim League for Child Welfare.
Violations of sexual autonomy involve offences at different levels, ranging from sexual
harassment to more serious forms of violence such as child sexual abuse and rape.
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Difficulties of definition complicate the approach to these issues. In society, legislation
defines acts that criminally violate an individual’s sexual autonomy. The law reflects
societal attitudes about sexual norms and limits, but the law and societal attitudes never
correspond exactly. For example, women’s, men’s, and children’s concepts of sexuality,
of themselves, and of their relationships with each other all affect how victims of sexual
offences are dealt with. According to research, attitudes in society, especially about
gender roles, have an impact on the prevalence of sexual offences.
In principle, women’s autonomy over their bodies and their sexuality has been recognised
in Nordic countries for quite some time. Nordic gender norms give women more freedom
to fulfil their sexuality based on their own needs than do norms of other societies.
Women’s autonomy over their own bodies is recognised as a matter of principle.
However, work with sexual offenders and with victims of sexual violence reveals a
darker picture of the realities of sexual autonomy than what is publicly expressed.
Unofficially, women’s sexual sovereignty is often questioned and denied. Legal definitions
cover only part of these acts, and the law does not interfere in attitudes that deny and
downplay women’s sexual autonomy.
In principle, defining sexual violence in client work is unambiguous: any kind of approach
that the target has experienced as anxiety-producing, forceful, or violent can be defined
as sexual violence from the victim’s viewpoint. Clients’ subjective experiences cannot
and must not be ignored when working with them. From this perspective, sexual violence
is defined according to the individual’s experience, and it expands to include acts and
phenomena excluded from legal definitions. Sexually objectifying and disrespectful acts
and phenomena, as well as sexual harassment in its more lenient forms can all be
seriously offensive to the victim and can affect the victim’s well-being even when not
legally defined as crimes.
Legal Definitions of Sexual Violence:
During the past several years, there have been important reforms in the legislation
concerning sexual crimes. In 1994, it was possible to consider rape in marriage a
criminal offence. Before that year, decrees in the criminal law concerning rape did not
apply to rape in marriage. Finland was one of the last countries in Europe to make rape
in marriage a crime.
Reforms in the criminal law concerning sexual crimes became effective at the beginning
of 1999. Validation of the law was preceded by quite intense debates about the reform
proposal published in 1993 by the law-preparing department of the Ministry of Justice.
Extensive discussions were held about the age limits for sexual consent, which were
proposed to be lowered from 16 years—for heterosexual relationships—and 18—for
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homosexual relationships — to 15 years. As a result of these discussions, the age limit
was kept at 16 years for heterosexual relationships but was lowered to 16 years for
homosexual relationships.
There was also a great deal of discussion about a proposal for dividing rape into three
categories, ranging from least to most severe.
The proposal to include a less serious rape category in the law was strongly contested:
many argued that rape is always a serious offence. Despite this discussion and other
claims that the three definitions were ambiguous, three categories of rape were included:
coercion into sexual intercourse, rape, and aggravated rape. Distinctions among these
three types of rape are made by considering the degree of physical and mental violence
used against the victim, the amount of suffering the victim has experienced, and the
number of offenders.
Criminal law reform reflects changes in attitudes. In the previous law, the literal translation
of the term for sexual offences, “chastity crimes” accurately described prevailing societal
attitudes. The law protected female chastity — not female sexual autonomy. In the
reform, the name of the law was changed to indicate concern about sex crimes rather
than chastity. Moreover, the previously used term “coercion into sexual intercourse”
was replaced by “rape”. The law was also modified to be neutral with respect to gender
and sexual orientation: the new law takes into consideration that both the sexual offender
and the victim can be either a man or a woman.
The new law also improved the victim’s position. The most important improvement
was to place the two most serious forms of sexual crime under general prosecution. A
crime under general prosecution is a crime in which a prosecutor makes a judgement
about the offender’s guilt or innocence on behalf of the state regardless of whether or
not the plaintiff wants the offender to be punished. Demanding punishment is no longer
the plaintiff’s responsibility. The change points to a tendency to consider sexual crimes
as violent crimes for which intervention is in the general interest. Such sexual crimes are
no longer taken as a private matter between offender and victim. The change also
significantly prolongs the length of time a sexual crime can be prosecuted. The least
serious type of rape is still considered a plaintiff crime and thus must be reported within
one year for the offender to be considered for prosecution.
However, the law was written to make it possible for the prosecutor not to prosecute if
the plaintiff requests this on her or his own accord. There has been much discussion
about what conditions the prosecutor can use to evaluate the decision to prosecute
when the plaintiff does not want the criminal proceedings to occur. Victims of sexual
and domestic violence often must face threats and pressure from the offender; fear can
induce a victim not to proceed to a formal case. Furthermore, it has been said elsewhere
that the victim must have the right to protect herself against the heavy juridical process
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if she feels that prosecution would not improve her ability to cope and her well being.
Legal procedures related to sexual crimes require the victim’s presence in court as well
as her verbal testimony. This experience can be extremely difficult and anxiety-provoking
for the victim. Moreover, a victim of sexual violence often fears that she might be dealt
with harshly and inappropriately in court. Seeing the offender face-to-face can also be
a frightening experience.
It must be mentioned that many victims of a sexual crime who have gone through the
legal proceeding have found it very helpful even though it was simultaneously very
painful. The juridical process helps victims’ mental reprocessing by re-establishing
boundaries that were broken and re-instituting justice that had been breached.
Previous law demanded that the victim had to have fought physically against the offender,
because otherwise the legal criteria defining sexual crime could not be met. In most
cases, the victim becomes paralysed at the moment of the crime and tries primarily to
protect her life and health. So the court often did not render judgement in her favour.
According to the new law, legal criteria defining sexual crime may be met even in cases
where the offender had induced such a state of fear in the victim that she was not able
to fight back. A clear verbal expression of not wanting sexual intercourse is now judicially
sufficient.
Another issue is that very few reports of sexual crimes are made to the police and often
remain private. It is difficult to prove that a crime has occurred when the victim has no
physical injuries and there are no witnesses. In cases where the only evidence of the
crime is the victim’s word against the offender’s, the crime is most often not considered
for prosecution.
The Prevalence of the Sexual Violence in Finland
Up to 1998 in Finland, the only information about the prevalence of rape was based on
police statistics and victim surveys. Between 1993 and 1997, approximately 400 rapes
per year were reported to the police. According to estimates often presented by the
police, approximately 10,000 rapes occur in Finland every year. This would mean that
less than 5% of the cases are reported.
Compared to international data for some countries, there is very little research on
violence against women and sexual violence in Finland. The results of the first large
survey on violence against women in Finland were published in 1998. The findings
provide exhaustive and statistically reliable information about the prevalence of violence
against women, its forms, and consequences. A questionnaire was mailed to a
representative sample of women between the ages of 18 and 74 (sample size = 7051
with 4955 replies, for a return rate of 70.3%).
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Findings from this survey confirmed the view that violence against women is a common
problem in Finland. According to the results, 16% of the women had had experiences of
sexual harassment or violence before their 15th birthday.
In the survey, violence experienced as adults was classified according to whether 1) the
violence occurred in an existing couple relationship, a previous couple relationship, or
outside the relationship and 2) the violence was sexually threatening behaviour, an
attempted coercion into sexual intercourse, or actual coercion into sexual intercourse.
Sexual violence was thus not defined in legal terms in the survey, because it is known
that victims of sexual violence do not define their experiences, for example, as rape
even though the acts would meet the requirements for the legal definition of rape.
In couple relationships, violence was more often physical than sexual, whereas outside
the relationship women had more often been subjected to sexual violence. For sexual
violence occurring outside of a couple relationship, almost 14% of the women had
experienced sexually threatening behaviour, 10.5% of the women had been victims of
attempted rape (attempted coercion into sexual intercourse), and 4.3% victims of rape
(attempted coercion into sexual intercourse).
Two and a half percent of the women had experienced sexual violence during the past
year in their present couple relationship, and 5.9% had experienced it at some time after
their 15th birthday. Almost one fifth of the women (18.7%) had experienced sexual
violence in a previous couple relationship. This is a large percentage and means almost
100,000 women in the whole population. Violence, as well as sexual violence, can be a
reason to divorce. On the other hand, we know that violence may occur only when the
woman wants to terminate an unsatisfactory relationship. There have been many contacts
at the Tukinainen rape crisis rape “hot-line” from women in the process of separation
who have been raped by their never-before violent partner. In these cases, the motive
would seem to be revenge for the divorce or even a wish to destroy the victim’s future.
According to the research, in more than one third of the cases the offender was a
complete stranger to the victim and was an acquaintance or a neighbour in less than one
fifth of the cases. Less frequent offender categories were, for example, colleagues,
landlords and relatives. In over 15% of the cases, the offender was a previous or
present partner. The results confirm that perpetrators of sexual violence are usually
people the victim knows, and that violence in couple relationships is much more common
than is usually assumed.
The research shows that women experience sexually threatening behaviour everywhere
in their surroundings: bars, workplace, schools, own apartment, streets, stairways, and
outside. Half of the rapes (coercion into sexual intercourse) take place either in the
victim’s apartment or in another private apartment.
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Sexual violence still remains a taboo topic. Almost one third of women who were raped
outside the couple relationship had not talked about it with anyone. Those who talk
about the experience usually do so with someone close to them. According to the
research, only a tenth of those who were raped outside the couple relationship seek
help in the health care system even though almost half of them are physically injured.
Seeking help in crisis centres occurs even less often.
Additional findings from the survey indicated that no woman raped by a non-partner
sought help or counselling at the rape crisis centre, whereas 15% of those who had
experienced an attempted rape contacted the crisis services (the survey asked about
seeking help after the most recent experience of sexual violence). The research does
not provide the percentage of those who sought help from crisis centres because of
violence in couple relationships.
The survey also provided estimates of the prevalence of sexual harassment. More than
half of the women had experienced sexual harassment at some point in their lives.
Sexual harassment includes making unwanted sexual advances or propositions, stalking,
and exhibitionism. An interesting finding is that more educated and highly-paid women
experience (73% of those with higher university degree) sexual harassment more often
than less educated and lower paid women.
Projects, Plans, and Initiatives Related to Sexual
Violence
Public discussion has also produced some progress: more information is available, and
attitudes and ideas have changed so that people are more willing to support programs
beneficial to rape victims. Public debate about sexual violence has gone hand in hand
with special projects, because these projects try to gain media attention in order to
promote awareness of sexual violence. Organisations that have been essential for
recognising, identifying, and treating sexual violence will now be discussed. The goals
of these organisations are to influence both the societal and individual levels by improving
the identification of sexual violence, by increasing the availability of support services,
and by providing support services themselves.
At the end of the 1980s, incest became a subject of public discussion; in the 1990s,
sexual abuse outside the family and paedophilia both became topics of public discussion.
In the last several years, sexual violence and rape experienced by adult women have
received more media attention. One reason for this is most likely the establishment in
1993 of the first rape crisis centre in Finland. Its existence may have attracted some
publicity to the issues. Another reason for media attention may have been the ongoing
legal reform.
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In the 1990s, intense debate occurred about the investigation and treatment of children
who have been incest victims. One case involved a child taken into custody because of
assumed incest even though incest had not been proved in court. This case was the
subject of lengthy discussion. The case aroused strong feelings and heated debate about
the professional skills and procedures of authorities working with children. In 1994, the
National Research and Development Centre for Welfare and Health (STAKES) published
a guidebook for investigation about and treatment of child sexual abuse, which aims to
unify health and research practices relating to sexual violence in social and health care.
The discussion also remarkably increased the availability of training about these issues.
In the 1990s, paedophilia chains were found in Finland, shocking the whole country.
The phenomenon had been assumed to be a problem of big urban centres and other
parts of the world, but was now discovered to be present in Finnish society, in cities as
well as in small rural areas. In November 1998, a national television channel showed a
documentary, “The secret we share,” which followed the reactions of one small region
after a paedophilia case was exposed to the public. Frequent features of social processing
about the issue included silence, inability to believe what had happened, and inability to
handle the emotions related to it.
Most of the paedophilia chains found in Finland have been so-called “solo chains,”
where one paedophile had abused numerous children and teenagers for several years.
The investigations have also found organised international connections between
paedophilia and child pornography. In addition, Finns were involved in an international
paedophile chain that exchanged child pornography through the Internet. This chain
was discovered in 1998 and led to court trials in different countries, including Finland.
These phenomena were all discovered very recently in Finland. Cases and court trials
that arose publicly show that investigation and treatment practices still are not adequate.
In 1990, the Council for Equality of the Ministry of Social Affairs and Health established
a committee to examine violence against women and its manifestations and to make
action proposals to prevent and treat violence. Members of different organisations and
authorities were invited as experts to serve on this committee. It submitted its report in
the end of 1991. The report stated that the availability of services for victims of sexual
violence did not meet the demand. It was also recommended that research and projects
on violence against women needed to be supported.
The report also emphasised that service centres for victims of sexual violence needed to
be established. Weaknesses in the law and in the practices of authorities were also
highlighted. In particular, it was emphasises that the treatment of victims by police and
members of the criminal justice system is sometimes insensitive and contributes to
additional suffering for rape victims.
158
In Finland, the first treatment group for adult female victims of childhood incest was
established in 1989 at the SEXPO counselling office in Helsinki. The formation of this
group was preceded by public discussion stimulated by a Norwegian incest documentary
shown on television and by telephone calls made to the programme on-call line. A
treatment project for sexual offenders and for victims of sexual violence was started at
the sexual consultation centre of SEXPO in Helsinki in 1992, partly because of these
discussions and partly from needs demonstrated by pilot groups of incest victims. The
project lasted four years. During the years 1992-1995, seven groups were established
for incest victims: five for women, one for men, and one mixed group. The groups
were formed in association with the counselling centre’s therapist and with private
therapists who had training in psychotherapy for groups. Detailed information about
these therapy groups was included in the final project report.
The Finnish Association of Group Psychotherapy also addressed the issue, and later
organised many short-term therapeutic groups for incest victims. This association
organised many training sessions, seminars, and lectures, and also examined the treatment
of victims. These training efforts helped to improve the recognition of problems related
to incest and to develop psychotherapeutic treatments.
In 1990, weekend gatherings of groups for incest victims were organised and led by a
psychotherapist who had specialised in this area in the United States. These groups
were called “Dolphin Groups.” The leader, Stina Sundholm, also wrote the first book in
Finnish about incest. In 1997, a Dolphins association was established from these groups.
The association listed as its goals helping and supporting victims of sexual abuse;
organising weekend courses for victims; giving consultation and guidance to people
close to the victim and to professionals; distributing and publishing information and
publishing activities; and gathering material related to issues posed by incest. The Dolphins
offered a forum for victims of sexual abuse to meet each other and to try to influence
societal improvement of their situation. Until 1999 the association functioned on a
volunteer basis and did not receive any finance. Currently, the Dolphins receive funds
from the Slot Machine Association.
In 1993, the first, and until now, only sexual violence crisis centre was established in
Finland, the Rape Crisis Centre, Tukinainen. Unioni, The League of Finnish Feminists,
initiated the establishment of the Centre. In the beginning this League only offered
small-scale crisis services (a group and on-call line) for rape victims. Because of the
great demand for these services, a plan for establishing separate crisis centres was
developed. The dream came true in 1993, when the Slot Machine Association started to
support the project financially, first as a 3 to 5 year project. The crisis centre office is
located in Helsinki, but its goals involve all of Finland. The aims are to help women
who have experienced sexual violence and to influence the general level of services in
society. Another specific goal is to increase awareness of sexual violence in society. In
1999, the crisis centre was made permanent.
159
In 1994, a crisis consultation and education centre was established in Oulu, in northern
Finland, through the co-operation of four organisations. The aim was to co-ordinate
help for victims of traumatic crises and their supporters together with volunteer
organisations and authorities. During the first year, emphasis was on developing a help
model for assisting rape victims. Later, emphasis was on traumatic crisis in general,
developing a support model, and organising training. The crisis centre is co-operating
closely with local networks. In 1999, the centre changed its name to the Centre for
Post-Trauma Therapy and Trauma Education. It functions as an expert centre of trauma
psychology, offering not only help but also training and consultation.
In 1995, a Crime Victim Support programme was established in Finland as a joint
project of different organisations. By the beginning of 1999, it had ten regional offices
throughout Finland. The report of the previously mentioned Council for Equality had
proposed starting this type of service in Finland. Crime Victim Support aims to improve
the victim’s situation and offers services for victims of all crimes. Those working in this
support programme have noted a high volume of female victims of violence seeking help.
SEXPO was the first group in Finland to pay attention to the therapy of sexual offenders
in its project for both victims and offenders. The project examined the availability of
therapy for sexual offenders, investigated the possibility of offering therapy to sexual
offenders in jail through therapists’ visits, and studied international treatment projects.
The final project report included information about obstacles to and possibilities for
therapy in Finland as well as proposals on how care should be organised in Finland.
At the end of 1996, the prison welfare department of the Ministry of Justice appointed
a committee to explore possibilities for starting treatment programs for sexual offenders
under the Finnish prison welfare system. The results were published in a report in
1998. The committee proposed starting a programme in Finland based on an English
model (The Core Programme) for those who are found guilty of sexual crimes. This
programme is based on cognitive-behavioural theories and deals with, for example,
denial and minimisation of the crime by offenders, damage caused to victims, and
developing offender skills for preventing recidivism.
Availability of Services for Victims of Sexual
Violence and for Offenders
A victim’s likelihood of obtaining therapeutic and juridical assistance varies greatly and
depends on the region where she lives. Help can be found throughout Finland in local
health care centres, mental health care offices, family health centres, and psychiatric
clinics. The special services of different associations have an important place in the
160
Finnish health and social care system. They complete the public health care system and
are usually mainly financed by the Slot Machine Association (RAY).
Victims of sexual crime can obtain initial legal aid from the national network of legal aid
offices, which cover the whole country. It is also possible to get assistance from private
solicitors and lawyers. Criminal process reform permits the victim to have a free legal
assistant. The reform facilitated obtaining a legal assistant from the quite expensive
private sector.
It is thus possible to obtain therapeutic help from services financed by the state and by
municipalities. The problem is that women living in small, rural regions often find it
almost impossible to obtain help from their own region’s services. Feelings of shame
and guilt related to sexual violence and the fear that others find out about their sexual
assault may prevent victims from getting help. Because acquaintances or acquaintances
of acquaintances may work in the local offices, the victim may not necessarily trust that
sensitive information about her will remain secret. The same applies to sexual offenders
who may be motivated to get help.
It is especially difficult for victims to talk about sexual violence. The first experiences of
telling someone about it often determine if the victim will begin to search for therapeutic
and juridical help. If the first person whom the victim tells about it minimises sexual
violence and makes her feel guilty or does not believe her, it is very unlikely that the
victim will try again.
There are no basic surveys examining what kind of help victims have obtained. However,
the survey published in 1998 about family violence and care in the social and health
system provides some information. According to this survey, social and health care
professionals feel that they have inadequate abilities to work with victims of sexual
violence. A total of 73% of those who replied to the questionnaire estimated that they
are not sufficiently prepared.
The experiences reported in the Rape Crisis Centre’s on-call line have varied remarkably.
The saddest cases are those where the rape victim has faced unprofessional treatment
in a health care centre, so that important evidence for the court hearing had been
overlooked and no offers of mental support or extended care were made. On the other
hand, at its best, the health care centre has been able to offer all-inclusive care. Thus,
some have been given the opportunities to make an appointment with a medical doctor
and to receive mental support from the nurse on duty, crisis consultation by the health
care centre psychologist, and, if needed, extended care in the mental health care office
or family health centres.
In Finland, longer psychotherapy is mostly provided by private psychotherapists. It is
161
possible to finance therapy through the Social Insurance Institution (KELA). Currently,
the rehabilitation allowance for psychotherapy is set at a maximum of two years, and
the criterion for granting the allowance is that therapy is supposed to maintain or restore
the person’s working ability. People living in different parts of Finland have very unequal
opportunities for obtaining psychotherapy. Many private psychotherapists work in
southern Finland, but in the north it is more difficult to find a psychotherapist. In rural
regions, long travel distances often create a problem.
In the different projects, it has been noticed that traditional methods of psychotherapy
are not adequate for treating the consequences of sexual violence. Specialisation is
needed for applied use of different frameworks and new approaches. Psycho-dynamic
psychotherapy has had an important place in Finnish therapy. According to research,
good results for the care of victims and sexual offenders have been achieved by cognitive
and cognitive-behavioural approaches; however, these do not yet play an important role
in Finland. Increasing diversification and experimentation in the field of therapy has
only recently started. Today, new approaches are gradually becoming more popular
among therapists such as solution-centred therapy, crisis therapy and trauma therapy.
Interest in the effectiveness of therapy and discussions about the value and outcomes
of different methods have increased.
Group therapy has many advantages. For example, victims of childhood sexual abuse
often benefit greatly from group therapy. Meeting others who have gone through the
same experiences and surviving together by helping one another make it considerably
easier to handle feelings of loneliness, difference, and isolation related to sexual abuse.
The availability of special services focused on these problems is still quite poor, and
these services are available mostly in the south of the country. For example, there are
groups for victims of childhood sexual abuse only in a few cities, and often they are
experimental programs of short duration.
The Rape Crisis Centre Tukinainen offers nation-wide services for victims of sexual
violence by providing cost-free crisis and juridical on-call lines. The Crisis Centre also
provides professional help in the form of crisis counselling, therapeutic groups, and
weekend courses. The groups have been meeting in Helsinki. Weekend courses have
been organised throughout the country, and make it possible for victims of sexual
violence to obtain help in coping from a guided, therapeutic group. The goal has also
been to offer longer group services in the other parts of Finland. The major difficulty in
pursuing this goal has been financing.
Tukinainen offers free juridical help and counselling. Its attorney also gives assistance
in court. The Crisis Centre provides training, counselling, and supervision for professionals
and volunteers in different fields. Tukinainen influences the societal level by its joint
projects, participation in committee work on reform and research, and providing
information and statements about sexual violence to the mass media.
162
Other services maintained by associations for victims of sexual violence have already
been mentioned, i.e., Crime Victim Support with offices in ten regions. This association
offers mental support and practical counselling for victims of crime and people closest
to them. It has a national on-call help line and juridical line. Crime Victim Support
provides educated, volunteer support persons. The association has also organised guided
self-help groups for victims of sexual abuse and violence in Tampere and Joensuu.
In addition, the Finnish Association for Mental Health offers services for victims of
sexual abuse and organises rehabilitation courses for adults who have had childhood
experiences with sexual abuse. RAY and KELA usually finance such services. The
Finnish Association for Group Psychotherapy organises brief crisis groups for incest
victims, mostly in Helsinki. These are financed by KELA. The Family Federation of
Finland has also begun gynaecological services for women who have been victims of
sexual violence. In the Sexual Health Clinic of the Family Federation of Finland it is
possible to get therapeutic help as well.
In the 13 crisis centres of the Finnish Association of Mental Health throughout the country,
help is provided for those experiencing different crises. For northern Finland, I have already
mentioned the Centre for Post-trauma Therapy and Trauma Education in Oulu.
Twelve-Step self-help groups for incest victims also exist in Finland (ISA). However,
detailed information does not exist about the number and location of these groups.
Possibilities for sexual offenders to get professional help are still poor. The SEXPO
project report mentions that sexual offenders may become motivated to seek help when
they have to answer to the legal system for their actions. Because such care demands
combining control and treatment, it is recommended that the responsibility for organising
and developing care be shared between units under the Ministry of Social Affairs and
Health and the Ministry of Justice. An important recommendation of the project was
that a unit concentrating on offender care should be established. This unit should take
responsibility for organising and developing care outside of institutions. The unit’s task
would be to offer care (meaning the prevention of recidivism), training, and consultation.
Another recommendation was to investigate the possibility for therapy to be guaranteed
during imprisonment.
By 2000, no units existed that specialised in care for offenders outside hospitals. Some
of SEXPO’s personnel continue their work at the private sector. The prison welfare
system has instead reached a phase in its projects where sexual offenders are treated in
a special unit of Kuopio provincial prison. This is a remarkable step. Treatment of
sexual offenders is based on free will, and aims to lower the risk of repeated sexual
offending.
163
Male victims of sexual violence still remain an almost unfamiliar client group in the
service system. Their likelihood for obtaining professional special help is still poor. The
threshold for male victims of violence to obtain help for these experiences is quite high.
Feelings of shame related to sexual violence are, if possible, even stronger in men than
in women. To make it easier for men to obtain help, it would be necessary to have a
special unit providing such help and to publicise its services. Currently, there is no
association concentrating on the care of male victims of sexual violence.
Conclusion
Sexual, domestic, and general violence against women are big problems in Finland but
have long been taboo. No means have existed to deal with these issues. In the 1980s,
training was not really offered. Nor have there been profound discussions about ways
to improve women’s safety or about how violence against women could be prevented.
Moreover, there has been little research on violence. Different projects have had problems
obtaining financing. This fact may reflect the existence of issues in Finnish society that
strongly prevent violence against women from coming out in the open. The importance
of understanding factors contributing to sexual violence as well as the effects of such
violence on society has not been fully recognised.
Some promise exists for a better future. In 1998, the first national, state-financed project
about violence against women was started under the National Research and Development
Centre for Welfare and Health (STAKES). One project goal was to create a national
network of professionals specialising in violence, and another was to create local models
of how the authorities should react when they face domestic violence. Other issues
related to sexual violence are part of the project as well.
Considerable growth is expected in research on violence. In 1999 the Academy of
Finland decided to grant 10 million marks for research in this area. This decision was
made partly because of initiatives taken by different organisations that work with victims
of violence. One of the currently funded projects is “Gendered Violence and Use of
Justice,” directed by the faculty of law of the University of Helsinki. The cultural and
social committee of the Academy of Finland has the responsibility of reviewing the
applications for research on violence under the general theme “Power, Violence, and
Gender“. Women’s studies networks could especially benefit from this opportunity
offered by the Academy of Finland.
Finland’s becoming a member of the European Union opened opportunities for obtaining
monetary support through European financing channels. The pioneer positions of the
feminist movement and non-governmental organisations have been recognised
internationally in the care and prevention of violence against women and children. For
164
example, through the DAPHNE program of the European Commission, organisations
can apply for financing for their projects. The criterion is to have an European joint
partner. Finland is a state at the edge of Europe, and international issues usually reach
Finland only after delays. Fortunately, international joint projects are changing that
situation.
In the mass media, different issues related to sexual violence seem to become the
subject of conversation only one at a time. Topics related to sexual violence that are
hardly discussed at all in Finland include women as abusers, children and youngsters as
abusers, and sexual violence experienced by men. The first interviews, articles, and
training about sexual violence experienced by young women were published in 1998.
Recognition of sexual harassment in the workplace is still in its beginnings. At the same
time that violence against women in intimate relationships is becoming a more important
field to develop, problems of sexual violence are probably also more visible to
professionals in the social and health care system.
Compared to the services organised for women in other parts of the world, the services
of Rape Crisis Centre Tukinainen have some special features. First of all, the basic
principle of Tukinainen is professionalism. There are no volunteers in the centre. Partly,
this is due to the fact that helping victims of sexual violence is seen to be so demanding
and requires considerable education, training, and supervision. Partly, it is due to feminist
ideology. When the crisis centre was being established, its founders did not want to be
part of a structure where a major part of the nursing and caring work was done by
women who were unpaid. Offering juridical and therapeutic services in the same unit is
also rare. Experiences with this during the experimentation period of Tukinainen have
been extremely good. Juridical and crisis on-call lines have made it much easier for
women to get help for their problems.
I would like to thank Emmi Lattu for her original translation of this article.
References
Naisiin kohdistuva väkivalta. Väkivaltajaoston mietintö (Violence against women. Report
of the violence department). Tasa-arvojulkaisuja. Sarja B: Tiedotteita 5/1991. Sosiaali- ja terveysministeriö. Helsinki.
Ronkainen, S. 1998. Sukupuolistunut väkivalta ja sen tutkimus Suomessa – Tutkimuksen katveet valokeilassa (Gendered violence and its research in Finland).
Naistutkimusraportteja 2/98. Hakapaino. Helsinki.
Heiskanen, M., Piispa, M. 1998. Usko, toivo, hakkaus. Kyselytutkimus miesten naisille tekemästä väkivallasta (Faith, hope, battering. A national victim survey of men’s
violence against women in Finland). Statistics Finland. Helsinki
165
Taskinen, S. (Ed.). 1994. Lapsen seksuaalisen riiston selvittäminen ja hoito (The
examination and care of child sexual abuse). Stakes Oppaita 23. Helsinki.
Heikkinen, Markku (Director) (1998). Yhteinen salaisuutemme (“The secret we share,”
television documentary). Production House, Helsinki.
Raijas, R. (Ed.) 1996. Seksuaalirikollisten ja uhrien hoito. Raportti vuosina 1992–1995
tehdystä projektista (The treatment of sexual criminals and victims. Report of the
project 1992-1995). SEXPO, Helsinki.
Huopainen, H. 1996. Seksuaalista hyväksikäyttöä kokeneiden hoitoprojekti (The
treatment project for victims of sexual abuse). In Raijas, R. (ed.) Seksuaalirikollisten
ja uhrien hoito (Treatment of sexual offenders and victims). SEXPO, Helsinki. Report.
Suomen Delfins ry. Toimintakertomus 27.3.–31.12. (Delfins society of Finland, annual
report).
Sundholm, Stina. 1989. Insesti (Incest). Helsinki: Gaudeamus.
Poijula, S. 1999. Kriisikonsultointi- ja koulutuskeskuksen projektiraportti (Crisis
Consultation and Education Center. Project report). Traumaterapiakeskus, Oulu.
Perttu, S. 1999. Perhe- ja lähisuhdeväkivalta sosiaali- ja terveydenhuollossa. (Family
violence in social welfare and in health care). Julkaisuja 19. Ensi- ja turvakotien
liitto. Nykypaino Oy, Helsinki.
166
Eija Hiltunen-Back and Annamari Ranki
12. Treatment Services for Sexually
Transmitted Diseases
Epidemiology of Sexually Transmitted Diseases
The first hospital for patients with sexually transmitted diseases was established in
Finland in 1756. By the end of the nineteenth century, up to 44 percent of bed days in
the hospitals was attributable to STDs. The first chair of dermatovenereology was
established at the University of Helsinki in 1874.
Systematic data on the incidence of sexually transmitted diseases in Finland have been
available since 1930, when gonorrhea and syphilis were the most common STDs. In
1935, 10398 new gonorrhea cases and 1775 syphilis cases were reported. During
wartime in the 1940s, the number of persons with STDs doubled. After the introduction
of penicillin in the 1940s, the incidence of gonorrhea decreased. In the 1950s, 4500 to
5000 cases were reported yearly. Penicillin became the primary treatment for syphilis.
An obligatory effective serological screening program for all pregnant women contributed
to the disappearance of congenital syphilis in the 1950s.
Today the National Public Health Institute collects notifications of reportable STDs
(chlamydia, gonorrhea, hepatitis-B, HIV, syphilis) made by physicians and clinical
microbiological laboratories. This statistical data can be used for the prevention of
epidemics and for education purposes. For example the incidence of gonorrhea decreased
constantly after 1970s until the 1990s , (Table 1). In 1999 of the patients with gonorrhea,
75 percent were men, and every other infection was contracted abroad, mainly in
Russia. Finland’s proximity to Russia affected its statistics on STDs. During the 1990s,
Russia had epidemics of gonorrhea and syphilis (Rakhmanova, A et al.,1998). As a
consequence, the incidence of these two STDs increased in Finland, especially in its
eastern part. Because the amount of syphilis was very low in the 1980s, only 30 to 40
cases a year, health care personnel and the general public had almost forgotten the
symptoms and signs of the disease. In fact, one generation of physicians had never
seen syphilis patients. After the opening of the border between Finland and Russia in
the beginning of the 1990s, the incidence of syphilis in Finland doubled. Local epidemics
were identified in Finland, but due to effective partner notification and education of the
health care personnel, the situation was quickly brought under control (Hiltunen-Back
et al, 1998). In 1998, 187 syphilis cases were reported. The proportion of women with
syphilis has increased yearly, and in 1998, 45 percent of the patients were women. Men
contracted the infection abroad in 67 percent of the cases, 50 percent of them in
167
Russia. Women, on the other hand, tended to be infected in Finland by their steady
sexpartner.
While the traditional bacteria STDs have decreased constantly, chlamydia and the viral
diseases (like genital herpes, human papilloma virus-infections and HIV-infections) have
become more prevalent. During the 1970s, awareness of genital herpes increased, and
in the 1980s human papilloma virus (HPV)-infections became common among young
adolescents. The new viral pandemic, HIV-infection, reached Finland in 1983 when the
first AIDS cases were diagnosed in a research project (Valle et al., 1983). National data
on the incidence of genital herpes and HPV-infections are not available because these
STDs are not reportable. However, these two infections are currently the two most
common STDs in Finland (Hiltunen-Back et al., 1998). HPV-infection is the most
common diagnosis made in STD clinics. According to the serological studies in different
parts of the world, 20 percent of adults are herpes simplex virus 2 seropositive, but only
some of them have classic symptoms. Most herpes patients have an atypical clinical
picture (no recognisable blisters), and they are unaware they have the infection.
Chlamydia is the most prevalent bacterial STD, and about 10000 new cases are reported
yearly. Chlamydia is a common STD among young adults. Thirty percent of women
with chlamydia are under 20 years of age. In 1999, a total of 10575 new chlamydia
infections were reported; 63 percent of these infections were in women. Surprisingly,
the incidence of venereal chlamydia infection is not decreasing, although condoms are
easily available from the supermarkets, diagnostic measures are accurate, and treatment
compliance is good in Finland.
HIV-infection in Finland, compared with other European countries, has been under
control until now. This is primarily attributable to effective information and education.
Scientists studying AIDS approached the Finnish National Board of Health in early
1984. As a result of these consultations, by July the Board had nominated an “AIDS
Expert Group,” which is currently operating under the Ministry for Health and Social
Affairs. HIV antibody testing has been made easily accessible. It can be obtained free
of charge at any health centre or occupational health service. Of course, hospitals and
STD clinics offer free testing as well. Anonymous HIV testing is possible in Finland’s
five major cities. This testing is conducted at the Finnish Red Cross and AIDS Support
Centres.
In Finland, the number of reported HIV cases has been at a constant level since 1990
with 70 infections a year. The cumulative number of HIV-infected between 1983 and
1998 was 939, and 219 of them had died of AIDS. The number of deaths has decreased,
and this decline is attributable to antiretroviral medication and prophylactic treatment of
opportunistic infections. HIV-infection was confined to homosexual or bisexual men in
the early years of the epidemic, but 30 to 40 percent of newly diagnosed HIV cases in
the 1990s were in women and 40 to 50 percent were heterosexually contracted (Table
168
2). Because of Finland’s own national blood and blood product service (Finnish Red
Cross Blood Service), only two cases of HIV-infection have ever occurred through
blood products in Finland.
In 1998, for the first time, a significant number of HIV-infections were found among
intravenous drug users in Finland (Table 2). The following year up to 56 percent of all
reported new patients were drug addicts. HIV-infection in this population spreads mainly
by infected needles and possibly also by unprotected sex because some drug users
finance their drugs by prostitution. Today many cities in Finland provide free needles,
and some pharmacies needles. In Finland the injecting drug problem has worsened
during the past few years, especially among young people. The Ministry for Health and
Social Affairs initiated collaborative efforts by responsible authorities that aim to control
and stop the HIV epidemic among injecting drug abusers.
Table 1. Reported cases of STDs, by gender, 1995-1999. (population 5 million.)
STD
1996
men/women
1996
men/women
1997
men/women
1998
men/women
1999
men/women
Chlamydia
3444/5873
3469/5969
3815/6360
3977/6677
4068/6507
Gonorrhea
361/117
159/67
151/67
202/67
181/64
Syphilis
116/53
125/92
102/70
102/85
69/48
HIV
45/27
49/20
48/20
48/32
102/39
Source: National Public Health Institute, Helsinki Finland.
Table 2. The means of contracting HIV-infection in Finland, 1994-1999
Year
Number Women
Homosexual
contact
Heterosexual
contact
Blood
Transfusion
a)
Intravenous
Drug
use
Motherto-child
Not
known
2%
1%
8%
1994
69
20%
49%
36%
1%
1995
72
38%
34%
55%
0
1%
0
8%
1996
69
28%
33%
52%
0
1%
0
13%
1997
71
32%
26%
57%
0
0
1%
12%
1998
80
40%
16%
38%
0
22%
0
22%
1999
141
27%
8%
17%
0
56%
0
15%
Source: National Public Health Institute, Helsinki Finland.
a). Transmission abroad. In Finland the last infection from a blood transfusion occurred in 1985.
169
The Sentinel STD Surveillance Network
The information from Finland’s national infectious diseases surveillance system is quite
limited. For instance, no data are available on the risk behaviour of the infected persons.
The most common STDs, such as the human papilloma virus and genital herpes
infections, are not reportable, and there are no national data on the epidemiology of
these common infections. Since the beginning of 1998, physicians have not been required
to notify patients of genital chlamydia infections any longer. Now the only information
on the epidemiology of chlamydia is available from the statistics of laboratories. In
order to get more detailed information on STDs, a sentinel STD surveillance network
was established at the beginning of 1995. This network consists of seven STD clinics,
three health care centres, two student health care centres and two gynecological clinics.
The sentinel STD surveillance network provides data on the epidemiology of STDs, on
HPV and genital herpes infection, and on possible changes in the behaviour of the
patients. The information is collected by a uniform questionnaire given to every visitor
to an STD clinic. From 1995 to 1998, over 52000 visits were registered. In STD
clinics 25 percent of men and 17 percent of female visitors were found to have a
sexually transmitted disease. In men, HPV infection was the most common diagnosis
(11 percent); in women, chlamydia was most common (8 percent). Women had low
incidence of HPV-infection because only visible warts were registered and not positive
cytological findings. Genital herpes with symptoms was found among 3 to 4 percent of
visitors. Most of the patients (84 percent) went to the clinics at their own initiative; only
12 percent went at their partner’s request. Half of the women considered their regular
partner as the source of infection. Fifty percent of men suspected their infection came
from a casual partner and 5 percent suspected the source was a prostitute. Thirteen
percent of men and women had partners from foreign countries. During the past 12
months, half of the women and men had had between 2 and 4 sex partners, and 18
percent of men and 9 percent of women had had 5 or more partners. Twenty-five
percent of the women and 37 percent of men had been tested for STDs during the past
year, but only 20 percent had been tested for HIV.
Legislation on Sexually Transmitted Diseases in
Finland
In Finland, a specific law on STDs was in force from 1939 until 1986. This law
recognised four STDs: syphilis, gonorrhea, Donovanosis (Granuloma inguinale), and
chancroid (Ulcus molle). In 1987, a new Communicable Diseases Act and Decree was
established, and STDs were considered comparable to other transmittable diseases.
The decree regarded only syphilis as a quarantine-like infection for which the examinations
and the treatment are free of charge for the patient in communal health care. Chlamydia,
gonorrhea, HIV-infection, hepatitis-B, and lymphogranuloma venerum are reportable
170
STDs, and their treatment is free of charge for the patient. Thus, all treatments, even
the expensive HAART (highly active antiretroviral therapy) for HIV infection, are
provided to patients. In 1993, chancroid and Donovanosis were added to the reportable
STDs. Then, in 1997, the decree was amended so that the examination of reportable
STDs became free of charge. Chancroid, Donovanosis and lymphogranuloma venerum,
common in developing countries, are rarely seen in Finland. Genital herpes and HPVinfection, which are the two most common STDs, are considered like any other infection:
patients pay the examination and the treatment costs themselves. Both costs, however,
are partially reimbursed by the National Health Insurance covering all Finnish citizens.
According to the law, the local community health officials have the first-hand
responsibility for prevention and early detection of STDs.
Partner notification is considered part of the treatment and prevention of infectious
diseases in Finland. According to the order by the Ministry of Social Affairs and Health,
physicians have the primary responsibility to ensure that persons who may have been
exposed to STDs are examined and treated. In most cases the index patient informs the
partners. One third of the chlamydia patients in STD clinics are there because their
partner got chlamydia. However, no national data on the success of contact tracing
exist. Partners can be contacted on behalf of the patient by the clinic and asked to
attend the clinic. The patient’s identity is not revealed. Most partners understand that
being tested is in their own best interest. The five university departments of dermatology
and venereal diseases have the responsibility in their district to organise teaching of
physicians, both during medical school and later in continuing education and to coordinate
activities to combat STDs.
In Finland the departments of dermatovenereology in the university hospitals are
responsible for specialist training in venereology. Specialisation in dermatovenereology
takes six years. The prevention of STDs is mainly the task of local authorities, but the
university hospitals are obliged to provide education and consultation. The education is
arranged yearly in regional meetings.
Examination and Treatment of STDs
In the main cities there are full-time or part-time outpatient STD clinics, some of which
are run by the University Central Hospitals and some by the city health care. Patients
do not need referrals or appointments. The first visit is free of charge, and the commonly
obtained screening tests include chlamydia, gonorrhea, syphilis, and HIV. In the main
clinics, chlamydia is detected from the first-void urine by gene amplification methods,
but it is common to take swabs for chlamydia and gonorrhea from the urethra or cervix,
too. Syphilis and HIV are diagnosed by antibody testing of the blood. The results of all
these tests are usually ready within one week, and the patients can personally find out
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the results by making a phone call or by visiting the clinic. According to the patient’s
symptoms, other laboratory tests may be taken. According to the statistics of the National
Public Heath Institute, 60 percent of all genital chlamydia infections were diagnosed in
health care centres, 25 percent in STD clinics and 5 percent by private physicians. In
small communities people may feel ashamed to visit their own health care centre,
preferring instead to attend an STD clinic in a near-by city. Patients use their own name
and social security number when testing for STDs. According to the order by the
Ministry of Social Affairs and Health, everyone has the right to be tested for HIV free
of charge and anonymously. Student health care centres have arranged STD and HIV
examinations for students for a small annual payment. Patients who want to see a
private physician, must pay both the examination and treatment costs themselves (but
they may be partly reimbursed by the National Health Insurance).
Screening of STDs
The incidence of chlamydia remained fairly constant from 1995 to 1999. During this
time, diagnostic methods based on gene technology were established. Chlamydia can
now be detected from first-void urine with gene amplification methods, which makes
sampling convenient for the patients. Instead of a 10-day course of antibiotics
(tetracyclines), a single dose treatment (acithromycin) is now available. However, no
decrease in the incidence of chlamydia has occurred. Chlamydia is mainly the infection
of adolescents and spreads easily. The most difficult problem is the asymptomatic
chlamydia infection in 75 percent of women and 25 percent of men. These infections
can be detected only by specific tests. Asymptomatic chlamydia is contagious, and the
risk of complications increases over time. Genital chlamydia is the main reason for
infertility in Finland (Paavonen et al. 1998). Screening for asymptomatic chlamydial
infection is currently considered of primary importance in Finland. It will be much
cheaper to screen the risk groups today than to pay for the expensive infertility
examinations and treatment later on (Paavonen 1998). The screening interval, however,
has to be determined. Antibodies to chlamydia trachomatis have shown an association
with cervical cancer, but further studies are needed (Hakama et al., 1993).
Human papilloma virus screening (antibodies in blood or demonstration of HPV genome
in PAP-smears) is currently not considered of primary importance, for according to
results of recent research, no excess risk of cervical carcinoma among women seropositive
for both HPV 16 and HPV 6/11 has been found (Luostarinen et al.,1999). The number
of partners and coital frequency have been found to be higher in females with cervical
intraepithelial neoplasia (CIN) compared with other age-matched groups in Finland
(Taina et al., 1987). However, Finland participates actively in vaccine development
against HPV and HIV infections.
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In Finland all blood donors are tested for HIV, syphilis, hepatitis-B and hepatitis-C
(about 300 000 tests annually). For years, all pregnant women in maternity clinics have
been screened for syphilis, and since 1998 voluntary HIV-testing has been offered to
every pregnant woman according to the Ministry of Social Affairs and Health. Because
medication of HIV-infection can prevent the transmission of the virus from the mother
to the baby, such tests by heath officials are considered essential. Each year these
screenings identify 5 to 10 women as HIV- or syphilis-infected. Mothers with syphilis
are treated during the pregnancy with penicillin injections and there has been no congenital
syphilis since the early 1980s. In Finland, several HIV-positive women have given birth
to a healthy child. Four children have been confirmed HIV-positive, two of them have
AIDS and one is dead.
STD Research in Finland
STD research in Finland concentrates on chlamydia infection and its sequels, HIV
infection and AIDS and the diagnosis of HPV-infection. There are also large studies on
the connection between HPV-infection and cancer. The vaccine studies on HIV- and
HPV-infection are ongoing, and international cooperation is active. The epidemiological
studies in Finland also concentrate on STDs.
Conclusions
Finland has a reliable national STD surveillance system. The incidence of STDs remained
quite constant during the 1990s. The epidemics of gonorrhea and syphilis in neighbouring
Russia, however, are alarming: diseases easily cross national frontiers. Therefore, the
continuous surveillance system is necessary in order to act in time. Persons in Finland
with STDs are being diagnosed and treated, and the treatment is easily accessible and
often free of charge. Common viral diseases that lack a curable treatment pose the
greatest future challenge. Effective measures are needed for decreasing the incidence
of chlamydia. In Finland the new problem is the HIV-infection epidemic among
intravenous drug users. Action now can prevent an expansion of the epidemic. STDs
can cause both physical and psychological suffering. Treating chronic infections and
their sequels is expensive. The most important goal is to prevent STDs. Public education
and persistent research in vaccine development are essential.
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References
Hakama, M., Lehtinen, M., Knekt, P., et al. 1993. Serum antibodies and subsequent
cervical neoplasms: a prospective study with 12 years follow-up. American Journal
of Epidemiology 137:166-70.
Hiltunen-Back, E., Haikala, O., Kautiainen, H., Reunala, T. 1998. Anturiverkosto: uusi
sukupuolitautien epidemiologinen seurantajärjestelmä Suomessa (A new STD
surveillance network in Finland. Suomen Lääkärilehti 53:1541-45.
Hiltunen-Back E., Reunala, T. 1998. STDs in Finland; Syphilis and gonorrhea
increasingly imported, chlamydia mainly endemic. Forum for Nord Derm Ven Vol3
3:5-7.
HIV-seulonta äitiysveuvoloissa (HIV-screening in maternity clinics). Kansanterveyslaitoksen julkaisuja. Helsinki: Kansanterveyslaitos 1997.
Luostarinen, T., af Geijersstam, V., Bjorge, T. et al. No excess risk of cervical carcinoma
among women seropositive for both HPV 16 and HPV 6/11. International Journal
of Cancer 80:818-22, 1999.
Paavonen, J., Puolakkainen, M., Paukku, M., Sintonen, H. 1998. Cost-benefit analysis
of first-void urine Chlamydia trachomatis screening program.
American Journal of Obstetrics and Gynecology 1998, 92:292-98.
Paavonen, J. 1998. Pelvic inflammatory disease from diagnosis to prevention. Clinical
Dermatology 16:747-56.
Rakhmaninova, A.G., Melnik, O.B., Vinogradova, T.N. 1998. HIV and other sexually
transmitted diseases (STDs) in St. Petersburg, Russia. Forum for Nord Derm Ven
Vol 3, 3:11-15.
Taina, E., Erkkola, R., Kilkku, P., Liukko, P., Grönroos, M. 1987. Sexual behavior
and cervical intraepithelial neoplasia in teenagers. Ann Chir Gynaecol Suppl 202:8890.
Tartuntataudit Suomessa vuosina 1995–1998 (Infectious Diseases in Finland). Kansanterveyslaitoksen julkaisuja. Helsinki: Kansanterveyslaitos.
Valle, S.L., Ranki, A., Repo, H., Suni, J., Pönkä, A., Lähdevirta, J., Pettersson, T.
1983. Acquired immune deficiency syndrome. The first cases in Finland. Brief report.
Ann Clin Res 15:203-205.
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New Views on Sexual Health
The Case of Finland
Sources of Sexual Health Information
13. Measures of the Central Health Care
Administration to Promote Sexual Health
from the 1970’s to the 1990’s
Tuulikki Nurmi
175
14. STAKES - Projects on Family Planning
Maija Ritamo and Sari Kautto
189
15. Sex Education in the School
Seija O. Lähdesmäki and Heidi Peltonen
203
16. Sexual Health and the Evangelical Lutheran
Church of Finland
Martti Esko
213
17. Sex Education in Finland
Arja Liinamo
217
18. The Media as Sex Educator
Osmo Kontula
234
19. Sexological Teaching at the Jyväskylä
Polytechnic
Sirpa Valkama and Kari Kaimola
243
174
Tuulikki Nurmi
13. Measures of The Central Health Care
Administration to Promote Sexual Health
From The 1970s to the 1990s
In Finland issues relating to sexual health became topics in health care when the related
legislation was amended at the beginning of the 1970s. Statistics, research findings, the
proposals of the Working Group on Sex Education of the Ministry of Social Affairs and
Health, and statements of the World Health Organisation, as well as direct feedback
from sexual health professionals have provided the basis for the development work.
The focus has shifted from the undesirable consequences of sexuality, such as prevention
of abortions and sexually transmitted diseases, to emphasising the positive aspects of
sexuality – sexuality as a personal resource and a factor of the quality of life. At the
beginning of the 21st century, operational areas of priority are to promote education on
human relationships and sexuality for adolescents, develop sexual counselling within
health services and family planning services, prevent the spread of HIV infections and
other sexually transmitted diseases, and to avert the social and health problems associated
with commercial sex.
From Abortions to Prevention of Pregnancies
Lively debates on sexuality related issues occurred in Finland in the early 1970s. Legislation
was revised, instructions and plans were prepared by working groups of the relevant
authorities, research was carried out, and training arranged. Sexuality issues received
much attention in the media as well.
The new, fairly liberal Act on the Interruption of Pregnancy became effective in June of
1970. The number of legal abortions increased rapidly thereafter. There was considerable
harsh criticism that a law promoting counselling on general birth control was not enacted
at the same time despite the fact that the committee drafting the abortion act had also
presented a proposal for such a law. The Act on the Interruption of Pregnancy only
provided that advice on birth control needed to be given to abortion patients.
The Decree (such decrees give instructions on how a law is to be applied) on the
Interruption of Pregnancy assigned the National Board of Health to direct and supervise
the educational activities concerning general birth control as a way to reduce abortions
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and prevent illegal abortions. The Act stressed that citizens must be provided information
about birth control through various channels.
The National Board of Health was worried about the increased number of abortions.
Thus, at the end of 1971 it sent a letter to municipal midwives urging prenatal clinics to
intensify their activities to prevent pregnancies in order to decrease the number of
abortions. The need for co-operation with the school authorities was emphasised so
that young people could receive information at a sufficiently early stage on issues related
to pregnancy, childbirth, birth control, and sexuality. The National Board of Health also
sent copies of the letter intended for midwives to municipal health boards and school
boards. At the beginning of 1972 the National Board of Health sent a letter to the
National Board of General Education, which referred to the one sent to midwives,
proposing to intensify co-operation by using health care personnel as experts during
lessons dealing with birth control.
The Primary Health Care Act that became effective in April of 1972 stated that general
counselling on birth control was the responsibility of local authorities. This Act reformed
the administration and funding of public health work, and a comprehensive health
centre system was established within primary health care. According to section 14 of
the Act, municipalities shall maintain health counselling services, which cover health
education services concerning primary health care, including advice on birth control,
and general medical checks on their residents.
The first National Plan for Organising Public Health Work from 1972 to 1976 urged the
local authorities to focus attention on developing health counselling, and in particular to
intensify counselling on birth control. It was stated in the plan that health workers at
health centres could in the context of counselling on birth control distribute contraceptives,
even contraceptive pills, in line with specific instructions issued by the National Board
of Health.
In 1972 the National Board of Health sent local authorities instructions on birth control
counselling that had been referred to in the Primary Health Care Act. These included
the goals for birth control counselling, groups to target, methods to use in giving personal
guidance and advice, general educational activities and instructions about the choice of
contraceptives, and follow-up procedures for clients. The instructions were accompanied
by additional education material for the staff on family planning and contraception
methods. The Provincial State Offices arranged educational seminars in central hospitals
in order to teach physicians how to fit an intrauterine device (IUD). Large numbers of
health care personnel also took part in education programs organised by non-governmental
organisations.
The National Board of Health issued a circular dealing with the quality control of
contraceptives after provisions on that had been laid down by Decree in 1975.
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Accordingly, all contraceptives on sale required approval from the National Board of
Health. The National Board revised the circular in 1978.
Law Amendment Gave Impetus to Birth Control
Counselling
In the 1970s there was much public debate about the Act on the Interruption of Pregnancy.
For instance, in 1974 members of Parliament conducted a broad debate on the
interpretation and application of the Act. The Act was amended in 1978 so that, in
general, a pregnancy should be interrupted prior to the 12th week of pregnancy, instead
of the 16th week as was required before. The amendment became effective at the
beginning of July 1979. In the process of amending the Act, a directive of Parliament
stated that the general public needed to be informed about the new requirement.
Furthermore, the Act stated that counselling on birth control needed to be intensified
and that co-operation between school, social, and health care authorities in this effort
needed to be supported and encouraged. In September of 1978, The Ministry of Social
Affairs and Health appointed a working group to facilitate these efforts of intensification
and co-operation directed by the Amended Act on the Interruption of Pregnancy. The
tasks assigned to this working group were to plan an information campaign, to make
proposals for intensifying access to counselling on birth control and the use of
contraceptives, to arrange for collaboration of various interest groups, to monitor the
impact of the Amended Act and the related action programme, and to make proposals
for remedying its shortcomings.
The responsibilities of the working group were later extended, and it subsequently
made proposals for facilitating access to contraceptive pills and for amending legislation
on sterilisation. The purpose was to harmonise the Sterilisation Act with the Act on the
Interruption of Pregnancy by simplifying the handling of sterilisation matters and
prescribing age and number of children indications as grounds for access to sterilisation.
The act amending sterilisation legislation was in general agreement with the proposal of
the working group and became effective in 1985.
The working group assumed the name of a Working Group on Sex Education. It
understood its duties to be broad, and considered that it was inappropriate to deal with
interruption of pregnancy and birth control as separate matters, but as matters that both
related to the field of education on human relationships and sexual health. In addition,
the working group made a number of proposals for developing education on human
relationships and sexuality. As an immediate measure linked to the enactment of the
Amended Act on the Interruption of Pregnancy, the working group prepared and carried
out – in collaboration with the National Board of Health an information and education
programme.
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After the passage of the Amended Act, the National Board of Health provided materials
to the local authorities about the handling of abortion matters: instructions for early
detection of pregnancy, advice to those considering abortion, and procedures related to
performing an abortion. The National Board issued new instructions for counselling on
birth control in 1982.
Early in 1979, the National Board of Health arranged a national seminar dealing with
education on human relationships and sex, followed by regional seminars in the provinces
and, after about half a year, a feedback seminar. After the regional education had been
completed, on average, half of the more than 200 health centres of the country and several
central hospitals arranged further education on sexual health issues for their staff.
In addition, at the beginning of 1979 the National Board of Health arranged a seminar/
education programme on sex education for representatives of the media. Subsequently,
the general public was informed about the amendment to the abortion law through
press releases and television coverage. A brochure dealing with prevention of pregnancy
and the interruption of pregnancy was distributed to young people. Health care personnel
were informed of the amendment, apart from the seminars, in a bulletin of the National
Board of Health and in scientific journals. Additional sex education materials were also
published and distributed to health care personnel.
Monitoring of knowledge of the population about the amendment to the law was achieved
through three telephone interviews conducted by Statistics Finland: in spring and autumn
of 1979 and in spring of 1980. Knowledge of the amendment was considerably better
in the inquiries made after the Amended Act became effective (July, 1979). The number
of abortions was followed by analysing the statistics for half a year before and after the
Act became effective. Before the Act, 91.9 % of all abortions had been performed
before the 12th week of pregnancy, and after it, the corresponding figure was 95.5 %.
Monitoring associated with birth control was accomplished by administering
questionnaires at regional feedback seminars. Counselling on birth control had been
intensified in two out of three municipalities or federations of municipalities. They had,
for instance, started family planning and birth control clinics, increased the number of
personnel doing counselling work, broadened the target groups and improved services
by, among other things, increasing consultation hours and arranging consultation in the
evenings. Additional health education material was also provided for clients.
In sexual health the main emphasis in the 1970s was on establishing competent counselling
on birth control in municipalities and training the health care personnel for this task.
Municipal counselling on birth control in 1973 covered about 5 % of all women of
fertility age, and in 1977 about 18 %. The interruptions of pregnancy dropped
simultaneously from the high of 1973: 23,362 (19.6 abortions/1000 women aged 1549) to 17,772 (14.7 abortions/1000 women aged 15-49) in 1977 . In 1998 the number
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was 10,744 (8.6 abortions/1000 women aged 15-49), and thus the trend has been very
favourable.
From Counselling on Birth Control to Education on
Human Relationships and Sex
The proposals of the Working Group on Sex Education for developing education on
human relationships and sex provided a basis for the long-term, purposeful promotion
of sexual health in Finland. The measures put forward by the working group included
the reorganisation of education on human relationships and sex through instructions
from the relevant authorities, new sexual health education and information materials,
research, and special projects. In this effort to provide better sexual health education,
co-operation among health and education authorities, NGOs, and communities was
stressed.
The proposals of the working group received broad recognition: altogether 40 different
bodies (several ministries, central authorities, universities, the Evangelical-Lutheran
Church, central hospitals, trade, municipal and public health organisations) expressed
their opinions about them. Its work was considered a significant societal action and an
important opening in the field of sexual health. The importance of education on human
relationships and sex was underlined, and attitudes towards the proposals of the working
group were very positive. It was considered necessary to implement them and to develop
them further, to guarantee long-term action, and to allocate adequate resources for
these actions. Resources for the national promotion of sexual health had been obtained
through an appropriation for health education in the government budget – an appropriation
intended for reducing smoking and for other health promotion work carried out by the
Ministry of Social Affairs and Health.
In health care the framework for promoting sexual health was created by means of a
directive dealing with human relationships and sex education issued by the National
Board of Health for health centres and hospitals at the end of 1980. The goal was to
make sexual issues a natural part of the holistic care of patients and to develop the skills
of health care personnel through education in human relationships, sex, and sexual
counselling. The directive presented central considerations and contents of education
on human relationships and sex for target groups; gave guidelines for organising activities,
on-the-job training and job supervision; highlighted appropriate teaching methods; and
stressed co-operation with interest groups. In accordance with the report of the Working
Group on Sex Education, the directive listed the following goals of education on human
relationships and sex: 1) to enable a person to experience sexuality in him/herself and in
others as a natural, integral element enriching personality and 2) to help a person create
and maintain lasting and warm human relationships and enjoy as happy and satisfying
sex life as possible. At the community level the aim was to promote humanitarian
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behaviour, a positive environment for growth, positive attitudes towards sex, and equality
between the sexes.
In the 1980s education on human relationships and sex was also included in some
health policy documents. It was mentioned as a priority in health education in the
National Plan for Organising Public Health Work from 1980 to 1984. It was likewise
mentioned in the Governments Public Health Report to Parliament in 1985 and in
Finland’s Health for All 2000 strategy from 1986. The plan for the development of
health education for the years 1984 B 1988 put forward by the Advisory Committee for
Health Education included a development programme for education on human
relationships and sex. This plan was based largely on the proposals of the Working
Group on Sex Education and the feedback regarding the proposals of other professionals.
The aim was to intensify education on human relationships and sex for adolescents,
young families, and people with disabilities.
Advisory committees or co-operation groups for health education of municipalities and
federations of municipalities drew up plans for education on human relationships and
sex. Personnel were trained, and co-operation improved within health care and with
interest groups. Health education activities were intensified, especially in schools, health
care, and youth work.
Research, Education and Information in Support of
Activities
Research provided information that was used to develop and evaluate educational
programs on human relationships and sexual counselling. At first, priority was given to
research on the sexual behaviour of adolescents. The National Board of Health carried
out, in co-operation with the University of Helsinki, the KISS study, which provided
useful information about young peoples’ knowledge, attitudes, behaviour and culture
concerning sexuality, as well as their experiences and opinions of the sex education
provided at school. The study has been followed up in subsequent years. In the 1990s
the same types of information were obtained through a school health study. Further
studies that have been supported financially include a study on the use of contraceptive pills
and health among teenagers, and a study on sex education in the comprehensive school.
Sexual attitudes, knowledge and behaviour of public health nurses and the sex education
they received have been studied in different decades. The purpose of these studies has
been to learn more about the skills nurses receive in their vocational education that
enable them to give sex education and provide sexual counselling. The National Board
of Health contributed to a follow-up study regarding sexual behaviour of the adult
population (FINSEX 1990 B 1994), supported mainly by the Academy of Finland,
through both financing and representation in the group of researchers. The purpose of
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this research was to acquire information about the adult populations sexual attitudes
and behaviour, the need for sexual counselling, and the use of the counselling service.
Further topics that have been studied include the nature of jealousy and problems
related to it; child sexual abuse, its treatment and prevention, and the threat of AIDS
experienced among Finns, their knowledge of HIV infection and AIDS tests and their
attitude toward those infected with HIV. Attitudes of Finns about information sent to
them about sexual topics have also been investigated. For example, surveys have been
conducted about attitudes toward an AIDS bulletin sent by the central health care
administration to every home and also about attitudes toward the magazine with sexuality
information sent annually to all 16-year-olds. The yearbooks of health education research
have published articles on sexuality research. The health education unit of the National
Board of Health gave expert assistance and material for sex research carried out by
students of universities and health care colleges.
The purpose of further education has been to arouse interest and activity in promoting
education on human relationships and sex in various organisations and to develop the
related skills of professionals working with different population groups. The aim is also
to develop the skills of health care teachers so that they can incorporate sexual issues in
their instruction and thus ensure that in vocational education, health care personnel
obtain skills that are necessary for the promotion of sexual health.
Following the regional education organised at the turn of the 1970s and 1980s, the
National Board of Health initiated and arranged in collaboration with universities and
NGOs further education, in particular, for professionals working with young people and
people with disabilities. These courses were organised annually for several years. One
to two courses in giving education on human relationships and sex were arranged for
teachers of health care colleges from 1989 to 1995. In the 1980s the National Board of
Health together with other organisations also contributed to arranging one-year education
programs in sexual therapy.
The central health care administration has provided expert assistance for the regional
seminars arranged by Provincial State Offices and central hospitals and for local seminars
arranged by health centres and health care colleges. Expert assistance and sometimes
even financial support has similarly been given to education about sexual topics arranged
by other organisations. In addition, sexuality was a common theme in seminars arranged
solely by the National Board of Health.
The most important group targeted for the provision of information and material has
been young people. The central health care administration has produced and distributed
free material for sex education for the use of those working with adolescents. This
includes, for example, material with the theme growth to man/woman-adult (slides with
texts and further education material); AIDS material for adolescents (video, slide series
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and support material, stickers, brochures, posters); an education programme for Interrailers (including a small bag to hang round the neck containing information about
sexually transmitted diseases and a condom); a video called To marry or to Burn; a
brochure Am I mature enough to begin dating?, which included a condom; It depends
on such little thing (a TV and film spot and a brochure) and Wonderfully embarrassing
sexuality (information with slides and further education material).
During the 1980s, in order to further improve the educational skills of health care
personnel, the National Board of Health sent the following materials to all health centres
and hospitals: a book on sexology, basic course material in sexology, an issue of the
Duodecim journal and its own publications dealing with sexology, such as a booklet on
homosexuality and bisexuality, a report on eroticism and health, and a video on care
takers of those infected with AIDS and a related instruction booklet. In 1995 the Ministry
of Social Affairs and Health published a book on Finnish sex which included information
about changes in the sex life of Finns. The aim was for professionals in hospitals and
health care units to use this book in their work with the adult population.
In the 1980s the central health care administration organised several working groups
and projects intended to develop education on human relationships and sex. Examples
of activities are subprojects of the national development project, the project of a hospital
district that focused on interactions between young abortion patients and personnel,
and a development project of a federation of municipalities for developing education on
human relationships and sex for young people. Representatives of the central
administration have also participated in working groups and projects of various authorities,
the Evangelical Lutheran Church, NGOs, and communities. These working groups
have focused mainly on 1) providing education and materials and 2) devising plans for
development and action.
The Threat of AIDS and Its Prevention
A new, serious disease transmitted through sexual interactions shook the world at the
beginning of the 1980s. The prevention of AIDS started in Finland in 1984, when the
National Board of Health set up an expert group to make proposals for measures to
identify the risk groups, to arrange treatment, and to prevent the spread of the disease.
A monitoring group was appointed in accordance with the proposal of the working
group, administrative instructions were issued, and research on HIV/AIDS was initiated
in 1985. The task of the monitoring group was, among other things, to follow research
in the field and to make proposals to the National Board of Health so that information
and education aimed at preventing the spread of the disease could be prepared.
In 1987 the National Board of Health set up a 30-member AIDS delegation to deal with
and map out the views and needs in society about the medical, social, economic, ethical
and other problems related to AIDS. This delegation was also instructed to make any
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necessary proposals and take initiatives to solve various problems linked to the disease.
The legislation on communicable diseases was amended in the middle of the 1980s to
provide the basis for promoting HIV health education, free tests, and prevention of the
spread of the disease without coercive measures aimed at the individual. The coercive
methods under the old Act on Venereal Diseases were abandoned, except in the case of
syphilis. In December 1986 the National Board of Health issued a circular on organising
the work to combat communicable diseases, to stress the importance of health education
at the general and individual level, and to highlight the need of providing further training
for personnel.
Large-scale education regarding the prevention and treatment of AIDS started in 1985,
when five regional seminars were arranged for physicians working at health centres and
hospitals, and four seminars were organised to provide support for AIDS patients. In
addition to health care staff, representatives of various interest groups participated in
these seminars. Education and seminars were also arranged in collaboration with interest
groups. Seminars were scheduled for societal decision-makers and representatives of
working life, such as shop stewards, personnel managers, and editors of trade union
and labour market papers.
The National Board of Health considered it important to reach all adolescents, and in
1987 sent all those aged 16 to 21 a paper describing how to avoid AIDS, herpes, genital
warts, chlamydia and gonorrhoea. The National Board also wanted to inform adolescents
about the results of the KISS study, and thus, in collaboration with the school authorities
the KISS paper was distributed in schools to all eighth-graders in 1988. In 1989 the
above-mentioned paper dealing with how to avoid venereal diseases was sent to all 16year-olds. In addition to adolescents, military conscripts have been a central target
group for sex education. The National Board has co-operated with the Defence Forces
and the conscripts committee to reach this group. There has also been close co-operation
with the non-heterosexual organisation SETA, which has been extremely active in
informing its members about HIV infection, and AIDS, and safe sex.
In addition to materials designed for young people, the central health care administration
has produced several brochures and information materials dealing with the prevention
of sexually transmitted diseases including HIV. They include an HIV/AIDS bulletin sent
to every home in 1986, an AIDS information booklet for tourists, sexually transmitted
disease materials, and the latest brochure, produced in 1997 entitled Remember while
your are travelling information about prostitution and sexually transmitted diseases.
Furthermore, it has produced a series of slides and videos; information spots for radio,
TV and cinema; placards and posters; and outdoor advertising campaigns (e.g., one for
the First of May celebration). The central health administration has also sponsored
theatrical performances and radio and TV programmes, and maintained a telephone
information service.
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As of the 7th of February 2000, 1,104 people had been infected with HIV in Finland.
Of these, 306 have fallen ill with AIDS and 225 have died. By international comparison,
the situation in Finland has been good. The efficient information and health education
and the easy access to services, including free tests to detect an infection, have all
contributed to the low rate of HIV. Nevertheless, increased drug abuse in just the last
couple years has led to an increase of HIV infections in Finland. Finnish authorities and
experts have taken an active part to deal with this new situation. These professionals
have also used their expertise to help combat AIDS internationally.
Development of Sexual Health in the 1990s
At the end of the 1980s the Advisory Committee for Health Education appointed by the
Government wanted to give an impetus to public discussion about the connections
between sexuality and health, and thus commissioned a group of experts to make a
Report called Eroticism and Health. This report, published in 1989, contains researchbased data on the impact of sexuality on health, a description of Finnish sexual culture,
and ways to improve sexual health and well-being. The report aroused broad and
heated debate in homes and workplaces. In the media the report was spotlighted
everywhere: in news segments, columns, cartoons, special programs, interviews, and
letters to the editor. Foreign media also showed an interest in this topic when the
proposal for enriching the relationships between couples by a sex holiday was publicised
out of context before the report itself was completed.
A magazine for young people was developed in the late 80s and early 90s to cover
adolescent sexuality more broadly, although information about sexually transmitted
diseases was still a major theme. Other topics of the magazine were dating, first sexual
intercourse, prevention of pregnancy (including clear instructions on how to use a
condom), sexual orientations, and commercial sex. The magazine contains a condom
sample and a separate letter to parents dealing with adolescent sexuality. This magazine,
updated every couple years, has been funded from a grant for communicable diseases
in the government budget. Attitudes of parents and young people about this magazine
have been investigated twice, and feedback has been positive.
The promotion of sexual health of special groups has also been considered important
within the central administration. For example, health education grants have been used
for supporting the preparation of sex education material for mentally handicapped young
people, birth control information in English for foreigners and immigrants, and
publications on menopause in easy-to-read language and Braille, and a textbook on
sexual minorities.
At the beginning of the 1990s the central health care administration underwent several
organisational reforms. For example, the National Board of Health was abolished. The
role of the Ministry of Social Affairs and Health in directing and guiding health promotion
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and health education at the national level was strengthened. The Ministry continued the
national work for the promotion of sexual health in accordance with the earlier guidelines.
It is responsible for preparing the magazine about adolescent sexuality sent to all 16year-olds and organising national seminars in collaboration with the National Research
and Development Centre for Welfare and Health (STAKES). In the 1990s seminar
themes included Finnish sexuality, male sexuality, middle age and sexuality, long-term
illness or disability and sexuality, adolescents and sex, and sexuality today – where are
we heading?
The task of the Ministry of Social Affairs and Health is to plan the strategy for sexual
health and to decide on the grants for health education. The operational side of the
promotion of sexual health has been delegated to the National Research and Development
Centre for Welfare and Health. Various bodies can also apply for financial support for
the implementation of projects intended to promote sexual health. Projects whose goals
are to promote education on human relationships and sex for adolescents or to improve
sexual counselling within health care services and family planning are given priority.
The National Research and Development Centre for Welfare and Health (STAKES)
has co-ordinated family planning and education on human relationships and sexuality
within the framework of its Family planning 2000 co-operative project. In he pilot
region of the project, Central Finland, the National Research and Development Centre
for Welfare and Health, the Provincial State Office of Central Finland, the University of
Jyväskylä, and the Health Care College of Central Finland have in collaboration
developed family planning services and sex education for adolescents. Several other
bodies have taken part in the work. As a result of this work a centre of excellence for
family planning has been established in Central Finland. The polytechnic of Jyväskylä
has provided education in family planning and sexuality since 1994. A degree programme
of 40 credits, the first of its kind in Finland, for supplementary studies in sexology was
introduced in the autumn of 1997. The establishment and development of the first
centre of excellence for family planning has been supported for several years from the
government appropriation for health education. The Family Planning 2000 project of
the National Research and Development Centre for Welfare and Health has also received
funding from this government source.
In the 1990s commercial sex was often in the spotlight in Finland. Measures to prevent
the social and health-related problems caused by commercial sex have been undertaken
within health care. The Ministry of Social Affairs and Health has examined these problems,
and its representatives have taken part in various working groups and committees of the
relevant authorities dealing with these problems and making proposals for preventing
and solving them. In accordance with the Government Equality Programme, in spring
1998 the Ministry started a five-year national project to reduce violence against women
and prostitution. The goal of the project, apart from combating prostitution, is to reduce
the harm associated with it and to promote a positive sexuality in society. Representatives
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of several ministries, regional administration, the National Research and Development
Centre for Welfare and Health, the National Public Health Institute, NGOs, and local
authorities are all involved in this project. Finnish social and health authorities are also
working to combat prostitution and child sexual abuse in various international projects
and other contexts.
Evaluation and Development Needs
In the field of sexual health many situations which previously caused great concern in
Finland have improved: the need for abortions has reduced, the rates of diseases
transmitted through sexual intercourse are relatively low, young people receive sex
education, the equality between men and women in sex life has improved, and according
to survey findings, people in the 1990s were more satisfied with their sex life than they
were at the beginning of the 70s.
There are still, however, many improvements needed. Many do not receive needed
sexual counselling by trained health care professionals, and the skills of health care staff
to counsel their clients are not adequate. In addition, health authorities are concerned
that the rate of abortions for young women is now slightly increasing after a long period
of a steady decline. Nevertheless, pregnancies of those below the age of 20 have remained
at the same level for the last six years. In the 1990s, for financial reasons, local authorities
reduced preventive health care services, such as birth control and family planning services
and school health care. For example, opportunities for school health nurses to serve as
experts in sexual health lessons have been reduced due to a decrease in time nurses
spend in a school. The sex education provided in schools is likewise undergoing a major
change. Some changes in the middle of the 1990s contributed to weakening the status
of sex education in schools. According to various studies many schools have not developed
comprehensive sex education programs for their students.
Many health policy documents have addressed the sexual health of adolescents. For
example, the Governments Public Health Report to Parliament suggests development
of sexual health as one of the challenges for promoting the health of young in the next
few years. Development of education on human relationships and sex for young people
has been included in the National Plan for Organising Social Welfare and Health Care
Services from 1999 to 2002. Regional projects to promote adolescents sexual health are
being supported out of the governments appropriation for health education.
There is a constant threat that rates of sexually transmitted diseases will increase. The
spread of HIV infections has been accelerated by increased drug abuse. The incidence
of syphilis which had almost been eradicated in Finland has somewhat increased. The
frequent travel by Finns to neighbouring countries such as Russia and Estonia where
rates of sexually transmitted diseases are high has increased the risk of getting such a
disease for Finns.
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In recent years, commercial sex has become more and more common and its marketing
has become more visible. Identifying people and their sexuality as a product or object
that is on sale and can be marketed impacts negatively on sexual health, human dignity,
human rights, and equality. The reduction of commercial sex, especially prostitution, is
a demanding task, both nationally and internationally.
In health care the development of education on human relationships and sexuality and
counselling on sexual matters has been long-term, purposeful work that has had good
results. This work must, however, be continually intensified in order that the progress
continues. New challenges continually present themselves – probably as a result of
globalisation, the development of information technology, and the ageing of the
population. However health care has good opportunities to promote sexual well-being
and to prevent and reduce problems in sexual life.
References
Act on the Interruption of Pregnancy 24.3.1970/239.
Act on Sterilisation 24.4.1970/284.
Act on the Interruption of Pregnancy
Advisory Committee for Health Education: General Plan for the Development of
Health Education for 1984-1988. Publications of the National Board of Health,
Finland. Health Education. Series Original Reports 2/1983. Helsinki. 1983.
Advisory Committee for Health Education: Eroticism and Health. Publications of the
National Board of Health, Finland. Health Promotion. Series Statistics and
Reviews 6/1989. Helsinki.
Aromaa A, Koskinen S, Huttunen, J (ed.). 1999. Health in Finland. National Public
Health Institute. Ministry of Social Affairs and Health. Helsinki. .
Communicable Diseases Act 25.7.1986/583.
Communicable Diseases Decree 31.10.1986/786.
Decree on the Interruption of Pregnancy 1.2.1970/359.
From Beijing to Finland. The Plan of Action for the Promotion of Gender Equality of
the Government of Finland. Publications of the Ministry of Social Affairs and
Health 1997:20. Helsinki.
Health for All by the Year 2000. The Finnish National Strategy. Ministry of Social
Affairs and Health. Helsinki 1987.
Kontula, O. and Haavio-Mannila, E. 1995. Sexual Pleasures. Enhancement of Sex
Life in Finland, 1971-1992. Dartmouth. Ipswich, Suffolk.
Kontula, O. and Meriläinen, J. 1988. Adolescent Maturation to Courtship and Sexuality.
Publications of the National Board of Health, Finland. Health Education. Series
Original Reports 9/1988. Helsinki.
National Board of Health: Human relations and sex education in health education.
Directives.DNo 7032/02/80. Helsinki. 1980.
National Board of Health: Instructions on counselling on birth control referred to in the
Primary Health Care Act. DNo 10868/09/72. Helsinki. 1972.
National Board of Health: Directives on counselling on birth control. DNo 2346/02/82.
Helsinki. 1982.
187
National Plan for Organising Public Health Work from 1972 to 1976. Helsinki.
National Plan for Organising Public Health Work from 1980 to 1984. Helsinki.
Nurmi, T. 1990. Public Health Nurses and Sexuality. Ability of public health nursing
students to understand, educate and counsel about human sexuality. Publications of
the National Board of Health, Finland. Health Promotion. Series Original Reports 3/
1990. Helsinki.
Nurmi, T. 2000. Sexual Health and Public Health Nurse. Promotion of sexual health
and public health nurse graduates expertise in sexual health in 1970s, 1980s and
1990s. LicSocSci Thesis (Sociology). Publications of The Ministry of Social Affairs
and Health 2000:13. Helsinki.
Primary Health Care Act 28.1.1972/66.
Public Health Report Finland 1996 by the Council of State of Finland to the Parliament
on the present situation and developments in public health. Ministry of Social Affairs
and Health. Helsinki. 1996.
Report on the Working Group on Sex Education. KomM 1979:29. Helsinki.
Report on the Working Group on Sex Education II. KomM 1981:14. Helsinki.
Rimpelä, M. and Ritamo, M. 1995. Family Planning Services up to the Year 2000.
Dialogi, English Supplement 1B 1995. National Research and Development Centre
for Welfare and Health (Stakes) Finland. 27-29.
Turunen, M-M (ed.). 1996. When everything is for sale... - Report of the Expert
Team on prostitution. Stakes. Reports 190. Helsinki.
188
Maija Ritamo and Sari Kautto
14. STAKES – Projects on Family
Planning
Stakes: Statistics, Research and Development in
the same Centre
STAKES, the National Research and Development Centre for Welfare and Health, is
part of a group of agencies overseen by the Finnish Ministry of Social Affairs and
Health. STAKES produces information and know-how that promote well-being and
health and that secure equal access to effective and quality services for everybody in
the field of social welfare and health.
The Act on STAKES specifies the following obligations, among other things:
•To follow and evaluate the state and development of social welfare and
health care in Finland,
•To produce and acquire Finnish and international knowledge and know-how
and to pass it on to users,
•To maintain official and non-official statistics, files and registers in the field,
•To conduct research and development in the field,
•To promote and carry out training in the field.
As far as matters of family planning are concerned, STAKES is the statistical authority
maintaining registers and drawing up statistics on abortions, sterilisation, anomalies and
reports on treatment. In the field of reproductive health STAKES has conducted a great
number of studies and surveys, for instance, on the use of family planning services, on
how they should be developed and on screening fetuses. Children’s sexual exploitation
has also been surveyed and the professionals in the field have been dispensed advice. A
project on prostitution is under way. Guidelines for screenings and co-operation in
maternity care have been given by a group of experts in family planning and maternity
care. In projects related to research and development STAKES employs even outside
experts and expert groups.
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Direction for Development Work through
Negotiations and Surveys
If compared internationally, family planning and sexual health are mostly maintained
well in Finland. The hopes of the Finns regarding families have been surveyed and the
number of children women wished to have in 1989 was 2,5 and the corresponding
figure relating to men was 2,3. In reality though, women have 1,9 children on average.
The number of abortions was 10 600 in 1999, i.e. 8.7/1000 females of fertility age. The
figure is one of the lowest in the world. Sexual life has been studied in many studies
based on the population. Especially women’s contentment has increased. By international
comparison, the number of sexually transmitted diseases is still low in Finland. On the
other hand, deliberate childlessness has risen.
The main responsibility for family planning services is shared by health care nurses and
midwives trained for this task. At the beginning of the 1990s there was no precise
information about how the services were arranged, since many municipalities had started
to follow the principle of population responsibility and the recession cut down resources
especially in the area of preventive health care. In this situation the assessment of
family planning services was considered important. What also affected the matter was a
debate on tightening the stipulations on abortion, which was conducted for instance in
Germany, Poland and the USA.
At the end of 1992 there was a public debate alleging that teenage abortions were a
problem in Finland. By means of statistics it was shown, however, that in fact the
number of abortions and teenage mothers had continuously been decreasing. In the
spring of 1993 several negotiations were held under the supervision of STAKES in
which experts assessed the situation. At the same time a statistical report on abortions
and a survey on the prevention of teenage pregnancies and abortions were being made.
An working group of experts including researchers and administrative authorities in the
field and representatives of trade organisations and specialist organisations surveyed the
state of family planning in Finland and set goals for development. What was considered
important by the group was drawing up a basic report on family planning services and
supporting research and development. The contacts between those actively involved in
the development and research activities in the area of family planning were regarded as
extremely important. As far as client groups were concerned, it was emphasised that
services ought to take boys and men into account better than before in addition to
groups such as the disabled, refugees and those at many kinds of risks. The working
group made more detailed suggestions for the training of health care and social welfare
personnel in matters related to family planning and for sex education and counselling
for the young. It was stated, however, that development work had to be started in
collaboration with those who are involved in family planning in practice. The province
of Central Finland was linked with the development work as the pilot area.
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An extensive group of experts were asked to give a statement on the above-mentioned
suggestions. In this way development work was made public and the network was
being created for the future research and development in family planning. The group of
experts met annually to view the situation and consider plans for further action while
pondering over the contribution of their own sector in developing family planning.
A Process as a Course of Action in the Project of
Family Planning 2000
The actual development project was launched by STAKES in 1994 and was called
Family Planning 2000 according to the guidelines set by the working group consisting of
experts. After a three-year period the project continued for an extra two years and
finished in 1998. In addition to the project manager, a project secretary and an expert
senior physician were also involved in it.
The project was built as a national co-operative programme in which every participant
gave his or her own resources for research, development and training. STAKES provided
a forum for co-operation while collecting and passing on information and experiences
besides maintaining the network of those involved in developing family planning.
The project was launched in the pilot area through practical development work, which
was also linked with research if necessary. The partners both in the public and private
sector were offered the chance to participate in the project with a focus on developing
public services. The role of STAKES can be described as that of a supporter and
activator. Regional issues have been tackled at the national level and on the other hand,
it has been possible to pass on information nation-wide to be used regionally in the pilot
area. A common goal has been to improve the service system and to test new innovative
models in addition to providing information. Promoting professional training has been
considered important from the very beginning.
What has been essential to the development work is networking and performing
development work as a process. There have been endeavours to make more specific
objectives, and the enthusiasm and opportunities of the sectors and employees involved
in some area of the project have been the basic ground for the development work. The
developing process has been structured for instance by arranging meetings at which
those engaged in specific areas of the project have introduced their progress and each
stage of their task.
Providing information openly has been a crucial part of the project. Even tough the
project of Family Planning 2000 was targeted at employees in the field, there have been
efforts to pass on the information born within the project such as sex education for the
young, which citizens might find interesting, through the media. Briefings have been
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arranged in connection with meetings and seminars, and journalists have been welcome
to attend these events. Employees engaged in practical family planning have been
encouraged and supported to be active in passing on information.
The leaflet, meetings and training events make the network
The network leaflet called Perhesuunnittelu 2000 (Family Planning 2000) was set up
by STAKES to promote the collaboration of developers and new connections. What
was aimed at was to act as much as possible in two directions: on the one hand, to
receive writings and comments from readers concerning various on-going development
projects in the field and on the other hand, to pass on collected, topical information,
which is easily legible, to readers. However, the number of articles asked and received
was rather small and they were mainly extracts of studies. The leaflet has been sent to
persons registered in the network free of charge and in addition, it has been distributed
at various training events. Besides, it has also been possible to read the network leaflet
in the Internet pages of STAKES.
Network collaboration has been strengthened by arranging regional meetings, national
seminars and training events. National seminars, such as Finnish sexuality for instance,
have been held every year in which issues related to sexuality coming up in the work of
the professional staff have been considered together. Long-term illnesses and disabilities
were a topic which made the participants talk who seem to be rather alone when these
matters come up with their clients.
Making study trips abroad and participating in conferences as one group have especially
tightened the co-operation of the core group and created a joint view on matters. The
travelling reports drawn up on the journeys have been published in special issues of the
network leaflet focusing on a theme (such as the conference on abortion in Holland and
the world congress of sexology in Spain). Thus their contribution has been passed on to
the whole network.
During the various smaller projects with a focus on a specific theme some more permanent
forms of co-operation were advisory boards of Fertility Festivals and the project groups
responsible for their planning and realisation. Encouraged by a trip made together to
attend a congress an idea to found a sexological association in Finland was born.
Central Finland as the pilot area
The province of Central Finland including 30 municipalities and 250 000 residents was
chosen as the pilot area while the group of experts were still working on the project.
Central Finland is a clear administrative whole and, as far as development and research
are concerned, its centre Jyväskylä has such important units as the hospital district and
the central hospital in addition to the university and the polytechnic specialised in the
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field. Measured by the number of abortions and sexually transmitted diseases it also
represented an average area. What was also important was the fact that the provincial
authorities as the co-ordinator and other partners involved were active and enthusiastic
about the development work.
The pilot project was launched by arranging a multi-professional meeting to which
interested representatives of the primary health care were invited in addition to employees
working for the private sector, the university, the polytechnic and organisations. At the
meeting the proposals made by the expert group of STAKES were introduced as well as
the state of family planning in Central Finland, which was interpreted by means of
statistics. The participants´ task was to define the main targets to be developed, which
included abortion, the first contraception, the treatment of infertility, sex education for
the young and the prevention and treatment of chlamydia. At the meeting small groups
were set up to focus on these areas.
The fact that the representatives of STAKES and provincial authorities visited all the
health care centres in the area proved to be a considerable addition to the pilot project
of Central Finland and it gave important feedback to the whole project as well. The
negotiations attended by the representatives of the social welfare and educational service
gave concrete information about the state of family planning. There was also a discussion
on issues that needed to be developed most among the services which the municipality
has available.
Fertility Festivals – Making Sex Education More
Fun for the Young
The question how to make many small projects visible and beneficial for more extensive
use was being pondered over while the pilot project of Central Finland was still going
on. An idea put forward was to arrange an event that would be both educational and
informational while also being an exhibition. The name chosen for it was Fertility Festival, which also aroused contradictory thoughts. Its purpose was to turn the tone, which
used to be warning and to make one feel guilty, into something more positive and
joyful. The most prominent part of the event, which lasts several days, is a street
performance one afternoon in which health care and social welfare students and related
organisations distribute information about sexuality and the family in a wide variety of
ways. Pupils can familiarise themselves with various information points with the help of
the students. There is information available about contraception, childlessness, various
support services for the family as well as about different kinds of sexuality. In addition,
musical and dance performances, briefings and various other performances are arranged
on stage. Events called “ask the expert“ targeted at young people are popular. Besides,
special opportunities are arranged for parents where they can talk. In the spring prior to
the festival, writing competitions related to the subject are held for schoolchildren to
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make the event known in advance. Those representing the army and the church also
participate in planning and realising the programme.
In connection with the festival special training is available for employees and teachers in
the field. Besides familiarising themselves with the festival participants can acquire new
information and stimuli for their work by attending the seminars.
The media have found the fertility festival interesting as an event itself and through the
themes introduced. The local papers, regional radio stations and the television have
covered various subjects in a variety of ways and matter-of-factly. A few local papers
have published special pages focusing on a particular theme beforehand. This is how it
has been possible to market the event.
The festival itself with its specialist training is just a climax of the work accomplished in
the area during the previous year. The major participants representing educational
institutions, provincial authorities, the hospital and the primary health care, various
organisations and the army have set up groups for planning. Students at the health care
and social welfare polytechnic have familiarised themselves with the themes of family
planning and sex education for a year with a view to the coming festival. The event has
been supported by the advisory boards which have met under the supervision of the
provincial authorities. What is regarded as the starting-point is that each sector does its
own share as part of its normal work and students as part of their studies. However, it
has been necessary to release one person, who can fully concentrate on his or her task,
and who is responsible for co-ordinating such a big event of 2-3 days and even 5000
participants. This has been possible since the Ministry of Social Affairs and Health has
supplied funds for the event as part of the task of developing sex education for the young.
The significance of the festivals lies in collecting the various participants to plan and
realise a prominent event. Co-operative relations that are born during the project have
also functioned well after the festival. Besides, the event has inspired both young students
and their teachers to start looking for working methods for health education that would
combine theory and practice. This is how employees have acquired new information
and new models for their work. The event has also raised the subject of sex education
for the young under public discussion through the media. For the first time the fertility
festival was arranged in Central Finland in 1996. It has become an event which takes
place every spring and only the location of the event has occasionally been changed.
Developing Professional Skills
The expert group of STAKES regarded the strengthening of one´s professional skills as
one of the most important tasks. The view that gained ground during the project was
that the attitudes, knowledge and skills of the personnel to deal with sexuality were
essential in developing the services in the field of family planning and sexual health.
194
Whether or not family planning and sexual health should be included in the health care
and social welfare education were surveyed at the beginning and at the end of the
project. What the reports clarified was that there were rather few and sporadic studies
focusing on a particular subject. However, a better direction is to be seen because in
various parts of Finland more organised complementary education has been arranged in
the field of sexual health.
There have been efforts to enhance professional skills in the project of Family Planning
2000 by arranging free meetings and national seminars. They have stimulated discussion
and co-operation while encouraging the participants to look for new information and to
test new working methods. New learning materials, videos, literature and ideas for
development, born in various smaller projects, and experiences gained at work, have
been introduced at exhibitions linked to the training events. Through the network leaflet
information has been passed on more extensively to those belonging to the network.
The training calendar included in the leaflet has served well in informing about the
coming training events.
Various working methods, adaptable even more widely, have been tested with purpose
of increasing employees´ knowledge and skills. The methods have included group interviews,
descriptions of local treatment practice as part of quality assurance, and festivals.
The response received from the employees in Central Finland highlights the following
aspects: their attitudes to sexuality have widened, their courage to talk about even very
intimate affairs has increased, their willingness to participate and their participation in
complementary training have also increased. These changes in attitudes are remarkable
results as far as the permanence of the changes is concerned.
In recent years the subject matter of sexuality has been increased especially in the basic
vocational education of health care and social welfare provided by the polytechnic in
the pilot area. As the only educational institution specialised in health care it has included
matters on sexuality in the actual studies. The polytechnic has commenced to provide
complementary and further education in sexology for those who have completed the
adaptable basic degree. Besides, it also collaborates actively with domestic and Nordic
partners to develop the educational content and structure. Moreover, wider contacts
with related international instructors have been made. A brave opening to sexological
education has been the building of a special set-up for study called Adam and Eve in the
polytechnic with literature, videos, music, aids and other material on family planning
and sex education. Adam and Eve aims to familiarise students engaged in various studies,
such as health care and social welfare and those intending to become teachers or doctors,
as well as employees working on the crisis telephones, with a variety of sexuality. The
visits are supervised by teachers trained in sexual therapy. Adam and Eve is becoming a
facility for SAR (Sexual Attitude Restructuring). Other activities, such as research and
guidance by telephone together with the hospital and the department of psychology at
the university, are being linked with the centre.
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Abortions at the Focus of Development
Abortion is not completely free in Finland. The main indications for abortion are social
(85 %), other indications include the mother´s or the foetus´s illness, the mother´s age
(under 17 or over 40) or the number of children in the family (4 or more) or pregnancy
resulting from rape. Two physicians have to recommend termination. Pregnancy has to
be terminated before the end of the 12th week of pregnancy. In special cases the National
Board of Medicolegal Affairs may allow abortion until the 24th week of pregnancy.
There is no evidence of illegal abortions in Finland and nowadays just a few miscarriages
occur every year when there is no knowledge whether they were abortions or
spontaneous.
Every now and then abortions are debated about publicly in Finland. This has often
taken place during the parliamentary election when it is usually a sector related to the
church that chooses the subject as their election theme. The development project of
family planning was launched by this kind of public debate on young girls´ abortions at
the end of 1992. Terminations of pregnancies were not considered a problem in Finland
then: the number of abortions had been reduced by half within 25 years and the downgoing trend seemed to continue. Compared internationally, the abortion situation in
Finland was extremely good and the opinions of Finns to abortions were neutrally
liberal and there was no pressure for changing the legislation. On the other hand,
termination was seen as a routine measure in health care and altering the practices was
not paid any attention to.
Figure 1. Abortions and teenage deliveries in Finland, 1976–1998
18
16
14
12
Abortions/1000
females, aged
15–19
10
8
Abortions/1000
females, aged
15–49
6
4
2
0
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
196
Deliveries/1000
females, aged
15–19
When the project was being launched, the statistical data was updated and further
surveys on teenage pregnancies and abortions were made. An extensive seminar on
abortion and contraception was held, which focused on their medical, social and ethic
aspects while the working group was still actively engaged in their work. The seminar
and the report published by STAKES, which was based on it, collected topical information
and created an excellent database for the team.
One of the advantages of the project was the fact that STAKES as the statistical authority
could easily benefit from abortion statistics both in the development work and in providing
feedback information for hospitals. The statistics inspired discussions at regional meetings,
for instance. Simultaneously progress was made in matters related to abortion at the
national level and in the pilot area. At the first meeting of the Central Finland project
abortion care was chosen as one target to be developed. A retrospective survey was
made on the abortions conducted at the central hospital. The senior physician and the
expert physician of STAKES clarified by means of questionnaires what kind of
experiences the senior physicians had about the treatment of abortions in all hospitals.
The senior physicians had the chance to comment on the questionnaire-summary and
give their response about the adaptability of foreign guidelines into Finnish practice.
The Finnish Journal of Medicine introduced the above-mentioned survey and the dialogue
with the senior physicians more extensively to the medical profession.
In the early 1990s preparations for providing evidence-based medicine for the main
illnesses were started on the initiative of Duodecim, the Finnish Medical Society. National
guidelines are used as a basis for regional treatment recommendations. In this system
the fact to what extent treatment is beneficial is monitored in the light of the results
achieved through research. What is also aimed at is to unify local treatment practices
and agree on nursing chains regionally. As the outcome of the pilot project regional
treatment recommendations on abortion for Central Finland were created. The
knowledge acquired through this development work was benefited so that the doctors
who had composed the regional treatment recommendations were also involved in the
working group which drew up the national guidelines for abortion.
Commitment to the development project on guidelines caused a systematic survey on
treatment practices used when abortions were conducted in Central Finland. The skills
of quality assurance available at STAKES were benefited by arranging special training
on treatment practices at the meetings. Besides providing the descriptions of treatment
practices, the Central Finland project supplied a model for a new practice, according to
which patients were divided into groups by the primary health care that would need
either one or two visits to hospital. In addition, the experiment included a questionnaire
for patients on the quality of the whole process.
From the very beginning patients´ needs for mental support were emphasised in
connection with abortion. A video was ordered from the students of the polytechnic in
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Central Finland on how the patients viewed abortion for the seminar called “Abortion
and Anxiety“, held in the spring of 1994. Making the video launched continuos and
various co-operation between the educational institution and STAKES. A study on the
experiences of patients who had had an abortion was made by the co-ordinator of the
pilot project, who worked for provincial authorities.
How the patient who had had a miscarriage or an abortion could be supported was still
being pondered over at a meeting arranged by STAKES in 1997. Representatives of the
primary health care, hospitals and polytechnics had been invited to attend it. The purpose
of the meeting was to co-ordinate and inspire a debate on the need for psychic and
social support and on developing client-oriented information and support forms. Thanks
to the meeting brochures for clients have been reformed in many hospitals.
STAKES arranged meetings for the hospitals conducting abortions to develop the
treatment of abortion in 1995, 1996 and 1998. The memorandum of the 1996 meeting
was sent to all the health care centres in Finland by STAKES. The theme at the first
meeting was the treatment practices of abortion and registering, while the second meeting
focused on quality assurance. The third meeting offered the chance to give feedback on
the draft of the national guidelines in addition to introducing the experiences in the
Netherlands. For the meeting the hospitals entered their own practices of treating abortion
into more detail and further surveys linked with them were made in many institutions.
Those attending the meetings were sent plenty of material in advance to inspire interest
in the development work. It was also possible to give feedback on the forms being
made. The statements given by the university hospitals were a kind of peer review. At
the meetings the development process was maintained by reporting on the next phase
as well as by giving a schedule with the date when the matter would be dealt with. The
network leaflet has introduced the content of the meetings extensively, and the articles
on abortion, published in the professional magazines, have been written with a view to
arousing interest and to maintaining discussion.
Culturally, Finland has been a very homogenous country until recent years. A study of
the opinions of the Finns proved that their attitudes and way of thinking looked rather
unified. Many international conferences such as the Fourth World Conference of Women,
which took place in Beijing in the summer of 1995, opened the eyes of the Finns to see
how culturally bound the attitudes towards abortion are. The study trip to Amsterdam
and the participation in the first world conference on abortion there in March 1996,
arranged by the project of Family Planning 2000, aroused plenty of discussion among
Finnish participants. The most significant contribution of the journey was to notice that
the treatment of abortion can be different as shown by the various practices and courses
of action in the Netherlands.
After the project of Family Planning 2000 finished at the end of 1998, collecting
information related to abortion and reporting on it were considered important at STAKES.
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In 1999 this work is still going on in the project called Reducing the Number of Abortions.
International Connections Support National
Development Work
The objective of the Family Planning 2000 Project by STAKES was to develop family
planning. What was considered important by the group of experts was, however,
collaboration with Finland´s neighbouring countries such as Estonia and Russia. There
were efforts to create systematic co-operation with Estonia in order to promote training
in the field of family planning, but at that time the Estonians had no resources for it.
Contacts were maintained by arranging seminars on family planning and maternity
care, in which STAKES also participated. One of them was held in Finland, the other in
Estonia. Since then more informal networks have been born and training and educational
visits have been arranged by both countries.
The international Women´s Health Action Foundation, WHAF (Holland), provided the
chance for Finnish representatives to take part in the comparative assessment of family
planning services in eight countries. The practical and client-oriented approach of the
WHAF encouraged Finns to participate in the study and this approach was expected to
benefit the development of Finnish family planning. The Finnish contribution to the
study focusing on Central Finland was accomplished by a researcher at the university.
Later a few other researchers and students made surveys on the situations with clients,
including interaction, as well as on the results of the interviews with groups of young
people. The surveys were sponsored as academic demonstrations in Finland and
developed further for educational material for health care.
Taking part in expert meetings on sexual health in Europe, organised by the World
Health Organisation (WHO), has provided an international viewpoint. The co-ordinator
of the project of Family Planning 2000 has also participated in the working group of the
Committee on Equality in the European Council on the right to free choice in matters of
sexuality and reproduction.
Nordic co-operation has a long history and because of the similar social structure, it is
worth collaborating in several cases. In the area of family planning this kind of
collaboration has been accomplished mainly in matters of abortion, sex education and
in the field of sexual health services. The family planning project invited a group of
Finnish experts to attend a seminar in which sexological education in the Nordic countries
was surveyed and assessed. In this area co-operation is extremely important, since the
systematic teaching of sexology in vocational education is rather limited in Finland. Cooperation continues concretely by developing complementary educational programmes
and by planning a co-Nordic seminar to be arranged in Finland. Professional skills of
sexology were strengthened when a group of 13, activated by the project of Family
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Planning 2000, participated in the 13th world congress of sexology in Valencia Spain in
the summer of 1997.
New views on developing Finnish family planning have been received from foreign
experts visiting Finland who have been shown the good results achieved in the field of
family planning and sexual health. The questions and comments by the foreign guests
have made those involved in the project ponder over threats, which the change in the
service structure and the reduced resources have brought out.
Results and Challenges
The number of abortions decreased in the pilot area,
guidelines are being made
Development work in the area of family planning has been active in Central Finland and
the progress seems to continue in the same direction even though the pilot stage has
already finished. The change, even measured by so called hard measurements, has
been positive: the number of abortions has been decreasing all the time, while the
numbers focusing on the whole country increased slightly in 1996. The number of
teenage abortions has grown a little in Central Finland, too, but on the other hand, the
number of births given by teenage mothers has still been decreasing.
From the point of view of clients using family planning services, there have been a
number of small improvements: a regional treatment recommendations on care of
infertility help the personnel direct the client to the correct place for treatment. The
change in the regional treatment recommendations on abortion mainly into one visit to
the outpatient department instead of two saves time and costs for both the client and
hospital. Savings on effort and expenses are attained when overlapping examinations
have been removed by means of the regional treatment recommendations.
Abortion treatments are an excellent example of how active engagement in drawing up
regional treatment recommendations also promoted the composing of national guidelines.
The programme of the pilot area has been a model for other hospital districts, too. A
national guideline on the care of infertility is being accomplished.
National guidelines are required for other essential sectors of family planning. The most
urgent ones would be those on contraception and on the treatment of chlamydia. In
addition to them, regional treatment recommendations are needed to define the cooperation of hospitals and primary health care. More emphasis is to be laid on the work
focusing on clients´ and couples´ needs when developing family planning services and
primary health care.
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Sex education is more abundant in central Finland than in the rest of the country,
professional skills are strengthened
Surveys on sex education at schools showed that according to both teachers and students
at the schools in Central Finland there was plenty of sex education in different grades,
which was also versatile, compared to the rest of the country.
Numerous regional reports have been made on sex education for the young as part of
the national school health study. Sexual behaviour of the young, knowledge of
contraception including postcoital/emergency contraception have also been studied in
the reports. Material for sex education for the young as well as their opinions of it have
been assessed.
A new extensive project is to be launched to develop sex education for the young as cooperation between health care and the educational system. A curriculum based on
pedagogical and socio- psychological knowledge will be drawn up and new teaching
methods will be developed and experimented.
The polytechnic in the pilot area has launched further education in sexology as the first
educational institution in health care and social welfare. Teaching focusing on sexology
and development work have been collected into a separate sexological unit at the
polytechnic. The unit is actively involved in promoting co-Nordic education in sexology
in which both the educational content and structure are being reformed.
A more systematic education of family planning and sexology, which had started in
Central Finland, is about to spread to other polytechnics as well, which is promoted by
the birth of the network for teachers who teach family planning at polytechnics. The
members of the Finnish Sexological Association, founded in 1997, mainly include
professionals engaged in practical health care and teaching. The association endeavours
to distribute information on the related field, to develop education and to make
international contacts. For its part the association continues the network co-operation
born in the project of STAKES.
The Family Planning Network in central Finland is to
continue development work
Co-operation in various development projects was tightened during the pilot project.
Those actively involved in the projects in Central Finland wanted to have a more
concise form for the continuance of collaboration. That was how the Family Planning
Network was born with duties to co-ordinate co-operation. The new centre, supervised
by the polytechnic, aims to develop skills in family planning and promote sexual health
regionally, nationally and internationally. Besides, it also operates as a multi-professional
network to improve the quality of services, and local treatment practices and related
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education are being developed, research conducted and educational material produced
by active participants. In addition to the polytechnic, primary health care, central hospital,
the university, various organisations, the church, the army and STAKES are represented
in the network.
References:
Gissler, M. 1999. (ed.) Aborter i Norden. Induced Abortions in the Nordic Countries.
STAKES, Statistical Report 10/1999.
Hardon, A. & Hayes, E. (ed.) Reproductive Rights in Practice, A Feminist Report on
the Quality of Care. London & New York: Zed Books Ltd, (Women´s Health Action
Foundation).
Kosunen, E. 1996. Adolescent Reproductive Health in Finland: Oral Contraception,
Pregnancies and Abortions from the 1980s to the 1990s. University of Tampere, ser
A vol. 486.
Kosunen, E., Rimpelä, M. 1996. Towards regional equality in family planning: teenage
pregnancies and abortions in Finland from 1976 to 1993. Acta Obstetricia
Gynecologica Scandinavica 1996; 75: 540-547.
Kosunen, E., Rimpelä, M. 1996. Improving adolescent sexual health in Finland. Choices
(former Planned Parenthood in Europe) 1996; 25, vol. 1, 1996, 18-21.
Liinamo, A., Ritamo, M., Heimonen, A., Launis, T., Pötsönen, R., Välimaa, A. Taking
Adolescents Seriously: Four Areas of Finland. In Hardon, A. & Hayes, E. (ed.),
Reproductive Rights in Practice, A Feminist Report on the Quality of Care. London
& New York: Zed Books Ltd, (Women´s Health Action Foundation).
Rimpelä, M., Rimpelä, A., Kosunen, E. 1996. From Control Policy to Comprehensive
Family Planning – Success Stories from Finland. Promotion & Education 1996; Vol
III, 1996/3, 28–32. IUHPE Journal, Paris.
Rimpelä, M., Ritamo, M. 1995. Family Planning Services up to the Year 2000. Stakes,
Dialogi 1b/1995.
Ritamo, M. Family planning in Finland up to the year 2000. Abortion Matters –
Proceedings 1997; International Conference on reducing the need and improving the
quality of abortion services.
STAKES: The Development of Family Planning Services up to the Year 2000. Report
of the working group. Themes 6/1994. STAKES, Helsinki
Väestöliitto, The Family Federation of Finland. 1994 and 1998. How We Did It.The
Evolution of Sexual Health in Finland. Helsinki: Väestöliitto.
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Seija O. Lähdesmäki and Heidi Peltonen
15. Sex Education in the School
By international comparison, general sex education and the sex education given in
schools in Finland is matter-of-fact and open in character. These qualities are evident in
many ways including the prevailing culture of public debate. The work of school nurses
has strong traditions in Finland, with respect to both individual counselling and health
education. On the whole, the general public appears to approve of openness in sex
education. An illustration of this acceptance is the favourable reception of the initiative
by the Ministry of Social Affairs and Health to send all young people turning 15 an
information package and a sample condom to their home address.
General sex education and the sex education given in schools are characterised by
regional equality and uniform objectives for both the instruction given and the activity
of school health care. According to the objectives the young, regardless of where they
live or go to school, or of the family’s ideological background or social environment,
shall have an equal opportunity of receiving instruction on sexual-related topics. Currently,
the inclusion of sex education issues in the curriculum of an individual school does not
lead to much public discussion in Finland.
Opportunities Awarded by the Curriculum
Early years of the comprehensive school
Issues related to human sexuality and interpersonal relationships have, despite the
description above, been dealt with in different ways in schools at different times. Especially
during the 1970s, but even toward the end of the 1980s, certain groups viewed the
current sexeducation very negatively. This opposition also extended to textbooks, which
were the source of many questions in the Parliament as late as the 1980s. Similarly, the
values and attitudes of teachers produced obstacles hindering sex education.
The second report of the Curriculum Committee for the Comprehensive School from
1970 created good opportunities for sex education. The contents of this report were not
primarily envisaged as core curricula according to the present view, but they were
considered as normative enough to warrant an almost literal observance. This would
have been entirely possible, because the reports mostly contained very detailed
descriptions of the topics to be dealt with in each subject for each grade. The
implementation of the comprehensive school curriculum proceeded gradually throughout
the country, starting from the north and ending in the capital region in the autumn of 1977.
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The Report’s Section II contains an excellent description of how sex education should
be constructed. The most comprehensive description of sex education is contained in
the family education section of the subject Civic Skills.
A balanced development of the personality also includes a natural attitude to sexual
life. One of the conditions for this is that the individual is sufficiently well informed
of the facts related to sexuality. … Even at the pre-school age … it is important that
issues of family education are dealt with at all stages according to the pupil’s age and
conceptual powers. At the primary stage, according to the teacher’s discretion,
differences between boys and girls, the birth of a child and a child’s dependence on
its mother, father and home should be discussed. … At the secondary stage, family
education should be integrated with the instruction in other subjects – primarily
Natural History [Biology]. Thus Civic Skills could concentrate on issues related to
mother- and fatherhood and the psychological and ethical aspects of marriage. … It
is important to remember that school is the only social institution to reach all members
of every age group. With the exception of certain special cases, sexual issues are most
naturally discussed in groups consisting of both boys and girls.
A matter-of-fact sex education not only offers the opportunity of decreasing the numbers
of abortions, children born out of wedlock or cases of venereal disease, but also
creates better conditions for a happy family life. With regard to the individual, the
task of sex education is to help the young to understand their sexuality as a constructive
force that is to be accepted and respected as an integral part of their development.
The content description for fifth grade Natural History (Biology) was stated as the
following: at a suitable stage, the human body and its vital functions are examined
and this instruction contains basic information on the changes occurring at puberty
and on human reproductive biology. The ninth grade topics included a brief mention of
reproduction, development of the foetus, growth and hormonal activity. The instruction
must bear in mind the contents allotted to Civic Skills.
In Home Economics, the section on child care and family education included the
following topics, among others: conception, main developmental stages of the fetus,
physiology of pregnancy, growing to be a mother and a father, preparing the family
for the birth of the child, childbirth and new-born babies. A reference is made here to
Natural History.
Instruction reform in the comprehensive school
The National Board of General Education approved the first official core curricula in
1985. The general objectives of these contain the heading all-round development of the
pupil’s personality, but the following text mainly concentrates on a description of the
development of the pupil’s overall personality and her or his opportunities for developing
and learning.
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The objectives for each subject were described in a general manner in the core curricula.
The contents again were listed by topic for each grade or for two successive grades
together. Municipalities were able to modify the core curricula to some extent to
accommodate local circumstances.
Topics connected with interpersonal relationships and sexuality can be found under
different subjects as follows:
Objectives for Civic Skills mention that instruction shall deal with human growth and
development, the creation and maintenance of interpersonal relationships, a healthy
lifestyle. … The content mentioned for the third and fourth grades include personal
growth and development and for the fifth and sixth grades puberty, differences and
similarities between people, interpersonal relationships, … responsibilities and duties
… and learning about and observing vital functions, problems related to puberty … .
One of the objectives of Biology instruction is to provide instruction particularly in
the structure of the human body and vital functions. Objectives related to attitudes
include a mention of awakening the pupils to a responsibility for their own health …
The content for the fifth grade includes a heading containing the topics puberty – adult,
what happens in my body and the birth of a child. During the ninth grade, the topics
are revisited for the objective is that pupils are taught about the structure and vital
functions of human beings, reproductive physiology … and an appreciation of health.
The content contains the heading reproduction and interpersonal relationships, heredity
and evolution.
In Religion, the objectives include to guide the young to identify moral problems in
their life, their family and immediate community and in the whole of humankind, and
to look for solutions to them on the basis of a Christian concept of humankind. In
Ethics again, the topic is approached through the objective to help the pupil to attain
the capability for positive interpersonal relationships. The family education within
Home Economics mentions interpersonal relationships, but areas related to sex education
are not mentioned explicitly here. Neither does the health and traffic education contained
in Physical Education include any topics related to interpersonal relationships and
sexuality.
Opportunity for school-specific curricula
In 1991, the National Board of General Education and the National Board of Vocational
Education were merged to form the National Board of Education. In terms of the
development of society, this was a period characterised by an increasing decentralisation
and by the organisation of activities as networks. This change resulted in the delegation
of more decision-making powers to schools, and school professionals also interacted
more with their community and with professionals from other schools. The flexibility afforded
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by the national allocation of instruction time and the core curricula, as well as the principle
of allocating resources specifically for each school, enabled a significant variation in curricula.
In 1994 the National Board of Education approved new Core Curricula for the
comprehensive school. The 1994 reform brought a significant change in the steering
practices. During the former period, a centralised steering committee specified core
curricula and provided objectives and contents of instruction in great detail for each
grade. After the reform core curricula no longer defined detailed contents of instruction
for each grade, but instead gave only general objectives of instruction for each subject
and topic area. Thus, currently core curricula issued by the National Board of Education
define on a national level the objectives and core contents of instruction. These objectives
are interpreted and applied when the curriculum of each school is being drafted. The
share of steering through information and evaluation is also receiving increasing weight
in the monitoring of how well the objectives of individual schools are being met.
The provision of education is the responsibility of the municipality. The basic principle
of the reform process was to increase schools’ opportunities of developing distinctive
curricula that are based on their individual strengths while at the same time conforming
to the national objectives of the core curricula issued by the National Board of Education.
The aim was to increase the commitment of schools to work toward the objectives and
to recognise the teachers’ role as experts in their own work.
The Council of State’s decision concerning the allocation of instruction time for each
subject determines the obligatory number of hours to be given to obligatory and elective
subjects. The schools draft their curricula within the constraints of this allocation and
on the basis of national objectives. Thus, schools can define the contents of instruction
to support the various objectives in many different ways. The increase in autonomy,
range of elective subjects and co-operation with stakeholder groups in curriculum work
presents a big challenge for teachers and administrators, and schools have taken it up in
many different ways. Thus, in the implementation of sex education, the curriculum
reform may provide a great deal of variation across municipality with respect to the
content of school curricula, modes of the instruction, and offerings to students.
Objectives describing sex education contained in the Core
Curricula
In the objectives of the current core curricula there is a description of all subjects to be
taught, and also a listing of various themes from which the schools may select one or
several; the design of new entities is also permitted. The list contains the entities family
education and health education. Both are described briefly.
The task of family education is to support the growth and development of the child
and young person towards adulthood and to create the basis for a successful family
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life. … In the Lower Secondary school, issues related to living as a couple, family
life, and parenthood are examined from the angles of a young person’s growth into
independence and of setting up a family... The contents of family education include …
the human physical, psychological and social development, … interpersonal skills
and relationships, sexuality, interaction with the opposite sex and forms of sharing
one’s life with another…
The task of health education in the school is to support the healthy growth and
development as well as the health-promoting behaviour of the pupil. The objectives of
health education describe the three broad tasks of health education: provision of
enlightenment, raising of awareness and support of mental health. The description does
not explicitly mention content areas related to sexuality and interpersonal relationships,
or other areas.
Environmental and Natural Studies for grades 1 to 6 contain the headings the pupil’s
living environment and interpersonal relationships and structure and vital functions
of human beings and differences between people, the human life cycle.
In grades 7 to 9, interpersonal relationships and sexuality are mentioned under several
subjects. One of the topics of Ethics is interpersonal relationships and moral growth,
which also allows an examination of sexuality.
One of the objectives of Biology instruction is that the pupil learns to know her-/
himself and understands the differences between people through learning about human
beings as biological entities, learns to accept her/his development at all stages of life
from birth to death. The topic is revisited in contents examining human beings, which
also contain the word ’sexuality’. Moreover it is mentioned that sexuality and
interpersonal relationships are a natural part of a person’s life and that they are
examined from the angle of the pupil’s life situation and set of values. The text also
refers to co-operation between subjects by stating that in planning the instruction,
health and family education curricula of all subjects need to be considered.
Under Physical Education instruction for grades 7 to 9 it is stressed that the young are
to be guided towards an acceptance of themselves and a constructive emotional
behaviour.
Materials supporting the drafting of curricula
When the core curricula were published in 1994, background materials and preparative
training were arranged to support curriculum work for each subject and central thematic
entities. The background material for health education, “Schools and the Enigma of
Health“, contains two articles to support the instruction in sex education.
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One of the articles, “Sex Education is Necessary, But Who Shall Teach It?“ examines
the educational task of the school and states that sex education is best taught by the
teacher or school nurse who is willing to do it. Whether nurse or teacher, the task is
both to provide information and to educate. The background material also gives an
example of how the more detailed objectives for an individual school could be drafted,
and the objectives of sex education given here are that the young person
1) understands sexual development at different ages,
2) accepts her-/himself and others,
3) is capable of building interpersonal relationships, of acts based on caring and
respect for others, and of acting with responsibility,
4) is given information on reproductive biology and sexual behaviour,
5) is conscious of the rights and obligations of an adult,
6) strives to understand variation in sexual life and its difficulties and
7) strives to grow into a good parent.
In addition to this description of objectives, the article contains a thematic breakdown of sex
education to support the drafting of the contents of instruction (Lähdesmäki, 1994).
The second article supports the objectives of sex education by providing background
material and deals with sex education from the point of view of juvenile gynaecology.
The article stresses that the instruction should acquaint the young with the broad scope
and different manifestations of sexuality instead of concentrating narrowly on sexual
intercourse. Human growth should be linked to something more profound, i.e., the right
to describe the values, manifestations and variations of sexuality from a multiplicity of
viewpoints (Cacciatore, 1994).
On development projects and instruction materials
In addition to the curriculum reform, the legislation related to the official approval of
instruction materials was amended. Textbooks and instruction materials are no longer
approved by the National Board of Education, as was the case with its predecessor, the
National Board of General Education. The producers of textbooks and instruction
materials must ensure that their products conform to the objectives of instruction, and
the responsibility of selecting high-quality textbooks and other material rests with the
school and the group or individual arranging the instruction.
Consequently, attention to local circumstances is one of the characteristics of school
development work in Finland, and this is also seen in development projects concerning
sex education. A large number of projects have been set up to support sex education,
and in this context materials have also been developed by the health care system, family
planning clinics, universities and various NGOs. Primarily, schools or municipalities
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decide independently on the materials they will use and the development projects in
which they will participate.
With respect to health education, during recent years the priorities have been the
prevention of substance abuse, the promotion of safe learning environments, healthy
self-esteem and social skills, and the prevention of social exclusion. In 1999 the National
Board of Education produced the instruction kit “Stages of Sexuality“ for use in all
forms of the comprehensive school. The book and the associated set of overheads deal
with the development of a child’s sexuality and her/his growing independence, starting
out from the emotions of the child and the young person. Children themselves can
assess which stage they have reached and how many stages must yet be gone through
before they are mature enough for a sexual relationship. Sex education proceeds in a
systematic manner from one grade to the next. The aim is that during the pupil’s entire
school career, sex education would form an entity examining the themes topical and
relevant for each development stage, while not forgetting the individual viewpoint.
The development projects undertaken by individual schools characteristically start out
from narrow, discrete topics (such as prevention of substance abuse or sex education),
but fairly soon these topics tend to be linked to a broader entity of life management and
health promotion, which is then developed holistically. An example of this is the controlled
substances project involving 18 comprehensive schools in the city of Espoo. During
the project the schools have very quickly begun to develop a broader, more holistic
curriculum for life management or health promotion, as well as various methodological,
pupil-centred options for implementing the instruction. This is necessary, in order to
avoid the artificiality of developing isolated content areas within health education outside
the context of health promotion or growth and development. Similarly, issues related to
sex education, interpersonal and interactive skills, family education or prevention of
diseases become a part of a broader health education curriculum. The project mentioned
has created extensive curricular themes that also include topics related to sex education.
The WHO project European Network of Health-Promoting Schools has been active in
Finland for several years, and currently involves about 40 schools. In recent years the
project’s activity has included the elaboration of health promotion and health education
curricula for schools, of which the objectives of interpersonal relationships and sex
education form a natural part. Special health promotion weeks also broadly deal with
various aspects of health and with themes related to sex education.
The National Research and Development Centre for Welfare and Health (STAKES)
has in recent years also co-operated with schools, particularly in developing projects for
schools jointly with school health care, family counselling clinics and family planning clinics.
The strengths of all these development projects include not only the development of
content, but also the development of instruction methods, emphasising the active role
of pupils and pupil-centred activities.
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Currently, as various organisations approach schools with a wide variety of materials
and projects, the proper selection of partners has increasingly become a subject to be
included when developing sex education programs. The risks lie not so much in cooperation with authorities as in accepting an approach adopted by a special interest
group. Insufficient expertise or a set of materials focusing on isolated topics can, if
offered and accepted by the school, also affect sex education negatively. Therefore, the
expertise of professionals in school health care, family counselling clinics or NGOs such
as the Family Federation of Finland is often of paramount importance when schools
assess the material available.
The role of school health care in the school’s instruction in
sex education
The traditions of school health care in Finland are strong and promote equality, regardless
of location. In addition to counselling given to individual pupils, school nurses have
participated in lessons dealing with sexual issues. Formerly, the school nurses worked
predominantly with issues related to the prevention of teenage pregnancies and prevention
of diseases. Nowadays the instruction and counselling also emphasise issues related to
life management and parenthood. The fact that an ever younger and ever increasing
number of children are starting to use all types of controlled substances has increased
the risk of HIV infections. Thus links between sexual behaviour and disease have lately
also come to be included as topics in programs designed for the prevention of substance
abuse by the young.
The work of school nurses has long traditions and is highly appreciated. Thus, a matter
of national concern is that the job description of school nurses has changed due to the
economic recession and the growth of the elderly population. The effect of this has
been to cut down the time available for school nursing; at the same time, the contribution
of school nurses to instruction or individual counselling for the young has decreased.
Discussion
Given the national steering, guidance, and support for curriculum work, sex education
could have been successfully implemented for 30 years by now. The core curricula
have created a solid basis, but there are still deficiencies in practical work at schools.
Surveys reveal that the results continue to be uneven and there is variation among schools.
The National Board of Education has not carried out surveys or studies on the
implementation of sex education after the 1994 curriculum reform. Studies carried out
before 1995 apply to instruction based on the former core curricula. Thus, at the
moment it is very difficult to obtain reliable information, upon which to generalise, on
the implementation of sex education in schools. Curricular variation creates difficulties
210
for determining nationally valid indicators, because content related to sex education can
be taught under a great number of subjects or general themes. Questionnaires directed
to the teachers of a small number of subjects will not lead to reliable school-specific
data; instead, a survey of the entire curriculum is needed. Thus, researchers must pay
sufficient attention to the changes due to the curriculum reform and understand that
these changes also make it difficult to use earlier studies as comparison data.
Currently, the National Board of Education is conducting a sample-based analysis of
comprehensive school curricula, which in most cases apply to one school only. The
process has revealed that very often the curricula are extremely concise. As such, they
do not necessarily give a true picture of the reality in schools. Even though the topics of
sex education to be taught are to some extent mentioned in headings, the actual text
does not allow very detailed conclusions to be drawn about the actual instruction situations
and their contents, let alone about the teaching approaches. It may be assumed that sex
education is being developed in schools, even when the written curricula do not contain
descriptions of activities that include sexual topics. Thus, systematic data are not available
on projects carried out with networks of partners, or about thematic weeks and days of
health education, containing topics linked to sex education or interpersonal and interactive
skills.
Core curricula for vocational education were modified after the publication of the
general core curricula in 1994. The legislation on school health care is shortly to be
reviewed and specified. In the coming years the National Board of Education will also
review the core curricula for the comprehensive schools and upper secondary schools.
This will then permit the further development of the objectives for the subjects and the
inclusion of various general themes in curricula. Thus an opportunity for reviewing the
objectives of instruction in sex education will occur in the future. To support this, the
National Board of Education is also producing learning material.
In the new system of steering schools through information, one aspect worth emphasising
is the quality of learning materials adopted by schools. Electronic and printed media
shape the ideas that the young have about sexuality and about issues linked to it. With
the Internet, the young have increased access to a wide variety of information sources
related to sexuality, whether at home or at school. The positive side of this development
is that high quality and balanced material is available everywhere. On the other hand, it
is difficult to screen out materials harmful for children and adolescents, because access
is difficult to monitor. Isolated cases of access to sexual materials by children and
adolescents need not give cause for concern. Nevertheless, vulnerable groups among
the young are those who have an interest in sexual material promoting violence and
contempt of human dignity. Access to such material has become easier with the
advancement of networks, and therefore media education, an analysis of its viewpoint,
purpose, and its consequences, will increasingly need to become an inherent part of
good sex education.
211
The primary support for the positive and healthy growth and development of sexuality
continues to be given in the home. Education in the home is complemented and supported
by education provided by the school. The importance of the school’s role in implementing
a matter-of-fact and selective sex education and in providing quality learning materials
will, however, increase in the future. This trend is also strengthened by the requirements
stated by parents.
It is very difficult to assess all the factors and their importance in the significant
improvement of young people’s information level regarding sexuality from the beginning
of the 1970s up to at least the mid-1990s. This increase in knowledge has resulted from
some combination of influences. These include the general development of an open
discussion culture related to sexual issues; the mass information campaigns conducted
by the social and health care sectors; the work of school health care experts; and the
development of curricula, contents and methods of sex education in schools. Various
non-governmental organisations working for sexual equality or health promotion have
been able to make their voices heard in public debate and in networks of co-operation,
and thus, also promote sexual information and knowledge.
Sources:
Cacciatore, Raisa. 1994. Seksuaalivalistus nuorisogynekologian näkökulmasta (Sex
Education from the Point of View of Juvenile Gynaecology). In Peltonen H. (Ed.)
Koulu terveyden arvoitusta pohtimassa (Schools and the Enigma of Health) .
Helsinki:Opetushallitus.
Lähdesmäki, Seija O. 1994. Sukupuolikasvatusta tarvitaan – kuka opettaa (Sex Education
Is Necessary – But Who Shall Teach It?). In Peltonen H. (Ed.) Koulu terveyden
arvoitusta pohtimassa (Schools and the Enigma of Health). Opetushallitus 1994.
Helsinki.
Peruskoulun opetussuunnitelmakomitean mietintö II, Oppiaineiden opetussuunnitelmat,
Komiteamietintö 1970: A 5 (Second Report by the Curriculum Committee for the
Comprehensive School, Subject Curricula, Committee Report 1970: A 5). Helsinki.
Peruskoulun opetussuunnitelman perusteet 1985, Kouluhallitus, 2. – 4. painos (Core
Curricula for the Comprehensive School 1985, National Board of General Education,
2nd to 4th Printing). Helsinki: Valtion Painatuskeskus.
Peruskoulun opetussuunnitelman perusteet 1994, Opetushallitus (Core curricula for the
Comprehensive School 1994, National Board of Education). Helsinki: Valtion Painatuskeskus.
Seksuaalisuuden portaat. Opetuspaketti peruskoulun 1.-9.luokille (Stages of Sexuality.
Teaching Kit for the 1st to 9th Forms of the Comprehensive School). Helsinki:
Opetushallitus 1999.
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Martti Esko
16. Sexual Health and the Evangelical
Lutheran Church Of Finland
Sexual Teachings and Values of the Church
The Evangelical Lutheran Church of Finland views healthy sexuality as an important
part of life and personal relationships. The position of our church is most clearly conveyed
by the following statements in a booklet containing the address of the bishops entitled
Growing Together, published in 1984 :
1. Sexuality is a strong, all-consuming and powerful drive which has an affect on
multiple areas of life and is present in most human interaction.
2. A man and a woman are not complete entities by themselves, but they need one
another to realize the full potential of life’s experiences.
3. At its best, a sexual encounter between a man and a woman involves the total giving
and receiving of one another.
4. Diversity of sexual expression has positive value.
These statements represent the Church’s most recent official stance on sexuality. Since
then, sexual issues have, of course, been frequently discussed by the bishops, various
work factions in the Church and in the Church Assembly.
In contrast to popular belief, the Bible’s position on sexuality is positive. The foundation
for our belief does not support asceticism, nor does it accept total freedom of sexual
expression or sexual interactions outside of loving relationships. In the first pages of the
Book of Moses it is stated that, “God created humankind in his image, male and female
he created them“. In the second chapter of the same Book it is written that, “it is not
good that the man should be alone“. In another part of the Bible, The Song of Solomon,
sexuality and love are boldly and openly praised. The central themes in the belief and
teachings of Christian love and sexuality are expressed in the commandments about
love: love your God, love your family and love your neighbour. The well-known and
often quoted statement of Christ is applicable here: “Love thy neighbour as thyself“.
This principle should guide us in our interactions with others in all areas as well as in
those that involve sexuality.
The Bible presents sexuality to us as a joyful, liberating and enriching experience.
Christian belief regards faithfulness and honesty as the foundations for all loving
relationships. Human beings differ from the rest of creation. The purpose of sex is
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more than simply procreation and, therefore, men and women need to be socially
responsible in their sexual relations and protective of new life. In every community,
including the Church, there are general and common values regarding sexuality. Our
community is changing to one of pluralistic values, and many people view some of
these values as optional, matters of personal choice and reliant on a sense of personal
responsibility. Our Church community has, at least, chosen to support the following
four values :
1. The equality of individuals and respect for human dignity.
2. The acceptance of every person’s right to self-determination.
3. A sense of social responsibility and neighbourly understanding.
4. The respect for truth, experience and knowledge.
These values are also closely connected to sexual behaviour, especially when we try to
reconcile contradictory sexual values. The aforementioned values are as important as
the following other central values of Judeo – Christian tradition:
1. Each person deserves respect regardless of her/his sex, colour or race.
2. Life has more value than death.
3. Promote love, not hate
4. Promote growth, not regression.
5. Individual freedom is a goal that must be pursued, but only within the ap
propriate social context and in a way that does not harm others.
The sexual teachings of our Church, when applied in accordance with these
aforementioned general norms, permit sexual behaviour which takes place within the
limits of responsibility and well-being of others set by the Christian community. The
Church cannot accept sexual behaviour which involves abuse, violence or other forms
of cruelty.
“Love is a raging flame. Many waters cannot quench love, neither can floods drown it.“
The Song of Solomon emphasises the power of sexual love, but also its danger. Everything
has its own time and place; love should not be highly disruptive. Sexuality has its own
limitations, and the Bible regards crossing the line as sin.
Fidelity and intimacy are inseparable aspects of relationships. Fidelity is the most vital
path to true intimacy between a man and a woman. Fidelity is often considered an
externally imposed burden and obligation. This view can be altered if, instead, we
present the idea of fidelity as an opportunity with special rewards. Sexual therapists
often emphasise that their counselling will not succeed unless both parties are fully
committed to a monogamous relationship. Fidelity does not signify limiting oneself to
interaction with only one person. There is much support for the view that a good long
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term sexual relationship can be built with only one person at a time. This viewpoint of
sexuality is also quite close to the ideals of Christian marriage.
Tasks of the Church in Matters of Sexuality
The Church’s first and, perhaps, most important task is to liberate people and relieve
them of any burdens they carry with regard to their sexuality. Sexuality often causes
anxiety, guilt, self-isolation and feelings and experiences of rejection. In addition, people
often engage in sexual acts against their own conscience. The paramount and deep
ethical responsibility of the Church surrounding issues of sexuality is in forgiveness,
freedom, and the reduction of the burdens of guilt. If the Christian Church does not
offer people the tools to liberate themselves, who will?
The second most important task for the Church is to develop and support programs
that help people deal with problem areas of their sexuality. The Church is in close
contact with people, especially during important years of growth and in times of crisis.
For example, in the teachings and studies during confirmation, the Church tries to
support the development of a responsible and healthy outlook on sexuality and a
channelling of that sexuality into rewarding and positive personal relationships.I n
discussions preceding marriage ceremonies, as well as through work with couples and
families, and in family counselling and crisis intervention, the Church faces important
challenges surrounding questions of sexuality. During a span of over 50 years, the Church
has already made systematic progress in the sexual education of couples and families.
The goal of the Church is to help people achieve harmony and happiness with respect
to their sexuality and not to try to control a person’s sexuality. To work toward this
goal, we provide many trained personnel and other resources which help individuals
deal with sexual issues, concerns, and problems. In these matters, the Church tries to
assume an accepting tone as the foundation of all teachings dealing with sexuality.
Control and punishment are inappropriate responses to sexual actions that have no
negative consequences. Healthy and positive outcomes from sexual interactions can
only be achieved when individuals are knowledgeable enough to avoid and minimise
negative ones. Exploitation, rape, subordination and the selfish and ruthless pursuit of
one’s own sexual interests are all too common. It is the task of the Church to defend the
weak and oppressed from various forms of sexual abuse and coercion, exploitation and
subordination and the ruthless pursuit of one’s own interests. The Church needs to actively
work to decrease prostitution, the sexual abuse of minors, and worldwide underground
child pornography profiteering. The Church needs to be involved in public discussions of
these social issues and be a part of efforts to reduce sexual exploitation and abuse.
The Church has offered family counselling services for more than 50 years, and these
services are currently available throughout the whole country. Family counsellors have
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special training for counselling couples in crisis as well as for handling sexuality issues.
Over the last year, 41 family counselling centres in Finland counselled more than 81
000 couples and families in crisis. Most of these sessions also touched on sexual relations
as part of the counselling process.
In 1981, the Church family counselling unit, in cooperation with the Family Federation
of Finland, organised Finland’s first training course in sexuality counselling. The course
was led by Dr. David Glegg and his wife, psychologist Alison Glegg, of Great Britain’s
National Marriage Guidance Council. Forty participants, including 15 family counsellors,
took part in the course. The continuation course was held in 1983. This course included
27 of those who began their training in 1981. Today, a specific unit of sexual therapy is
a mandatory part of the three-year family counselling training course.
Sexuality is also a central theme in Finland’s confirmation studies, and especially in
confirmation camps. Over 90 % of young people aged 15 attend these camps. Thus,
the impact of these camps on youth cannot be overlooked or underestimated. The
confirmation programme has been discussed thoroughly and has been formulated with
the help of experts from a variety of fields. In dealing with community work, children,
families and the elderly, it is always important to approach sexual issues with sensitivity.
Fortunately, Church employees in these helping capacities come from diverse backgrounds
and represent both sexes. In general, the Church offers an important supportive and
healing network for parishioners in the areas of sexuality and relationships.
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Arja Liinamo
17. Sex Education in Finland
Sex education is of utmost importance in the promotion of reproductive and sexual
health. According to the Alan Guttmacher Institute those countries which have a positive
and open attitude towards sex education also have made the most progress in the
prevention of teen pregnancies and abortions (Jones et al. 1985). According to assessments
of school programmes, sex education increases young people’s knowledge about sexuality,
leads to positive changes in attitudes, decreases instead of increases the number of
those who have experienced sexual intercourse compared with control groups, and
improves the use of contraceptives (Kirby 1989, Mitchell-DiCenso et al. 1997).
The attitudes in Finland towards sex education are positive. Schools, social and welfare
services, the church and the media all provide sex education. Sex education in schools
is offered as part of the curricula. In the field of health care, sex education concentrates
on contraception and pregnancy as well as the prevention and treatment of sexually
transmitted diseases. Information is given as part of health counselling of public health
centres, family planning clinics, and school health care. Also in congregations, sex
education is part of youth work and sexuality is discussed, for instance, in confirmation
schools. In schools sex education is mainly provided by teachers (physical education,
biology, home economics) and the school nurse. Both pupils and parents consider the
sex education given in schools important and necessary.
Ideally, comprehensive sex education should be given in all schools in approximately
the same way and extend to all age groups. In Finland this kind of extensive sex
education also takes place by means of a sex education leaflet mailed by the Ministry of
Social Affairs and Health. This journal with the name of Sexteen has been mailed since
1987 annually to all young persons reaching the age of 16. According to a study done in
1993 by the International Planned Parenthood Federation (IPPF) regional office of
Europe (Vilar 1994), sex education was most easily available in Finland, Sweden, Denmark
and Norway.
The sex education of adults is mainly integrated in activities associated with the fields of
health and social affairs. Health checks and health counselling for adults include to a
varying degree information on sexuality and sex life. According to reports by physicians
and health counsellors themselves, the proportion of matters dealing with sexuality in
client contacts at the end of the 1980s was about 2% among physicians and 4% among
health counsellors. The initiative for counselling has usually come from the client (Laitakari
and Pitkänen 1989). Sex education material intended for adults and information about
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sexual topics is available in Finland. For example, the Family Federation of Finland
provides sex education and information material for people of various age groups and
organises training connected with sexual health and sex education for professionals in various
fields. Sex counselling is offered by sexual health clinics in the largest cities, Helsinki,
Tampere, Turku and Oulu. This chapter mainly discusses sex education for young people.
Introduction
The Finnish educational system is divided into compulsory education consisting of
comprehensive school including primary and lower level (grades 1 to 6; ages 7 to 13
years) and upper level (grades 7 to 9; ages 14 to 16) and a gradeless upper secondary
school (ages 17 to 19).
In national surveys that examined the sex lives of Finns (Sievers et al. 1974, Kontula
1993), people belonging to various generations were asked about the sex education they
received in school. In 1971 28% of the men and 33% of the women belonging to
various age groups (18-54 years) reported that they had received information about
sexuality in comprehensive school (ages 7 to 16).
In 1992 the percentage of persons having received information in comprehensive school
was significantly higher, 64% of men and 74% of women. In both studies the proportion
of those who had received sex education in school increased steadily for each younger
age group compared to the next older group. The percentage of those who indicated
that they had received sufficient sex education in school in 1971 was 17% of the
youngest age group (18-24 years old) and 2% of the oldest age group (45-54 years). In
1992 the corresponding percentages were considerably larger, 58% and 7%. The studies
cited above indicated that no sex education whatsoever existed in schools in the 1950s.
Subsequently sex education gradually became more common, especially in the 1980s.
Discussions about matters related to sexuality have also become more common in the
homes, especially during the 1950s and the 1960s. According to Sievers et al. (1974),
during the period from 1920 to the 1940s about a third of children received sex education
in their homes and, of the children of the 1950s and 1960s, about one half had such
education. The percentage of those who had received sex education in their homes in
the beginning of the 1990s was over 60% (Kontula 1993). In 1971 about 10% of men
and women (18-54 years) considered the information given in homes sufficient while in
1992 almost one third did so. Those who indicated they had received sufficient
information in their homes were concentrated in the youngest age groups (18 to 24
years): 21% in 1971 and 52% in 1992.
About one half of the 15-year-old girls living in Helsinki, interviewed in connection with
the KISS study at the end of the 1980s (Tirkkonen et al. 1989), reported they had not
218
talked about sexual matters with their parents. They felt discussing sexuality with their
parents was embarrassing. The boys interviewed in the same study reported that they
had had hardly any discussions about sexuality in their homes.
Evidently discussing sexuality and having been taught about it have become more
common, at least among those who were young in the 1980s. This increase accelerated
during the last 20 years. The number of those who have received sex education in
school almost tripled from 1971 to 1992. In spite of this fact almost half of those who
were young in the 1980s report not having received enough information about sexual
matters in their homes or in school (Kontula 1993).
Most people seem to have confidence in the sex education given in schools. For example,
a finding from a 1992 survey indicated that almost two thirds of men and women of
various ages thought that sex education in schools does not lead youths to prematurely
begin a sex life. Only about one fifth of the men and women in various age groups
expressed fear that sex education would lead to premature intercourse and this view
was most common among older adults: nearly one half of those who were over 55
expressed this fear. (Kontula 1993.)
Research on sex education given in schools has concentrated on examining the teaching
at the upper level of comprehensive school (ages 14 to 16). There is no national data on
the realisation of sex education at the lower level of comprehensive school or gymnasia
or vocational schools. A study was carried out at the University of Jyväskylä looking at
the opinions of pupils in the lower level and their parents concerning sex education
(Nykänen 1996). Both the pupils and their parents expressed the opinion that sex
education ought to have already begun during lower level of comprehensive school.
(Nykänen 1996, Kannas and Heinonen 1993).
Sex Education in the Finnish Lower Level
A study was done in 1995 in Middle Finland among pupils in grades 2 to 6 (n= 89, ages
8 to 12) and their parents (n = 179) in order to examine their views on sexuality and sex
education at the lower level. Pupils stated that they wanted matters related to sexuality
to be discussed in school at the lower level. Over one half of pupils in sixth grade
wanted sex education to begin in fifth or sixth grade, and almost one quarter of the
pupils wanted to have sex education start even earlier. The pupils wanted sex education
in the lower level to deal with puberty, liking someone special, providing information
about girls for boys and about boys for girls as well as the birth of babies. The respondents
considered detailed sexological information about intercourse more appropriate for the
older pupils at the upper level. (Nykänen 1996).
The parents were asked about the right age to begin sex education in the home and in
school. Most parents agreed that sex education ought to begin immediately after the
219
birth of the baby. The parents themselves had discussed questions with their children
dealing with going steady, the birth of a baby and puberty. The parents of the oldest
pupils in the lower level had also talked at home about contraception, sexually transmitted
diseases, and in some families also about, homosexuality and sexual morals. More than
one half reported that their children are asking questions dealing with sexuality at home.
About 80% of the parents considered discussing sexuality with their children easy,
while about one fifth of the parents considered it difficult (Nykänen 1996).
The opinions of the parents about the time of beginning sex education in schools varied
from first grade to ninth grade. A majority of parents considered ages of 10 to 11
appropriate for beginning sex education. Almost all parents thought that sex education
should be an essential part of the curricula in the lower level. The parents wanted sex
education in lower level to deal with going steady, liking someone special, the birth of a
baby, why babies are not always born in spite of such hopes and about the fact that one
does not have to immediately experience everything. Additionally, the respondents hoped
that education would deal with the importance of the family, contraception, taking
responsibility and the right to make decisions concerning one’s own body. However,
parents did not know what their children were being taught in school. They wanted
intensified co-operation and information about sex education in joint meetings of parents
and teachers. The parents also hoped to get support for themselves in their parenting
responsibilities, for instance, lectures directed at parents on the sexual development of
children. (Nykänen 1996).
Sex Education in Upper Level
Pupils in the seventh and ninth grades of comprehensive school were asked in the KISS
study (Kontula 1991, Kosunen 1993) about sex education given in schools in the years
1986, 1988 and 1992. A third of the pupils in grade seven and four fifths in grade nine
had received sex education in at least one lesson designed for this purpose in their
school during the ongoing school year. A teacher and school nurse and sometimes the
school physician or an outside expert provided the sex education. The main emphasis
had been on intercourse, going steady, contraception and sexually transmitted diseases.
The first national study in 1994 (see Kontula 1997) of sex education in the upper level
of the comprehensive school occurred during the 1995-1996 school year in the transition
period of the latest curriculum reform (see chapter 15 by Lähdesmäki and Peltonen).
Kontula collected information from teachers in the upper level classes of the
comprehensive schools (N = 412). Sex education had been included in some form in
the curricula of almost all (94%) schools. About one tenth of the schools had a relatively
detailed sex education plan. According to the replies, sex education in the seventh grade
was most often in connection with hygiene or pupil counselling. In eighth grade, sex
education was most generally included in health education, and in ninth grade in the
220
curricula of biology, family education, and also quite often in religion. According to
Kontula sex education had been given according to various criteria in seventh grade to a
substantial degree in about one third of the schools, in eighth grade in 60% of the
schools and in ninth grade in three quarters of the schools. There were differences
among various provinces of Finland: it was most successful in Middle Finland and
North Carelia and poorest in the provinces of Kuopio, Oulu, Turku and Pori, and
Häme. There were large differences among schools. Sex education was concentrated in
the ninth grade and focussed on contraception and sexually transmitted diseases. Teachers
in about one half of the schools estimated that sex education would be decreased in the
near future.
Sex education in the upper level of comprehensive school has been monitored from the
year 1996 with the School Health Promotion Survey co-ordinated by STAKES (National
Research and Development Centre for Welfare and Health). The survey covered the
majority of the upper level grades of the Finnish comprehensive school system. The
purpose of the survey is to provide information about health and health promotion
work directed to the local youths for the schools, municipalities and provinces. The
surveys will be repeated in the same areas at intervals of two years in order to monitor
health and health promotion activities for the young (Rimpelä et al. 1996).
According to the school health surveys of 1996 and 1997 (Liinamo et al. 1999a) about
one half of eighth graders and three fourths of ninth graders reported they had had at
least one class particularly designed for sex education in the previous academic year
(1995 -1996 or 1996-1997). About one fourth of the eighth graders and ninth graders
from various parts of Finland participated in the surveys. The results indicated large
differences in sex education among various schools, municipalities and regions. In some
municipalities and schools as many as 86% of the pupils indicated they had not received
a single sex education lesson in the previous school year. On the other hand, there were
several municipalities and schools where almost all pupils (97%) indicated they had
received at least one sex education class. Thus, young Finns are not in an equal position
to get sex education.
Sex education was most often offered in the ninth grade and the teaching emphasis was
on going steady, contraception and sexually transmitted diseases. Teachers and the
school nurse were the most common instructors of sex education. About one tenth of
ninth graders had visited the family planning clinic of their local health centre in
connection with sex education.
According to regional comparisons using data from the School Health Promotion Survey
(Liinamo et al. 1999a) and the survey of Kontula (1997), greater proportions of pupils
received sex education in the upper level of comprehensive schools in regions where
sex education had been best organised (this includes regions in the middle and eastern
221
parts of Finland: Middle Finland, North Carelia, Southern Savo). Correspondingly, pupils
who reported least exposure to sex education lived in the areas (such as the northern,
religious areas around Oulu) where sex education was least developed according to the
descriptions of the teachers as reported in the study by Kontula.
According to the follow-up survey (Liinamo et al. 2000) sex education decreased during
the two-year follow-up time from the school year 1995-1996 to the school year 19971998. The number of pupils who reported participating in one or several sex education
classes among ninth-graders decreased (79% vs. 70%) but remained stable among
eighth-graders (63% vs. 62%). The providers of sex education and the content did not
change. In a school-level analysis, an assessment was done of how extensive sex
education is for eighth and ninth graders. In about one fifth of the schools the coverage
of sex education remained on the same level, in 44% of the schools the coverage
decreased, and it improved in about every third school. The proportion of schools with
sex education with an estimated poor coverage increased from 14% to 25% during the
follow-up period. In order to check the reliability of the survey, the replies of the pupils
and the teachers in 25 schools concerning sex education were compared. In this study
on the quality of sex education, it was found that the responses by both pupils and
teachers were identical in 22 of 25 schools.
The quality of sex education
When adults and adolescents have been asked in various studies about their opinions of
the quality and quantity of sex education they received in school, at least one half
considered the amount of sex education inadequate. For instance, in the KISS study in
1986, one half of the adolescents aged 13 to 16 wanted to have more sex education in
school. In the Finnish comprehensive school the main emphasis of sex education has
been for ninth grade, when the pupils are 15 to 16 years old. A majority of both
adolescents and adults wanted sex education to begin earlier, in the sixth and seventh
grade, i.e., considerably earlier than sex education has usually been offered.
According to recent research data, sex education in schools is not very systematic and
co-ordinated. Kontula (1997) found that only about every tenth teacher considered sex
education in her/his school to be well co-ordinated. Often the teachers did not know
what other teachers in their schools taught about the subject. The School Health
Promotion Survey (Liinamo et al. 1998a,b; Liinamo et al. 1999b,c) examined sex
education by asking questions of teachers and nurses. According to the results, teachers
and health nurses at the same school often had different views about sex education in
different grades. The content, goals and methods were rarely co-ordinated. The teachers
and school nurses stressed the importance of improving co-operation and co-ordination of
sex education and increasing the number of hours allotted to sex education. The majority of
teachers and school nurses felt they needed further training to provide sex education.
222
According to several studies the main topics of sex education have been contraception,
going steady, and sexually transmitted diseases. The tone of teaching has been criticised
for emphasising the risks of sexual behaviour. The same themes are repeated in different
grades, while many requested topics have been ignored. However, pupils want to discuss
sexuality in more detail. For example, they want time to discuss emotional matters,
loving and making love, talking with one’s partner, masturbation and sexual minorities
(Nykänen and Sironen 1996; Kontula 1991). Pupils interviewed (Liinamo et al. 1997)
also criticised sex education in schools for being superficial.
Nummelin (1997) looked at the sex education pamphlets (n=31) used in Finland during
1988 to 1994 from the point of view of facts and cultural analysis. The Family Federation
of Finland and the Ministry of Health and Social Affairs produced the majority of
leaflets. An examination of the facts revealed that the pamphlets were usually written
from a narrow point of view and considered only one or two themes. The topics most
often dealt with were pregnancy and sexually transmitted diseases and their prevention,
especially by condom use. The other half of the pamphlets had a wider perspective and
included more themes. According to Nummelin the emphasis in both types of pamphlets
was on facts. A cultural analysis of the descriptions and pictures indicated that sexuality
was defined in terms of heterosexuality, sexual intercourse, and its risks and problems.
According to studies parents have received very little information about sex education
in schools (e.g., Nykänen 1996; Liinamo et al. 1998a,b; Liinamo et al. 1999b,c). For
example, in joint evening meetings of parents and teachers, information about sex
education has only been given in a very few schools. The parents, however, would like
to know how sex education is presented in school. According to Kontula (1997) parents
have given feedback about sex education and expressed their views on its contents in
15% of upper level classes. Feedback from parents has mainly emphasised the
significance and importance of sex education.
The most common methods used in sex education have been lectures and groups
discussions. Videos have also been commonly used. Other methods, however, such as
role practices, sociodrama or study visits have been very uncommon. Most sex educators
consider their preparation inadequate and have wanted further education in the subject.
According to Kontula (1997), teachers with specific qualities provided the most versatile
teaching. Those who had participated in further training in sex education, thought that
sex education in their schools had been rather well co-ordinated, taught in schools
where the parents had given feedback about sex education, and found it easy to talk
about sexuality used a greater variety of teaching methods.
According to Kontula (1997) those who provide sex education in the upper level consider
the most important goals to be teaching responsibility, giving correct factual information
and encouraging a natural attitude towards sexuality. The goals classified as least important
223
were teaching abstinence, teaching that casual relations are unsatisfactory and changing
attitudes to perceive sexuality as a good and refreshing thing. The teachers wanted to
avoid moralising and interfering with the choices of pupils. They did not want to give
too many warnings about sex. Neither did they want to encourage it.
Assessing the Sex Education Magazines
The sex education magazines mailed by the Ministry of Social Affairs and Health to all
16-year-olds includes many topics, including the sexual experiences of young people,
sexual fantasies, masturbation, the first intercourse, homosexuality, and sexual counselling
available from the school nurse and school physician, and sexually transmitted diseases.
An analysis was done on the reception of the 1992 magazine (Hannonen 1993).
Adolescents’ knowledge about the magazine and its reception has also been analysed in
connection with the School Health Promotion Survey co-ordinated by STAKES. The
1997 survey was conducted two weeks after the magazine had been mailed to the
target group that consisted mainly of ninth-graders in comprehensive school.
In 1992 97% of the adolescents (n=521) who responded to the survey had received a
sex education magazine. A total of 72% of the respondents said they had read the entire
magazine. The respondents considered the mailing of the magazine to adolescents
necessary. The majority of respondents wished that it would be mailed to pupils who
are one year younger, to 15-year-olds. The attitudes of the respondents towards the
pictures, texts and the condom attached to the magazine were generally positive. The
respondents were most critical about the articles dealing with homosexuality and
masturbation. Almost everyone who had read the magazine had discussed it with her/
his friends. About one half of the respondents had discussed the magazine with their
mothers and every fifth with their fathers. In spite of the favourable reception of the
magazine, less than half of the respondents reported they learned new information from
it (Hannonen 1993).
According to the School Health Promotion Surveys about two thirds of ninth graders
looked at the magazine. About one fourth reported they had read the entire magazine.
At the same time, however, more than a fifth of the adolescents responded that they
had never heard about the magazine. (e.g., Liinamo et al. 1998a,b; Liinamo 1999b,c).
Compared to the 1992 edition of the magazine, the proportion of adolescents who read
the magazine was significantly lower in 1997. The difference may be due to different
sampling techniques. The 1992 survey used a mailed questionnaire with a response rate
of 65%. It is possible that those who had read the magazine responded more than those
who had not read it. The School Health Promotion Surveys were administered in
classrooms to the whole class and that sample includes almost all pupils who were
present in the classroom during the time of the survey.
224
In the year 2000, the name of the sex education magazine for adolescents was sent to
homes of both 15 and 16 year olds and the magazine was given a new name (“Itching
that can not be scratched“). In the subsequent years only 15 year-olds will receive this
magazine. The decision to send the magazine one year earlier was made in response to
feedback from pupils and teachers. This magazine is revised frequently in order to
include current information and keep interest in it high.
Young People’s Information about Sexuality
Finnish adolescents have reported in various studies that the most important sources of
information about sexuality are friends, television and magazines as well as the teachers
and school nurse (Hannonen 1993; Pötsönen et al. 1996). In interviews done at the
end of the 1980s (Tirkkonen et al. 1989) both boys and girls stated that they have
enough information about sexuality. Friends were the most important source of
information.
The KISS Study of the 1980s and 1990s and the School Health Promotion Survey at
the end of the 1990s examined the level of knowledge about sexuality of young people.
In the 1990s the Health Behaviour of School-age Children (HBSC) study co-ordinated
by WHO studied adolescents’ knowledge and sources of information about AIDS. In
addition, the level of knowledge and sources of information have been studied in some
smaller studies. According to these it has been estimated that the knowledge of young
Finns about sexual matters is relatively good. Often knowledge increases with age. It has
been found in many studies that the knowledge of girls is better than that of boys. However,
no significant difference was found between the genders in knowledge about AIDS.
The KISS study of 1986, 1988 and 1992 examined the sexual knowledge of seventh
and ninth graders by asking pupils to agree or disagree with statements (Appendix 1) on
sexual maturity, pregnancy and protection against sexually transmitted diseases. In 1986
and 1988 adolescents were well acquainted with the most common contraception
methods. About 90% reported they knew how to use contraceptive pills and the condom.
A total of 60% knew about the IUD and 45% were familiar with contraceptive foam.
(Kontula et al. 1988; Kontula et al. 1992.) According to the KISS study the level of
knowledge of adolescents significantly improved from 1986 to 1992. In 1992 about
80% of the 15 year old boys and 90% of the 15 year old girls knew the most important
matters related to becoming pregnant and using contraception. In 1986 about one half
of girls in seventh grade and about one third of girls in ninth grade did not know that the
beginning of menstruation signified a possibility of becoming pregnant. In 1992 the
percent of those who did not know this fact was 13% (Kontula 1997, Kontula et al.
1992.) According to the preliminary results of the School Health Promotion Surveys
the level of young peoples’ knowledge no longer increased by the end of the 1990s
(Kontula 1997; Liinamo et al. 1998a,b; Liinamo et al. 1999b,c).
225
For 15-year-old adolescents living in Oulu and Helsinki (n = 429) in 1988 the following
were recognised as sexually transmitted diseases: HIV (by 98% of the respondents),
gonorrhoea (88%), chlamydia (75%), herpes (71%), syphilis (51%) and human papilloma
virus (genital warts or HPV infection) (40%) (Hämäläinen et al. 1991). More than 98%
of these adolescents knew that HIV can be transmitted through sexual intercourse,
intravenous drug needles and syringes, and blood transfusions. On the other hand, one
fifth replied that a non-symptomatic HIV carrier does not spread the disease. In the
HBSC study of pupils in 1990 and 1994 (Pötsönen et al. 1994; Pötsönen and Kontula
1999) it was found that young people aged 13 to 15 were well acquainted with the
modes of transmission of HIV. Adolescents living in the Helsinki area and in other cities
knew more about AIDS than did adolescents living elsewhere.
The protective influence of condoms in the prevention of AIDS was quite well known
as early as 1988: over 90% of 15-year-old adolescents knew this (Hämäläinen et al.
1991). In the HBSC study of 1994, 96% of 15-year-old adolescents knew that HIV
infection can be prevented by using a condom and that the virus is not transmitted by
handshakes. About 90% mentioned that the number of sex partners and not knowing
one’s sex partner influence the risk of HIV transmission.
According to the KISS study, knowledge that the statement “of all contraceptives only
the condom protects against sexually transmitted diseases“ is true, increased for
adolescents from 1986 to 1988 (Appendix 1). In 1992 every tenth 15-year-old girl and
about one fifth of the boys did not know this fact (Kontula 1997; Kontula et al. 1992).
The correct answer to this statement was given in about equal proportions in both the
KISS study of 1992 AND of School Health Promotion Survey 1998 (Liinamo et al.
1998a,b; Liinamo et al. 1999b,c).
According to the School Health Promotion Survey, in 1998 the statements that received
least correct replies were “a sexually transmitted disease is sometimes unsymptomatic“
and “a chlamydia infection can cause infertility“. Only about one half of pupils in the
eighth and ninth grades of comprehensive school knew that a sexually transmitted
disease is sometimes totally unsymptomatic. Even fewer young people knew that a
chlamydia infection may cause infertility, a little over 40% (e.g., Liinamo et al. 1998a,b;
Liinamo et al. 1999b,c). This result is rather surprising considering the fact that the
topic of sexually transmitted diseases (STDs) and contraceptive methods have been the
most commonly taught topics in school sex education. It may also be true that sex
education is superficial, as some pupils have claimed. In order to both reduce STDs and
to protect fertility, comprehensive coverage of STDs needs to be a basic goal of sex
education.
There are not many studies in Finland on the relationship between sex education and
knowledge about sexuality. According to the HBSC study co-ordinated by WHO, those
226
young people who reported having a large amount of information from different sources
had better knowledge about AIDS than those who reported receiving less information
from fewer sources (Pötsönen et al. 1994). A mini-size intervention of one lesson on
AIDS and other STDs was carried out in 1998 in the upper level of the Oulu and
Helsinki comprehensive schools (Hämäläinen and Keinänen-Kiukaanniemi 1991). In
this class knowledge about AIDS and STDs increased significantly for both girls and
boys. It was found that in the control group this knowledge had increased among girls
but not among boys. The researchers interpreted this as meaning that girls profit from
the mere fact that attention is directed towards the matter (survey questionnaire), but
boys need explicit information and teaching. According to the preliminary results of the
School Health Promotion Survey, knowledge about sexuality among the young is
somewhat higher in Middle Finland than in other areas under study (Liinamo et al.
1998a,b). In Middle Finland sex education has also been provided in a more effective
way than in other areas of Finland (Liinamo et al. 1999b,c, Kontula 1997). In the
HBSC study it was found that the AIDS information of the young is higher in the
Helsinki region than in other areas of Finland (Pötsönen et al. 1994); in the Helsinki
area young people had also received more education about this subject than in other
areas (Kannas and Heinonen 1993). Data suggest that knowledge of young people
about sexuality is better in areas where sex education has been organised more
systematically and extensively than in other areas.
Discussion
Sex education for adolescents in Finland has decades of tradition. One of the strengths
in Finland has been the co-operation between the teaching and health authorities in sex
education for the young. From a sexual rights perspective policy makers have made
considerable progress in guaranteeing young people their right to sexual knowledge and
information. Nevertheless, there are still schools where sex education is quite inadequate.
The quality of sex education varies very much according to individual municipalities
and schools. This inequality of sex education is likely to have negative outcomes for
those who receive less information.
Although adolescents get knowledge about sexuality from sources other than schools,
school sex education has important significance for the promotion of sexual health.
According to a study done in Great Britain at the beginning of the 1990s (Wellings et al.
1995), women and men whose main source of sex education had been the school had
later used contraception more frequently than those whose main source of information
had been friends or the media. Men who had received sex education in school had
experienced sexual intercourse less often under the age of 16 than those who had
received their sexual knowledge primarily from other sources.
227
It has been found in many studies that broad-based programmes which involve the
whole community and which take into consideration both sex education and health
services for the young are efficient in promoting the sexual health of young people
(Orton 1994; Vincent et al. 1985). In Ontario, Canada pregnancies of young people
decreased (1976-1981) more in communities where more sex education was given both
in school sex education and in connection with sexual health services for the young in
comparison to communities without such joint efforts (Orton 1994). Co-operation among
the sectors of a community tends to increase the availability and efficiency of services.
In the state of North Carolina in the United States a community-level intervention
programme aimed at decreasing teen pregnancies in the 1980s significantly reduced the
number of teen pregnancies in the target area. The opposite development occurred in
the control area (Vincent et al. 1985). Participants in the programme included school
authorities, congregations, and parents. The aim of this programme was to develop
decision-making and interaction skills, to promote the self-esteem of the young, and to
increase information about human reproduction and prevention of pregnancies.
It has been shown in recent studies on school sex education in Finland that sex education
is given in the most extensive and versatile form in Middle Finland, which was one of
the pilot areas in the programme Family Planning 2000 of STAKES in 1994-1999 (see
chapter 14 by Ritamo and Kautto). Several educational events related to sexual health
have been organised in this area with sex education of the young as their goal. Local
government has actively promoted sexual health in both the education and social and
welfare sectors. As a result of the Family Planning 2000 project, specialised studies in
sexology and sexual health were begun at the Jyväskylä Polytechnic. In this Polytechnic
it is possible for experts in the social and welfare and education fields to supplement
their expertise in sexual health (see chapter 19 by Valkama and Kaimola).
The national curricula of the Finnish Ministry of Education (Ministry of Education
1994) specify that the organisation, goal and content of education should be determined
by the school legislature. Although health and hygiene knowledge is not defined as an
independent subject in the new school law, its importance is emphasised. The 1998
Committee Report states that “...family and interaction skills must be made an integrative
subject and these shall be taught in all subjects and especially they shall be included in
religion and ethics and civics“ (See Liinamo et al. 2000, 62). According to recent findings,
sex education has decreased in several schools and municipalities from 1996 to 1998
(Liinamo et al. 2000). The latest curriculum reform has reduced national guidance and
increased the responsibility of individual schools and municipalities. This seems to have
weakened the position of sex education in schools. At the same time, changes in the
health care systems (e.g., population responsibility [see chapter 5 by Kosunen]) and the
increase in the planning responsibility of the municipalities) and reductions of resources
made by communities have also weakened health promotion in the social work and
health care sector. It has been estimated that these changes will weaken the functioning
228
of school health care and family planning clinics, which have been of great importance
in Finland in providing sex education and contraceptive services.
A clear challenge in Finland is the development of progressive curricula and teaching
methods for sex education. In order for Finland to have an effective and progressive
sex education programme for all young people, each school must systematically plan
and co-ordinate the teaching of sexuality in different classes by different teachers.
When the emphasis in sex education is on sexual behaviour, mainly intercourse and
risks associated with it, the young are likely to acquire a narrow view of sexuality and
sexual health. The emphasis on contraception and sexually transmitted diseases is largely
due to their association with medical health topics and factual material. Only a few sex
education programmes in Finland attempt to approach sexual issues from the perspective
of adolescents’ social reality, in terms of broad sociological contexts, or using adolescent
involvement/interaction teaching techniques.
According to international literature good sex education should increase pupils’
understanding of sexuality, support the sexual development of the pupil and promote a
broad understanding of sexuality and factors related to sexual health. A precondition for
this is that sexuality and sexual development are discussed in a broad way in sex education.
Pupils ought to receive sex education at a time when they can profit from it and thus
receive the relevant information before each phase of sexual development. Sex education
should aim at supporting and improving the knowledge of the young and a broader
understanding of sexuality, as well as increasing discussion and social skills. Researchers
have found that important factors determining the positive impact of sex education are,
among others, clarity of goals, consideration of the age and cultural background of the
pupils, the grounding of teaching in theoretical approaches, an adequate amount of
time, versatile teaching methods and well-prepared teachers. (Wight et al. 1998; Kirby
and Coyle 1997.)
New development and research projects have been started to promote sex education.
These projects for the development of sex education materials are both grounded in
theory and supported by empirical evidence. Methodological development work on sex
education at the lower level is underway at the Department of Health Sciences of
Jyväskylä University (Maija Nykänen). The Jyväskylä Polytechnic is starting a
municipality-by-municipality development programme on sex education of the young.
The goals of the project are to simultaneously develop sex education in schools and sex
counselling and sex education at municipal health care centres.
In addition to adolescent sex education it is necessary to also develop sex education for
children and the adult population. Sex education ought to begin in childhood and extend
throughout the life span. This requires that support for the sexual development of the
229
child be included in the work of municipal child counselling clinics and the educational
activities in day care centres. Sex counselling and sex education for adults ought to be
developed by improving the ability of professionals within health care and social services
to deal with questions related to sexuality in their client work.
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232
Appendix 1. The percentages of girls and boys who replied correctly to statements
concerning sexual knowledge by grade and gender in the KISS study.
Girls, grade 9
Girls, grade 7
Statement
1986
1988
1992
1986
1988
1992
The beginning of m enstruation
is a sign that the girl may
becom e pregnant
56
74
86
66
79
87
The beginning of ejaculation is
a sign that the boy has
becom e sexually m ature and
m ay conceive children
61
73
86
84
89
92
A wom an cannot become
pregnant during her first
intercourse
57
68
73
81
85
85
Of all contraceptive devices
only the condom protects
against sexually transmitted
diseases
34
58
64
76
89
90
Boys, grade 7
Boys, grade 9
1986
1988
1992
1986
1988
1992
The beginning of m enstruation
is a sign that the girl may
becom e pregnant
29
50
58
36
54
69
The beginning of ejaculation is
a sign that the boy has
becom e sexually m ature and
m ay conceive children
57
70
78
80
80
85
A wom an cannot become
pregnant during her first
intercourse
54
64
64
73
81
80
Of all contraceptive devices
only the condom protects
against sexually transmitted
diseases
49
61
55
70
88
81
233
Osmo Kontula
18. The Media as Sex Educator
In order to ensure that sexual activities produce satisfaction and promote sexual health,
versatile information and knowledge are needed as well as an open attitude and skills
acquired through sexual knowledge and experience of both about sexuality and about
sexual interaction with partners.
A lack of knowledge hampers the formation of relationships, reduces the quality of
sexual experiences and often easily leads to undesirable consequences. Attitudes also
may become an obstacle for high quality experiences. Adequate skills for interaction
between an individual and his or her partner in sexual communication are necessary for
satisfying experiences. An individual is not born a good lover, but is able to learn and
develop to become such a person.
Media and Sexual Health
Although the school system, other public authorities, and various organisations do a lot
of work to improve sexological knowledge, attitudes and skills of the population, a large
part of sex education and sexual health promotion occurs through the media. The media
disseminates the latest sexological information, news from that field, and provides a
public forum for discussion of the sexual topics through its information and images the
limits of socially acceptable sexual activity. The media is one of the most important
factors in determining peoples’ views of the meanings of sexuality. This includes also
the ideas of the significance of different sexual experiences, or the lack of them, for the
well-being and health of the individual.
The role and significance of the media in promoting knowledge about sexual matters
has varied greatly in different times. The content of sexological messages conveyed by
the media has been largely determined and influenced by the particular professional
group or authority chosen to present such messages in various times (for instance, a
priest or a medical doctor). Before the 1960s especially the media tended to mystify
sexuality more than convey factual sexological information. Part of this was due to
censorship restrictions of the media.
Sexological topics have created innumerable pieces of news and various review articles
for the daily press, magazines and electronic media. News departments of the media
have reported sexological news and events of current interest (often crimes). In other
areas of the media since the 1970s sexuality increasingly has been presented in more
enlightening ways and it has been described as an area of life which promotes human
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well-being. When the importance of the media has grown, it has become the main source
of information about sexual matters for a large number of people. Therefore, it is justifiable
to consider the media as a significant societal institution affecting sexual health.
The significance of the media is partly based on the fact that people often trust experts
appearing in public more than their own experiences. For example, in Finland the authority
of physicians was used as late as the 1950s to distribute scare stories about the illeffects of masturbation. This presentation was regarded as true by many and it caused
a lot of unnecessary fear and anxiety. At a time when people were, in other ways as
well, made to feel guilty about their sexuality, the perceived physiological threatening
images portrayed by medical doctors led people to be afraid of the consequences of
masturbation, an act that makes them to feel good. Enjoyment was loaded with a
sickness label. Fortunately, the media later actively corrected these misconceptions and
eased unnecessary fears connected with them.
Thanks to the media, more and more positive meanings have been associated with
sexuality and especially with women’s rights to enjoy sexual experiences. This process
was slow in the beginning but still irresistible. Views of the meanings of sexuality by the
present media generation are significantly more positive than the messages of preceding
generations.
The Finnish Media as Sex Educator before the 1990s
During the post-war years, sex life was publicly accepted only between married partners.
Most commonly priests were asked to be the experts and commentators on the subject
of sexuality. Sexual matters were then interpreted as moral questions. Only after the
mid-1960s did media take an active role in actual sex education work. This created
very lively sexual-political debate. Some magazines published their first theme issues
about sexual matters. Men’s magazines even wrote articles about the Kinsey report and
the pioneering sexological studies of Masters and Johnson. Gradually, information leaflets
and guidebooks became available for all who were interested. This break-through in the
media concerning sexuality was later called the sexual revolution. It was, above all, a breakthrough of sexological knowledge becoming the common property of the whole nation.
I have studied changes in the presentation of sexuality in the Finnish media by comparing
material of the years 1961, 1971, 1981, and 1991 (Kontula and Kosonen 1994). The
break-though of sexological information and broader attitudes was clearly visible already
in comparing press material for the years 1961 and 1971.
For instance, the leading newspaper Helsingin Sanomat diverted from old traditions in
the early 1970s by starting to frequently write about contraception. This newspaper
also discussed changes in sexual culture, the dismantling of censorship, the development
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of the skills of loving and the standing of sexuality in some cultural articles. These kinds
of topics were hardly at all to be found in the early 1960s. In addition, the crimes were
repeatedly reported in the way of a daily newspapers and the problems of commercial
sex were discussed.
Medical doctors acquired, at least from the beginning of the 1970s, a leading position as
sex educators and authorities in the field. In their columns they answered questions
about sexuality sent to them by their readers. Because of their professional background,
abortions and sexually transmitted diseases got a good deal of coverage. The liberal
abortion law enacted in 1970 created discussion. The image in magazines had changed
from the early 1960s in that there were no longer warnings about sex. Instead it was
often written about in a positive spirit and took women’s sexual rights into consideration.
Men’s magazines taught men in a practical ways how to become better lovers. In the
mid-seventies these journals started to publish sex stories of their readers, and these
stories provided stimuli and models for the sex life of readers.
In addition of educational approach sexual topics started to get a more entertaining
content. In the beginning, men’s magazines published reports about the sexual customs
of exotic cultures and the services of commercial sex abroad. In the middle of the 1970s
verbal description of sexual acts was allowed. Starting in the 1970s the media gradually
started to focus on the sex appeal and intimate life of domestic public figures. This was
a continuation of the earlier Hollywood movie star culture and pin-up pictures of barebreasted film stars. Even in everyday life and rural communities the interest became
focused on sex appeal, and even men began to acquire the status of a sex object. As a result,
matters of sexuality came closer to the consciousness of everyday life in peoples’ minds.
New topics of the media in the early seventies, even in the United States, were the
sexual enjoyment of women, women’s sexual fantasies and various sexual problems,
especially male impotence. The criterion for the acceptability of sexual acts no longer
was the legality of the relationship but rather its quality (Herold & Foster 1975.)
During the 1980s the sex education given in the medical columns of the Finnish magazines
spread to even the most conservative magazines. Journalists started to write about sex
without the need to associate it only with marriage. Simultaneously, women’s magazines
began to discuss women’s right to sexual self-determination and their right to sexual
activity in a much more direct way. The discussion included, however, warnings about
the threat of sexual violence.
During the 1980s men’s magazines had evolved into distinct sex magazines in which
both the sex material produced by the editors and the readers’ letters described much
more explicitly different stages of love-making. The stories can be interpreted to represent
the peak sexual experiences or favourite fantasies of the writers. They changed the sex
education given by these magazines to a level close to given reality.
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In the 1980s sexual matters were naturally also subject to entertaining gossip and joking.
At this time sex videos started to appear and they were recirculated from user to user
because of their novelty interest. Pictorial descriptions of intercourse were allowed in
domestic sex magazines in the mid-eighties. Soft porn came to at disposal of everybody
interested at the latest in 1987 when the Finnish commercial television (MTV) started
to show Emmanuelle movies. This was followed by the erotic evening programmes of
the Finnish television channel three. With the help of videos and television, people
received more versatile stimuli and models for the development of their sexual skills.
The Media as Sex Educator in the 1990s
In the early 1990s the Helsingin Sanomat began to write about sexuality in a more
versatile, moderate and positive way. Its articles described the spread of sexuality into
new areas, the sexuality of minorities and ways to improve one’s sex life. AIDS,
commercial sex and excessive sex were identified as problems. The viewpoint of the
articles was often to support sexual equality.
Sex information provided by medical doctors for both general and women’s magazines
had decreased in the beginning of the 1990s because the number of these columns was
reduced. Instead writing about the sex life of celebrities became more common, as did
presenting sex as an entertainment. A new aspect of women’s magazines was a more
diversified presentation of men, including their portrayal as sex objects. Women were
repeatedly told how to develop their erotic skills and make them more versatile. Sexual
matters were often discussed from a feminist point of view.
Sex magazines struggling with diminishing sales figures have tried to inform their readers
about how to have better sex. It has often been women who have answered the questions
of male readers in their columns about how to get new zest into a sex life which has
turned stale. Different fact-based articles have also been published about various aspects
of sex. Sex magazines have provided a wide range of material for the development of
love-making skills.
In order to compare the current sexual material from newspapers and magazines, I
analysed the way the Finnish press presented sexuality in a sample of material from the
end of 1998 and the beginning of 1999. The analysis was based on the contents of the
Helsingin Sanomat, the freely distributed newspaper “100“ and twelve magazines which
were either women’s magazines or health magazines.
The magazines of the end of the millennium differed significantly from each other
depending on whether they were daily newspapers or magazines. Sexuality articles in
the newspapers were much more sociological than in the magazines whereas they were
more personal. The major difference was that the newspapers continuously wrote about
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sex crimes and the world of commercial sex (especially prostitution). In contrast, the
magazines concentrated on educational information and informative documentations
on the subject sexuality.
Of all newspaper articles about sex in 1999 (with the addition of some news about
commercial sex) crimes were the topics in about 40% of the articles. The second most
common genre was material which dealt with sexuality from an entertaining point of
view. Their share was about one fourth. The rest of the articles were divided into sex
information, medical news about sexuality, and sexual political news and articles. The
share of each of these of all newspaper articles dealing with sexuality was about 10%.
The articles dealing with sexuality in the magazines at the end of 1998 and in the
beginning of 1999 were often informative. Magazines often included articles about, for
instance, how to seduce a man and how to keep him, how more zest can be added to
sex, how a woman can make a man happier, information about the woman’s g-point,
about imagination as a spice in sex life, advice about sensual massage, information
about how to cuddle a man, and information about risks of contagious diseases. In
addition, sexuality was dealt with from an entertaining perspective and documents were
published about such topics as, for instance, flirting, searching for partners, the first
time with a new partner, things which spoil good sex, the sex of celebrities and the sex
life of fat women.
The Break-through of New Values
During the 1960s the church was still a strong authority in defining the forms of publicly
acceptable sexuality. A that time sex was strongly subordinated to a Christian marriage.
At the end of the 1960s the authority and status of the medical profession gradually
rose and it became more interested into sexual issues. Some knowledgeable medical
doctors started to provide public sex education. During the 1970s there was a public
clash of different values. The authority of the medical profession together with a liberal
view defending the rights of an individual challenged the foundations of Christian sexual
ethics. Medical doctors did not restrict themselves to merely providing information but they
also gave guidance about how to have a safe and satisfying sex life from a health perspective.
In the beginning of the 1980s some religious groups with moralistic attitudes toward
sexuality tried to create a backlash (by trying to change the contents of school textbooks),
but they could no longer seriously challenge the authority of the medical profession in
matters of sexuality. The status of medicine was at its strongest in the press in the
beginning of the 1980s.
The individualistic ideology became more accepted during the 1980s and gradually
reduced the status of the medical profession in spite of the lively AIDS debate after the
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mid-eighties. The significance of medical profession further reduced in the beginning of
the 1990s, when a value debate began heavily to emphasise respect for an individual’s
basic right to sexual self-determination and the relativity of sexual values and ideas.
Public discussion emphasised more strongly than ever that the individual has an
independent right to chose his or her partners of refrain from doing so, that one is
entitled to demand sexual knowledge and skills from a partner and that people have the
right to sexual satisfaction and to realising their own sexual images and fantasies. People
were no longer satisfied with a monotonous and boring sex life. The media supported in
many ways these kinds of expectations of a higher-quality sex life.
After the early 1960s, one may conclude that sexuality and questions of sex were
strongly transferred from the private sphere into the public sphere by the press. In a
most concrete way this became visible in images of scantily dressed people becoming
more common, detailed descriptions of the intimate lives of celebrity figures, and the
detailed sex stories of the readers of sex magazines. Sex and nudity became a more and
more everyday phenomena and they were described in more and more versatile ways.
In a similar way the norm connecting sex with marriage was broken and the sexual
rights and independent choices of individuals were recognised. The right to sexual selfdetermination received more and more support in the media. This change was shown
most clearly in the promotion of the sexual rights of women.
Public discourse about sex in the media has a clear significance for the sex life of private
individuals because most people will not otherwise get much practical information and
guidance on the topic. Sexuality in films, videos and literature (also guidebooks) are for
most people the only concrete models of sexual behaviour available to them (Abramson
& Mechanic 1983). It is usually not possible for children to observe the sex life of
adults or to formulate fantasies or models about how to enjoy their own sex life. Erotic
literature, sex magazines and sex videos are therefore the main source of information
about different sexual patterns and various forms of sexuality. This guidance is
supplemented today by the stories in women’s magazines about how women developed
the skills of a good lover. All this sexual material simultaneously promotes sexual health.
The Effect of the Media on the Attitudes and LoveMaking Skills
Empirical evidence clearly demonstrates that sexuality has been publicly discussed during
the 1990s in a more detailed way than ever before. It has been suggested that this
discussion increases liberal attitudes toward sex (Stauffer & Frost 1976). The hypothesis
has been that the more public discussion there is in both quantity and detail, the easier it
is for people to accept sexuality in its various forms. The assumption is that as a result
of wider and more versatile public discussions about sex, peoples’ attitudes toward
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sexuality will become more liberal. This means that people would accept for themselves
and others more and more versatile relationships and experiences.
This hypothesis about the effects of the media on behaviour is consistent with the
results obtained in the follow-up Finnish sex survey (Kontula & Haavio-Mannila 1995).
According to this survey attitudes of the general population became clearly more liberal
from the beginning of the 1970s to the beginning of the 1990s. As a result of this
change, sexual intercourse between young unmarried people was generally accepted,
casual sexual relations were considered more satisfying, and sexual intercourse was
accepted more often without love.
These changes in attitudes were especially great in the age cohorts that were young or
young adults in the beginning of the 1970s or later. The more open public discussion
about sexuality which began at that time had changed attitudes toward sex in these age
groups to a more liberal direction. People who were young before the 1970s were
significantly more conservative compared with younger age groups. In their youth public
discussion about sexuality was much more restricted, moralising and closely tied to marriage.
It seems evident that public presentations of love-making and love-making fantasies as
well as the practical guidance on sex have had a liberating effect on the sex lives of great
number of men and women. According to the results of the Finnish sex survey (Kontula
and Haavio-Mannila 1995) the sexual habits of respondents under the age of 35 were
significantly more versatile and more satisfying in the beginning of the 1990s than in
older age groups. Sexual habits seems to have become more versatile by people
experimenting with their partners about what they have seen and read.
From the point of view of the love-making skills of the population, sex magazines have
fulfilled an important function of public educators in sexual matters. For decades they
have guided men to be better lovers and disseminated theoretical and practical information
to improve interactions between partners and make their sex lives more versatile. All
this has taken place in a kind of an underground spirit, because these magazines were
produced and sold under the threat of confiscation and suppression.
The bold sex education pioneering work done by the sex magazines has been continued
in recent years by the women’s magazines and health magazines. This has become
possible for people in Finland have understood that sexual activity and satisfaction are
health-promoting. This view is also a commonly accepted life value for women.
Commercial sex has created for its share the new symbolic world associated with sexuality.
Receiving sex on a symbolic level and handling it psychologically is easier than to carry
it out in concrete activities, because there isn’t need to invest or apply the fantasies
which arise to any physical relationship. They can remain as sexual fantasies in the
same way as, for instance, the imaginary fantasy world of the television series “The
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Bold and the Beautiful“. In the future people will be able to accumulate and test their
interaction skills in the world of virtual sex and virtual relationships.
When sexuality has occupied a significant and permanent position in the media, it has
led to a gradual significant erotisation of peoples’ symbolic world. This has been found,
for instance, in sexual autobiographies (Kontula & Haavio-Mannila 1997), where sex
often signifies an continually present erotic tension in women in the younger age groups.
More and more of the components and situations of everyday life have acquired a
sexual significance or interpretation as a result of the change in the symbolic world.
This has contributed, for instance, to the fact that masturbation has lately become
significantly more widespread in both genders in all age groups.
In addition to being an important institution of improving sexual health from the point of
view of sex education, the media has a strong effect on attitudes toward sexual matters.
When people have the chance to see, hear or read about the sexual habits, likings and
dreams of different groups of people, they can better understand the variability of
values related to sexuality and they are more ready to accept differences. This should
lead to increasing tolerance. The most important aspect in this change is that people
have been given permission (i.e. giving permission in the PLISSIT sex therapy scheme,
chapter 10) to realise their own sexual needs and wishes in a more satisfying way that
earlier. Sexual tolerance and liberalism has promoted sexual health.
Estimates on the population level indicate that the lack of a partner is possibly the
biggest obstacle on the way to good sexual health. Even in this area the media has
offered its services. In the articles, programmes and the counselling columns, advice is
given on how to find a partner and people have looked for contacts and partners in the
advertisement pages. Entertaining partner-finding programmes have given people models
for how to make a good impression on a potential partner. In recent years various
telephone services and the chat boxes for singles on the Internet have provided quick ways
to find people in need of a partner. These new forms of making contact are suitable for a
busy lifestyle in which people otherwise have too little time to search for a partner.
Sex therapy and family therapy can give people practical knowledge and guidance for
the development of sexual skills. Also good friends can guide each other in these skills.
In most cases the development of the love-making skills of individuals and couples
remains, in addition to lessons learned from previous experiences, dependent on the
contribution of the media and the commercial sex industry. They show and describe
ways people can touch and satisfy each other in enjoyable ways. These kinds of stimuli
encourage individuals to realise their own dreams and listen to the wishes and feelings
of their partner in more sensitive ways.
Often, of course, expectations of the partners conflict. The media also gives unrealistic
models about sexuality or models which are not suitable for one of the partners. Solving
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these problems inevitably belongs to the reality of human partnerships. Nevertheless, if
one is not able to solve them with one’s own resources, sexological experts are available.
I wish to thank Juha Timonen (research assistant of Ilsa Lottes) for his systematic
collection and coding of the contents of the articles from several magazines and from
Helsinki newspapers for 5 months in 1999.
References
Abramson Paul R. and Mindy B.Mechanic. 1983. Sex and the Media: Three Decades
of Best-Selling Books and Major Motion Pictures. Archives of Sexual Behavior
12:3:185-206.
Herold Edward S. and Marnie E.Foster. 1975. Changing Sexual References in Mass
Circulation Magazines. The Family Coordinator 24:1:21-25.
Kontula Osmo. 1993. Suomalaisten sukupuolimoraali (The sexual morality of the Finns).
In Osmo Kontula & Elina Haavio-Mannila (eds.) Finnish Sex: Information on the
Change in Sexual Life in Finland. Juva: WSOY. pp. 50-85.
Kontula Osmo and Elina Haavio-Mannila. 1995. Sexual Pleasures: Enhancement of
Sex Life in Finland, 1971 - 1992. Dartmouth. Hampshire, U.K..
Kontula Osmo and Elina Haavio-Mannila. 1997. Intohimon hetkiä: Seksuaalisen läheisyyden kaipuu ja täyttymys omaelämäkertojen kuvaamana (Moments of Passion:
The Longing for Sexual Intimacy and Its Fulfilment Described in Autobiographies).
WSOY. Juva.
Kontula Osmo and Kati Kosonen. 1994. Seksiä lehtien sivuilla (Sex on the pages of
magazines). Painatuskeskus. Helsinki.
Stauffer John and Richard Frost. 1976. Male and Female Interest in Sexually-Oriented
Magazines. Journal of Communication 26:1:25-30.
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Sirpa Valkama and Kari Kaimola
19. Sexological Teaching at the
Jyväskylä Polytechnic
As part of the Family Planning 2000 Project of the Finnish National Research and
Development Centre for Welfare and Health (STAKES), training and development work
started in sexology and sexual and reproductive health at the Jyväskylä Polytechnic in
1995. Development and training began in conjunction with the Family Planning Resource
Centre of Middle Finland. The purpose of this Resource Centre is to improve the
service know-how of family planning within multi-disciplinary networking. The Jyväskylä Polytechnic has served as the co-ordinator of co-operation in the network. In
addition, this Polytechnic has performed both regional and national assessments of
professionals in dealing with issues and problems connected to sexuality in their work.
Widespread interest and debate about sexual questions, for example, about modern
expectations concerning the quality of sexual life and partner relationships, have produced
challenges that require further education for professionals in social and health care
fields. Research indicates that professionals in these fields do not have the skills to
adequately address sexual issues in work situations with their clients. Clients also feel
that they do not receive the best possible services in this area (Poikajärvi and Mäkelä
1998, Sihvo and Koponen 1998). Compulsory courses dealing specifically with sexuality
in educational programmes leading to a degree are rare (Nykänen 1995). Therefore, it
is necessary to develop additional education programs to help professionals handle the
sexuality concerns and problems of clients in their work.
In Finland curricula for the professional training of those in the social and health care
fields has been fairly stable since the early 1970s. Attempts to add comprehensive
sexological courses to this training have only occurred since the middle 1990s. The first
sexological unit for such training is starting at the Jyväskylä Polytechnic and plans are
underway to develop and offer education for both degree-oriented and professional
development programmes. The curricula of these programmes differ from those of the
university by recognising practical needs of work life. The goals of the sexological
training are to increase the ability of professionals to acknowledge and handle sexual
matters at work, meet the developmental needs of students preparing for work in social
and health care, and help professionals prepare for changing job situations.
The most important goals in the Jyväskylä sexological training involve promoting sexual
and reproductive rights and health and examining sexual issues throughout the entire
human life span. Sexuality is viewed from a comprehensive framework which includes
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ethical, medical, social and psychological perspectives. In the programme, good sexual
health is viewed as a broad-based positive life energy instead of only with respect to the
traditional illness-health dichotomy. Sexual health issues occur for people in all life
stages and involve the attainment of individual autonomy and personal resources such
as communication skills, the capacity for empathy, a positive body-image, as well as
sufficient information required to carry out choices in a responsible way. The purpose of
the program is to prepare its students to function effectively in the large field of sexology.
The health programmes of the Jyväskylä Polytechnic prepare students for careers as
nurses, public health nurses, and midwives. There are 320 hours of sexological teaching
in the training leading to a degree. In this training students are encouraged to examine
their own sexuality and life situation as well as forms of sexuality in the surrounding
society. Feedback from the students regarding the experience of studying their own and
varieties of sexuality have reinforced the importance and value of this part of their training.
Presently sexological training is offered as further education for professional development
to multi-disciplinary student groups. These include many types of professionals such as
physicians, psychologists, nurses, social workers, rehabilitation experts, and researchers.
Thus, these students are already experts in their own professional field. Currently the
programmes which have been completed are Sexology I : Basic sexology, 800 hours
and Sexology II : Sexual Counselling, 1600 hours. The program Sexology III : Special
expertise in clinical sexology, 1600 hours will be started in the near future. The curricula
of the courses offered at the Jyväskylä Polytechnic have been developed in co-operation
with professionals in Sweden, Norway and Denmark in a working group of the Nordic
Association of Clinical Sexology (NACS). The final program was adopted at the Nordic
Sexology Conference held in Norway in 1999. New curricula are also being developed
for sexological pedagogy and scientific sexology. Education in these areas will be carried
out as multi-media training with the use of the Internet.
In the sexological professional development programmes, students can examine their
own beliefs, attitudes, and values concerning sexuality during Sexual Attitude
Reassessment (SAR) courses. From courses based on real situations, students can build
their own professional identity and meet and work on their own issues and boundaries
with respect to sexuality. In the Jyväskylä Polytechnic there is a special place called
Adam and Eve which provides students a stimulating, innovative and inspiring learning
environment. In Adam and Eve there is a large collection of sexological educational
material and equipment illustrating the diversity of sexuality. The learning environment
is suitable for those who want to develop their practical skills to understand sexuality
and its diversity in counselling, care or teaching.
In sexological education, the first sexological teaching clinic in Finland is currently being
established in the Jyväskylä Polytechnic to provide students an opportunity for guided
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training. For example, the teaching clinic will provide medical examinations and
counselling, personal and couple therapy, and telephone counselling. Several projects
will start at the clinic in 2000 including an examination of problems and treatment
methods in two areas, sexual inhibition and incest.
The training of a sexual counsellor includes the development of a project by each
student. The goal of the project is for students to apply what they have learned in the
courses in a way that benefits the whole working community. In this project students
with their team analyse their own needs — related to developing skills to deal with
sexual issues in their jobs — and the needs of those they work with. There are three
parts to the project: designing the plan, carrying out the project plan, and evaluating it.
Experience has shown that the work project greatly facilitates the acquisition and
internalisation of new information and knowledge for a working community. This has
been evident by an increase in internal training, more consultations related to the topic,
more attention to sexual health services, and by individuals recognising their own area
of expertise.
The unit responsible for sexological training at the Jyväskylä Polytechnic co-operates
with other expert organisations on a regional, national, and international level. Studies
and applied research carried out together with various universities guide activities and
the development of projects that support this Polytechnic’s work in sexology. In addition,
the sexological unit has received support from STAKES and the Finnish Sexological
Association.
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New Views on Sexual Health
The Case of Finland
Sexual Health of Specific Population Groups
20. Sexual Health of Children
Raisa Cacciatore
246
21. Adolescent Sexual Health
Elise Kosunen
268
22. Non-Heterosexual and Transgendered
People in Finland
Jukka Lehtonen
280
23. The Sexual Health of Disabled Persons
Kaija Karkaus-Rikberg
290
24. The Sexual Health of Aging People
Pirkko Kiviluoto
304
Conclusions
25. The State of Sexual Health in Finland:
A Summary
Ilsa Lottes and Osmo Kontula
315
Authors
336
245
Raisa Cacciatore
20. The Sexual Health of Children
The Sexual Health of Children in Finland
Sexual health means an important part of the well-being of a human being: the capability
to enjoy one’s own body, the ability to seek human contacts and experience pleasure
from closeness, the skills necessary to give pleasure to someone else, and adequate
preparation for a partnership and parenting.
In childhood this includes the following:
•Creating the foundations for one’s entire sexual self-image and sexual
development
•Learning about one’s own genitals and developing an understanding of the genitals as
a natural part of everyone’s body
•Realising that sexual life is part of human life
The purpose is to acquire a readiness for tenderness, closeness, communication and the
pursuit of pleasure, skills which are later also needed in reproduction. Childhood
experiences form the basis of an individual’s sexual potential.
The goal of evolution in individual development for most people is to acquire the
necessary skills for procreation and care of the young. Sexuality is a vital and strong
drive influencing human behaviour. Childhood is the time for practising how to approach
others, how to maintain human relationships, and how to give and receive tenderness
and care. At the same time, during the whole development period, a child can learn
about the pleasures associated with his or her body. Human interaction on the
psychological, physical, and social level is vitally important for the human being in all
stages of his or her life. Equally important is the experience that one has been accepted
by someone as a friend or potential partner. The ability to give affection and care
develops through satisfying experiences.
Sexual development takes place in all societies and for all individuals. Different societies
at different historical periods have taken very different attitudes towards this development
process and children’s sexuality. Theories formulated about psychosexual development
(for instance, Freud’s psychoanalytic view) reflect their specific era and societal values.
All adults and especially parents are sex educators, irrespective of whether they
acknowledge this role. In Finland a relatively open developmental environment is provided
for children. Children usually are able to proceed along the way of their sexual maturation
246
at their own pace, to ask questions and get answers, and to have sexual experiences
appropriate for their stage of development. There are only a few groups in Finland
where an anxious and restrictive attitude towards the sexual development of the child
exists, or where a child’s sexuality is viewed as bad or dangerous. This negative way of
thinking is steadily decreasing, however. Sexuality is usually regarded as a natural
developmental area of the child, as part of the child’s health and as different from adult
sexuality (see e.g. Huttunen 1999).
Very early childhood events can determine adult sexuality. The child can experience his
or her own body as either a source of positive feelings or negative feelings. The pursuit
of pleasure can be closely associated with shame and danger or it can be an exciting
joyful discovery. These experiences depend to a large extent on the actions and reactions
of the parents and other adults in a variety of situations. The child also learns by
experience whether the consequence of closeness is abuse or tenderness.
Moments of joy and insults are remembered for a long time and may affect a person’s
entire life, although the significance of later events is also great (Kontula and HaavioMannila 1995).
The adult should provide a safe environment for sexual development and a model not
only for closeness and tenderness but also for limits. The adult needs to help a child
understand the rules of proper behaviour. The younger the child, the fewer inhibitions
he or she will have in approaching other people. This may be considered problematic
by the parents and other adults. If the child is masturbating, the adult should guide the
child to do this only in privacy. The adult must also tell the child that no one is allowed
to violate his or her right to bodily self-determination.
Traditionally and especially since the 1960s, children in Finland have been given
possibilities for privacy and avoiding inappropriate control. In rural communities there
has not been time to constantly watch over children nor has it been considered necessary.
The fact that children examine and get satisfaction from touching their own bodies has
generally been considered part of the child’s normal development. Nowadays this is
considered a positive activity that strengthens sexual health.
For many generations the sauna culture has provided an excellent opportunity for Finnish families to discuss sexual matters. Going to the sauna together provides the child a
natural opportunity to examine the details of various parts of the body and to ask
questions that might occur in this situation. It also can reinforce two important messages:
(1) one should not be ashamed of nudity or the human body, not even nudity between
genders and generations and (2) being together naked is an area of sexuality under the
control of people themselves, instead of being something dangerous or driven by
uncontrollable instincts. The sauna experience supports sexual health in many ways
because it can strengthen self-esteem, body image and identity, self-control, and a
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sense of belonging and closeness to the group of one’s sauna companions. On the other
hand, the natural embarrassment of a young teenager later often causes the young
person to go to the sauna alone or together with his or her peers.
Areas of the sexual health of children
Supporting a child’s sexuality is possible when sexuality is widely understood as part of
growing up and coping in society. What early developmental processes increase children’s
ability to enjoy their sexuality in an all-inclusive way and in all stages of the life cycle
without subordinating or hurting other people? To answer this question I present five
images in which the child’s thoughts about the value of his or her own body and
possibilities for achieving personal goals become focussed. Development in areas related
to these images has a strong impact upon the later sexual health of the individual.
Body-image
Starting with birth, if not earlier, children construct through their own experiences images
of themselves. A positive body-image is constructed in an all-inclusive way, through
sensations of touch, hearing, balance, taste and smell. Skin contacts with the baby,
rocking, stroking, joyful voices and baby talk convey the positive message that the
baby is good and accepted, that people enjoy his/her company and think in a positive
way about him/her. During feeding the baby obtains oral satisfaction, skin contacts, eye
contacts and moments of play which are also important for many mothers, even in a
sexual way. The needs of bottle-fed babies can be satisfied equally well by the above
activities, and the baby can also be tended by the father or another adult. In this way a
baby acquires basic experiences of enjoying its own body and mutually enjoyable
relationships. In these moments a baby acquires the skill and permission to love. The
baby experiences love by and giving pleasure to another human being. If a child has
experienced violence and insults directed at his/her body, the child’s positive body
image can be seriously damaged, and sometimes such experiences lead the person to
hurt or objectify his/her body as an older child or adult.
Image of sexuality
During each stage of psychosexual development the child becomes interested in new
areas of sexuality. In early childhood, this interest is expressed by an uninhibited
curiosity. Internalising the meaning of sexuality begins early. Attitudes towards the child’s
curiosity and various parts and functions of the body as well as how they are talked
about and how the child is touched reveal whether bodily functions connected with the
genitals are viewed as natural, understandable and controllable. The child also learns
whether sexual expression and affection are openly displayed and how important these
displays are in the life of those around them. The importance of experiences during
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various age periods depend on the quality of the child’s own developmental endeavours.
If a child’s sexual interests expressed by questions, touching one’s own body, and
attempts at approaching close family members or friends are harshly punished, the
child’s image of sexuality will be associated with something that is forbidden and
dangerous. However, because the sex drive remains and gets stronger with age, this is
likely to cause internal conflict and suffering. An image of sexuality that has been
influenced by pressures to avoid sexual expression can lead an adolescent to think that
sexual activity is expected to take place but not expected to give any pleasure.
The best environment for growing up is one where a child can openly talk about sexuality,
closeness and all kinds of enjoyments of life without embarrassment and in which
sexuality is an ever-present, natural part of human life and growth. In such an
environment, sexuality can become a refreshing resource of life.
The image of gender roles
A child makes conclusions about society’s attitude towards each gender at an early
age, for example, about whether the people in their surroundings consider it a fine thing
to be a girl who will grow up to become a woman or to be a boy who will grow up to be
a man (see also Mäenpää and Siimes 1995).
Children first compare the satisfaction and life control of their father and mother, their
parents’ mutual respect or the lack of it and also think about the treatment of themselves
and their siblings. At times children prefer to seek the company of same gender-friends
to get support for their gender identity, and acquire knowledge, understanding and
acceptance. The closest friends are of great importance. A child may even wonder
about his or her own sexual orientation and the possibility of having homosexual leanings.
Children talk among themselves about gender-related models, rights and duties, for
example in jokes, and reach conclusions about how they should act in their roles now
and in the future.
The image of one’s importance in the social community
The social development of children is of great importance for their sexuality. Getting
support, encouragement and trust, and spending enjoyable and fun times together with
others give the child experiences of successful and joyous interactions with others.
Through these experiences a child develops the courage to make contacts, take initiatives,
and enter into a relationship. The feeling of being accepted in the community is also
closely connected with developing a positive identity. An individual with a strong positive
identity is better prepared to enter into a sexual relationship, to express his or her
wishes, to consider the needs of a partner, and to avoid undue dependence on or
restricting one’s partner. Individuals with good social experiences will have the skills for
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a relationship which include mutual respect, and also will have the confidence that a
long-term relationship is possible. The experience of feeling unfit as a member of the
community may cause withdrawal and contact problems in adolescence.
Images of the degree of self-control
Protecting one’s body from abuse and taking control of one’s sexuality as a child depend
on one’s surroundings, and a child needs help and protection to achieve these goals. In
a culture where incest and child abuse are strongly condemned it is important to let the
child know this. It is also important to talk about the protection of intimacy from the
point of view of respect and to avoid connecting intimacy with shame. Children should
be told that there are personal areas of the body over which they have control. In
addition, children should be encouraged at an early stage to wash these areas and
otherwise take care of them by themselves. Children should be taught that these parts
of their body are private, and that they themselves can decide who, where and when
someone can look at or touch these parts.
Children have the right to defend their private territory and demand that this right is not
violated: if somebody’s closeness feels unpleasant, the child has the right to withdraw. A
child’s bed, for example, should be considered private territory, and a child should be
able to prevent others from entering this private space. It is also advisable for adults to
maintain their private territory. Children should not touch the genitals of their parents or
see them making love, although talking about sexuality is appropriate. Children should
be encouraged to sleep in their own beds, because both children and their parents have the
right to the privacy of their own beds. Playing doctor among children is allowed but
pressurising and compelling other children for such play are not allowed even among children.
Sexual Abuse
Children will not demand their right to protect themselves from abuse unless they have
been given information about this topic; therefore, uniformed children are vulnerable to
abuse and often do not know how to ask for help. Educating children about their right
to protect their bodies from unwanted touching can help to protect them from sexual
abuse. Children who feel they are valuable individuals and who have been informed
about their rights will find it easier to recognise danger and talk about it. A child who has
experienced pleasant tenderness without sexual demands will find it easier to avoid
embarrassing conflicting situations.
Lack of sexual boundaries means that the child sees, hears, or experiences things which
do not promote a positive sexual development. Children may see, for instance, porno
videos, adult intercourse or masturbation. Also, school-age children ought to wash their
genitals themselves.
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Children should be taught the social norms about sexuality at an early age. For instance,
a child needs to be taught that scratching one’s bottom or touching one’s genitals are not
done in front of other people. This conveys a behavioural norm which helps the child
cope better in society. In teaching appropriate behaviour, an adult must not give the
impression that touching one’s genitals is wrong but simply that this activity is done in
private. Adults need to be careful not to promote negative views of sexuality that will
later provoke feelings of guilt.
Sexual violation involves the distortion of the child’s body image by words or deeds
through humiliation, excessive control or intrusiveness. In such a case a child may feel
submissive and consider him/herself a passive object. For the child, sexuality becomes
an area difficult to understand or to control. These situations involving violations
contribute to feelings of low self esteem for the child. In addition, violated children’s
feelings of helplessness and low self esteem encourage children to view themselves as
legitimate objects of abuse. Such abuse also damages a child’s overall sense of self control.
A false suspicion of sexual abuse is also a violation of the child’s sexuality. Investigations
of abuse which are improperly carried out may violate a child’s sexuality even if they
are necessary. If a child has to undergo, for instance, a painful and involuntary
gynaecological examination, or if s/he is pressured to confess or to give statements or if
the trauma is repeatedly brought to the child’s attention without the necessary
psychological support, then such experiences can impact negatively upon his/her sexuality.
A child may sometimes become an object of abuse without an adult actually intending
such a violation. Not so long ago, spanking was a common form of punishment in
Finland. This often meant that the child was bent over in an adult’s lap and hit on the
bare buttocks. This action is now considered a form of sexual violation. All kinds of
spanking have been prohibited in Finland. Similarly, various examinations by a physician,
such as examination of the testes or the anus or catheterising should always be carefully
and tactfully performed and their necessity should always be carefully considered.
The vocabulary describing sexuality often includes value-loaded hidden meanings. Certain
words may have negative connotations such as the Finnish term for the vulva “häpy“
(derived from the word “häpeä“ [shame]) or the Swedish term “springan“ (meaning
“cleavage“) or the most common Finnish swear word “vittu“ [vagina]. In the same
way the term “regret pills“ is a moralising and labelling way to refer to post-coital
contraceptive pills. On the other hand, there are examples of words generally felt to
have positive connotations, such as “rakastella“ (“making love“) and the terms used by
children themselves for the vulva and the penis (“pimppi“ and “pippeli“). These words
clearly sound nice, child-like and joyful. Talking about sexuality inappropriately by
providing too detailed or too private information or by making disparaging remarks
about gender or sexual orientation to a child who is not mature, willing to hear, or able
to understand, is also sexual violation.
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Sexual exploitation creates a distortion of sexual norms in the victim. Sexual contact
with a child arising from adult sexual needs is especially psychologically harmful for a
child. In such a case the child experiences sexuality as demanding and one-sided. This
kind of sexuality may satisfy a child’s needs for closeness and safety but leaves no
space for a child’s sexual interest to emerge gradually at her/his own pace. Typically the
child becomes saturated with experiences s/he would like to postpone. Children are not
ready to have sexual experiences with a partner who is not at their same developmental
stage. Children with distorted norms are also more likely to experience future violations
of their limits and to violate other peoples’ personal boundaries. An abused child feels
that being close to another human being is not safe or without ulterior motives. Sexual
experiences cause more pain than satisfaction and only offer the child a temporary
feeling of closeness. In general, the development of a child’s personality is easily damaged
by unwanted sexual contact with an adult.
A child who grows up in an atmosphere without psychological and physical respect and
tender closeness is particularly prone to sexual abuse. If a child experiences closeness
only in connection with sexual abuse, s/he often grows up to expect and seek abuse.
Experiences of sexual violence can turn one’s whole sexuality into something cruel and
oppressing and may channel someone’s sexual arousal to become dependent on violence.
Determination of sexual abuse is very difficult for various reasons. It can be a stressful
and heavy experience for the investigator, even traumatising. Therefore many people
avoid the whole matter.
The criminal investigation ought to be done by the police. Health and social authorities
often do not have the capacity, training, or appropriate motive to look for a suspect
because their primary aim is to help the child. It is also problematic from the point of
view of the child and her/his family if the party looking for evidence and providing
support services to the child are the same. It does not guarantee an impartial investigation
and reduces time available to help the child.
It is very difficult to prove sexual abuse of a child. The less the victim is able to seek
help and defend his/her rights and the more the victim is in a dependent and submissive
position, the easier it is for the perpetrator not to be identified and punished. It is easy to
silence children by threatening that if they talk about the abuse, something bad will
happen to them, their parents, or their family. It is known that there are children who
have suffered long-term systematic abuse (Hobbs and Wynne 1996) but who will not
tell the truth about their abuse under any circumstances. When a child’s basic trust is
extremely weak and even adults closest to her/him at times behave in a sadistic way, a
child will not trust even friendly casual contacts. In many cases children simply are
incapable of talking about their abuse.
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Children psychologically understand their helplessness and total dependence on their
parents. The easier a child can be abused, the more a child is susceptible to abuse. The
smaller, the more ignorant and isolated a child is, the easier a target the child is for the
perpetrator. Children tend to demonstrate solidarity and loyalty to their family regardless
of what their parents are like.
Estimating the frequency of child abuse is made more problematic by the difficulties of
the investigation of sexual abuse described above, the limited skills and inability to
communicate of some children, and functional or dissociative memory disturbances
caused by the trauma of sexual abuse. It is also difficult to compare the results of
published studies due to investigations of different age groups and different definitions
of abuse. The findings of two major child abuse studies in Finland are contained in the
reports “Experiences of Child Abuse and Violence“ (Sariola 1990) and “Faith, Hope
and Battering“ (Heiskanen and Piispa 1998). Currently it is estimated that about 736% of girls and 3-29% are being abused (Finkelhor 1994; Fergusson, Lynskey and
Horwood 1996; Garrasco; Atabaki and Paradise 1999). The cases coming to the attention
of authorities in Finland are being followed by STAKES (National Research and
Development Centre for Welfare and Health). According to the latest statistics, cases of
suspected abuse have increased four-fold in 15 years, now being 778 per year. The
reason for this increase might be that people have been more willing to report suspicions
(STAKES 45/2000)
Supporting sexual health at various ages
Baby age
A little baby is totally dependent on other people and builds his/her world view with all
senses, continuously from cumulative experience. A baby is the visible evidence of the
sexual love between his/her parents. Babies start to build an image of their (sexual)
bodies and the importance of closeness and contact very early. Holding in the arms and
rhythmical rocking pacify a restless baby; gentle talk and eye contact communicate that
the baby is valuable. The baby itself tries to touch everything with its hands and
mouth. Fetuses even touch their genitals. Strong and confident touching, cheerful
encounters, abundant closeness and skin and eye contact give a baby a safe and rich
beginning and a good foundation for healthy sexuality. Baby massage (repeated
systematic whole body massaging) and dialogical baby dance (mutual anticipation between
the dancing partners) are good examples of how to support the sexual health of a baby.
(Määttänen 1999).
The sensations of the mother connected with breast feeding range from pleasant and
wonderful to disgusting and indifferent. Some may even experience strong sexual
satisfaction when the baby sucks. Sexual sensations of this kind do not constitute sexual
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abuse of the child. Nature has only given some people this additional pleasure. There is
no reason to be afraid or ashamed of sexual feelings while nursing. By talking with
other mothers one learns about other people’s experiences and this knowledge may
relieve feelings of anxiety or guilt. There is no need to make breast feeding a problem.
An anxious, tense mother is a worse alternative than milk substitutes, and a mother who
bottle feeds her baby can still provide plenty of skin and eye contact.
Toddler and pre-school age
Sexuality in the toddler and pre-school age (up to age 6) is an active discovery of new
areas. Children should learn to feel accepted by others, to feel safe and secure and to
enjoy the closeness of others.
A healthy development is rich interaction based on giving and receiving tenderness. The
parents have a unique opportunity to offer the child wonderful experiences of warmth
and togetherness, from which the child can later draw resources for its sexuality. Exhibiting
one’s own body, the need to be admired, and an enormous curiosity about other people’s
bodies are typical for the toddler and pre-school age child. The method called Theraplay
is a good example of how to promote the sexual health of the child at the toddler and
pre-school age (Jernberg and Booth 1999).
A child of the toddler and pre-school age will be eager to enlarge his/her experiences
outside the home by engaging in hobbies or getting to know neighbours or children in
day care centre. Children may compare some parts of their bodies and how they function.
Children in the toddler and pre-school age are ready to start to take control of their
sexuality and reflect on attitudes with peers and compete with them. Boys may compare
the size of their penises, whose father has the biggest penis, and whose mother has the
largest breasts. Children know exactly to which gender group they belong and what it
means. They openly discuss everything in the presence of adults if allowed, but they
don’t want to tell everything to their parents. They already feel sexuality is a personal
matter but, on the other hand, children can also be afraid of being accused of exaggerating
and colouring matters. Children often do not want to make a distinction between truth
and imagination. A little boy may want to become pregnant, and a little girl may want to
have a penis. Age peers are likely to be the ones who best understand why such thoughts
are appealing.
Playing doctor is typical sex play in childhood. Sexual interest toward other children is
satisfied also by playing home, chasing or wrestling games. Some have already had
masturbation experiences (Kontula and Haavio-Mannila 1995). Curiosity is equally
directed toward both genders. Children may stay with their friends overnight and the
children get acquainted with multiple sources of information. In a study from 1975,
between 20 and 30 percent of respondents reported that they had played doctor in
childhood. In reality playing doctor may have been more common (Virtanen 1975). In
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the Finnish KISS study in 1987, 40% of respondents aged 13 to 17 reported playing
doctor at least once, and the experiences were equally common for girls and boys
(Kontula 1987). In playing doctor children may be satisfied by only taking off trousers
or underpants and peeping or they might do actual examinations of the other one’s
genitals with their fingers. Usually a small group participates in this type of play and
visiting the “doctor“ is a public occasion. Sometimes the “doctor“ does the examination
under the bed covering. Actual coital play seems to be much less common in Finnish
culture than playing doctor (Mäenpää and Siimes 1995).
In day-care centres events related to sexuality occur at regular intervals. Some children
have seen a porn video and one may blurt out while eating at the table that s/he, at least,
is not going to suck anybody’s penis as an adult. Another may bring a package of
condoms and distribute them to his/her friends. Another child may fondle or play with
his/her genitals in public. Boys may compete to see whose pee flies the farthest or ask
girls to show their genitals. The personnel of the day care centre need to be prepared to
deal with these kind of situations and to develop skills to handle them in a way that is
open and supports the child’s development. Today some training about children’s
sexuality is being arranged for the personnel of day care centres (e.g., the Rovaniemi
Polytechnic of Health and Social Affairs has organised a course called “the challenges
of women’s sexuality“ from 1999).
Talking about sexuality interests children in the toddler and pre-school age. For example,
Joensuu (1994) has written about this. It is good to give names and brief explanations
for private parts of the body to children at home. A girl can be told, in the words used
by children themselves, that she has a vulva, vagina, labia, clitoris and a pee hole, baby
hole and an excrement hole. In addition, in their tummies girls have a little home for a
baby or womb, where a real baby can one day live. A little duct leads to the womb from
both the baby hole and the ovaries where the baby seeds or ova are grown. A boy can
be told that he has a penis, which has a glans, a foreskin, and a pee hole, from which
the baby seeds come when he matures. In addition, boys have the scrotum and testicles,
which later produce spermatozoa, and an excrement hole.
Reproduction can be explained in the following way: To make the baby grow in the
baby’s home in the mother’s tummy, seeds are needed from both the man and the
woman. When these seeds meet in the baby’s home, they are fused and the baby
begins to grow. The father’s seed or the spermatozoon gets into the mother’s body via
the baby hole in intercourse.
Intercourse means that a man and a woman want to be together, very close to each
other and finally one inside the other. In intercourse a man’s erect penis is in the moist
baby hole of a woman. The man and the woman move in intercourse, caress each other
and it feels good. Therefore it is also called making love, and the man and the woman
do it even when they don’t want to have a baby. After a while semen with a lot of
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spermatozoa is ejected from the penis inside the woman. Once a month a woman has a
seed of her own or an ovum. If a man and a woman have intercourse during that time,
the woman may become pregnant. The baby grows in the woman’s womb for nine
months and when ready, the baby is born through the baby hole.
Menstruation: If there is no baby in the woman’s womb, there is some bleeding from
the baby hole for a few days per month. Usually it does not hurt.
Ejaculation: Some sperm may be ejaculated from a man’s penis even if he is not having
intercourse, for instance during the night or when he touches himself. Even that is not
dangerous and does not hurt. The human body produces new sperm all the time in the
same way it produces blood and neither is depleted.
When one learns as a child to consider signs of growing up as natural, they are easier to
deal with in adolescence. Then it is natural to talk about them. The family might even
celebrate puberty by holding a small menstruation or ejaculation party for the youngster.
The celebration would signal that development is a good thing and something to be
proud of. One should also always remember to talk about enjoyment connected with
ejaculation, for a positive attitude helps a boy accept the changes during puberty.
Menstruation in itself is not a source of pleasure, but girls also have a right to hear about
their possibilities to enjoy sexuality.
6-9 year-old children
When children reach school age, the culture of their own gender is accentuated: girls
have girl things and boys have boy things. Both are eager for admiration from adults
and acceptance from their peers. A child accumulates experiences which show whether
both genders are equally valued in the family and the community and learns what kind
of gender role norms prevail. There is a discussion in the scientific community about
whether the differences in behaviour are caused more by biology or the social
environment. The reality is probably some combination of both nature and nurture.
There are large differences among individuals within each gender.
The beginning of school means that children enter a new world of gender role education
through their interactions with a heterogeneous group of children and its culture.
In the beginning of school a girl often wants to associate with another girl, to form a
quite intensive pair. She often develops an especially “feminine“ form of verbal
communication and taking care of her looks. The boys usually try to enter functional
boys’ groups, where “masculine“ competition, feats and boasting are accentuated.
Human anatomy interests children and they are capable of understanding the details
connected with reproduction. Sexuality is not anxiety-provoking and a child can be
taught about health issues in a very broad context. Children still need a lot of cuddling
and tenderness from their parents and occasionally want to sleep next to their parents,
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but the sexuality of their parents is no longer of great interest. It is more important for
children now to know how other children of the same age act and to imitate them.
Children at this age already play going steady and to being mother and father. A play
partner’s gender is not important but the same gender is preferable. In earlier times
children showed interest in each other by teasing. Now children openly may say they
“hang together“, but this saying is playful in character and there is not a sexual tone in
the relationships (Anttila 1995).
10-12 year-old children, early adolescence
Just when a child has come to a conclusion of how girls and boys, children and adults
function, the biological changes of early adolescence muddle up everything. Bodily
changes are embarrassing, as well as the changes in the state of mind and stimulation
caused by hormones. When children reach early adolescence, they begin to try to
answer questions like “Do I want to grow up?“, “Is this right?“, “Am I gay or lesbian?“,
“Do others feel the same way?“. Sometimes the answers are sought in an asexual, selfsufficient, adventurous identity resembling that of Tom Sawyer’s or Pippi Longstocking’s.
Sometimes there is a need for regression or to emphasise the sexual characteristics of
one’s own gender in unique ways. During this period children are developing
independence and often feel they are primarily individuals and not somebody’s child.
Insecurity and shame caused by the changes in the body and its awkwardness can be
disturbing. Those whose development is slower or faster than the others need extra
help. Sexual feelings cause excitement in many kinds of situations, and there is no
simple relief for the feelings. When girls begin to develop rounder forms they do not,
for instance, want to let boys see them in swimming suits. Boys try to peep at girls and
to pinch them. It is important to talk about the right to the privacy of one’s own body and
how to make and avoid contact. Parents should discuss in detail what the words “whore“,
“transsexual“, “lesbian“ or “gay“ mean and forbid their use as a form of abuse.
The child already knows quite well that sexuality is not exhibited in public. The interest
in peers grows stronger and stronger, and allusions to sexuality become more common
in jokes, speech and games. It becomes more and more difficult to seek answers from
adults. However, reception of factual information is still possible even though it may
feel embarrassing. Books provide many young people a good source of information which
can be received at one’s own pace, and they do not have to worry about getting excited in
the company of a book. Porn videos are used as a source of information by many because
there are scarcely any other sources of information about sex techniques available.
Teasing between children may have sexual overtones. The physical development of
boys lags about 1-2 years behind that of the girls and they try to look bigger with the
help of loose clothes and big words. An excessive macho culture can lead to teasing the
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smaller ones: a head may be forced into the toilet, trousers or underpants pulled down,
or some other form of humiliation. Some girls feel like giants next to much smaller
boys and try to be unnoticeable and away from the centre of attention and only giggle at
the boasting of boys. Especially those who are overweight may get the idea to start a
diet to become more popular. Eating disorders become more common at this age. Even
a very beautiful girl may easily become the target of teasing by others. A faltering selfesteem is very common at this age for both girls and boys and serious long-term damage
may occur (see e.g. Aalberg and Siimes 1999).
A physical change from a child to an adolescent occurs during the ages 10 to 13. It is
recommended that teachers in schools help their pupils to deal with their feelings and
their own development. In this way, sexuality could become a resource in school work,
and a culture could be developed where positive sexuality can be openly discussed. In
this way it will later also be easier to give information about risks related to sexual
behaviour. Children need support in various phases of their development from familiar
and reliable adults. Otherwise obtaining information about sexuality is available only
from television, videos, friends and leaflets. Already at kindergarten age children receive
education from older children, but the quality of this information is questionable. Access
to information about natural sexuality, possible to understand and to handle, which is
everybody’s right in all stages of life, ought to be part of a child’s upbringing. According
to a study by Maija Nykänen, parents consider the best age for sex education to begin
around the age of ten. The vast majority of parents (92%) thought that sex education
should be an integral part of the curriculum at the lower level of comprehensive school
(ages 7 to 12). (Nykänen 1996.)
The Mannerheim League for Child Welfare carried out a study in 1999 about the role
of adults as providers of health information. This survey included 5383 pupils aged 9 to
14 in Espoo, Joensuu and Mynämäki. The most important providers of sex information
for children aged 9 to 10 were the mother (16.3%), class supervisor (5.6%), and older
brother or sister (4.1%). More than one half (57.9%) had not received sex education
from anyone. The most important sources for children aged 11 to 12 years were the
school nurse (29.9%), class supervisor (13.8%) and mother (12.5%). Only about one
fifth (21.9%) had not received sex education from anyone. These figures show how
immediately after the onset of adolescence the rank of the mother drops from first
place to the third.
Ability to reproduce – the end of childhood?
Menstruation has started in Finland in 50% of girls by the time they reach 13 and one
half of the boys have had their first ejaculation before the age of 14. At the same time
there is the period of regression in psychological development (Aalberg and Siimes
1999). Thus a young adolescent may have difficulties acting in sexually responsible
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ways. An 11 to 15 year-old may imagine that he/she has the complete authority to make
decisions, especially in the area of sexuality, but still needs limits, safety and protection
from adults. The adolescent may test his/her charm by childish provocation without
understanding the dangers. Adults ought to regard adolescents less than 16 as children
and not as potential sex partners and protect these young people from abuse.
Table 1. In which order do various matters interest the child?
When
What interests?
What is taught?
Development of the
child
Pre-school age
0 to 6 years
The structural differences of a
girl and a boy:
- the vulva, vagina and the
- baby’s home, the penis and the
testicles
Intimacy, words
Gets acquainted with
the body and the
surroundings
The role of girls and boys as
women and men:
- the mother cleans and father
goes to work?
Role expectations, the
meaning of the family
Emotions, values,
closeness
Fatherhood, motherhood and
where do children come from:
- the ovum, spermatozoon,
lovemaking, childbirth
The formation of values
and models of sexuality
Structural differences of a girl
and a boy:
- erection, fondling,
menstruation
- what words to use?
Acceptability, rights
Accepting and starting to
control one’s own body
School starters
7 to 9 years
Anatomy, reproduction
Terms associated with sexuality
The right to self-determination,
bodily integrity
Pre-adolescents The beginning of adolescence
Infatuation, beginning to go
10 to 12 years
steady
Differences between girls and
boys
Masturbation, sexual needs
Knowledge and attitudes
Words associated with
sexuality
Course of physical
development
Access to information
Getting to know the
world outside one’s
family of origin
Time sequences,
normality
Making contact,
Roles, needs, fantasies,
contraception
Adolescence begins
Understanding oneself
as a future potential
partner for age peers
Sexuality leads from childhood family to a partnership
Sexuality is a strong factor influencing the child’s progress towards independence. It
directs attention from the sphere of the parental family towards the peer group and a
partnership. Characteristics of sexual development are completely different in different
age periods, and the existence of same-age friends is important at all stages and facilitates
development. Sexual feelings, crushes and thoughts about going steady consume a large
259
2
part of the early adolescents’ time and energy. If the gradual changes of the mind and
the body seem understandable and natural, they will probably not cause problems.
A baby is totally dependent on its caretakers and one may say “in love“ with them. It
wants continuous closeness and contact and is afraid of loneliness. In the toddler age
around 3-4 years the child usually falls in love with one of the adults in the family: often
girls intend to marry their father and boys their mother. The primary parent-child
relationship is influenced by the new possessiveness of the child reaching this age: I
want and ask to be the only one for you, can I do it?
At the same time the child begins to understand its individuality, he/she often finds the
special pleasure coming from touching one’s genitals. This touching pleasantly strengthens
the child’s feeling of “me self“. At this stage children should have developed an
understanding that their body and sensations are good and their very own. Children
should learn to protect themselves from unpleasant touching and to seek help from a
safe adult if needed.
When mother and father turn out to be unreachable as partners, a sibling may do as a
substitute. The attitude of the people closest to a child determine whether the child
finds the tender expression of attraction ridiculous and stupid or positive and worthwhile.
The first attraction with an outsider may be a distant love object such as a teacher, bus
driver or a public idol. On the everyday level children show affection to pets, horses
they take care of and ride, soft toys, bicycles, motorbikes and computers. An interest in
the changes that take place in adolescence is present long before the body changes
actually occur. Curiosity is immense. Children like to discuss differences between
friendships and romances as well as taking care of themselves and, for instance, their
hygiene. Factual information about puberty should be offered to 8 to 9 year-old children
for they are very willing to listen.
When the influence of the peer group becomes more important, often a familiar person
from this peer group becomes an object of attraction, but first the child does not share
this infatuation with anyone. The child gradually comes to grips with the feeling in his/
her own mind before having the courage to tell others about it and get feedback. Children
expect their friends to give approval and support for their feelings, and nowadays many
children have the courage to show their emotions more openly. They examine friendship
in a deeper way; the confidence and respect of a friend are an essential part of friendship.
One’s own sexuality becomes the object of scrutiny: will I become straight or gay/
lesbian? The fantasised future partnership and leaving the childhood home in the future
are also in their minds.
Children or pre-adolescents often express their feelings to the object of infatuation with
a slip of paper or via a messenger. Requited love brings extra happiness. At this point
260
the child’s self-esteem is already so strong that it doesn’t decrease too much even if
rejected. They do not yet need or want physical interaction at this time but there is a
great curiosity toward the biology of sexuality: what happens in sex between adults and
why do they do it? Occasionally youngsters strongly distance themselves from the
adults of their own family.
The first tentative attempts at courtship are often experienced at the time fertility is
reached. Being together is bewildering, even talking can be difficult, but there is a lovely
tension in the air, which both parties feel. The adolescent begins to learn about being
rejected and rejecting. Information is needed in order for everyone to evaluate his/her
own puberty and to be able to take care of his/her sexual health in both physiological
and emotional areas. The foundations for sexuality developed before puberty strongly
determine the kind of values, moral ideals and ability for sexual enjoyment adolescents
have and how they will start their journey toward adulthood. (Korteniemi-Poikela and
Cacciatore 2000.)
Sexual Health Services for Children in Finland
The services of a network of municipal child counselling centres are available throughout
Finland. Almost one hundred percent of families use them. In these centres health care
nurses and physicians support and guide families and follow a child’s development until
school age. In principle, the health care professionals in these centres are supposed to
support the psychosexual development of children. Experienced workers are able to
consider, for instance, a three-year-old child’s interests in her/his genitals as a normal
phase of development. However, more education and information is needed by a great
number of health care professionals in order to answer the questions of the families.
There are 126 municipal family counselling centres in Finland which are municipal units
under the jurisdiction of the social welfare authorities, and they specialise in helping
families with children in problem situations. They carry out, for instance, psychological
assessments and provide treatment, if a child has symptoms that involve sexual issues.
They also have some preparation for investigating incest. Municipal child welfare
authorities are on duty and take care of the safety of children and are ready to support
the family or to take a child into custody if, for example, a child’s sexual integrity has
been violated in the family. Unfortunately, social welfare authorities have a shortage of
resources.
Pre-school child day-care is usually organised by trained personnel in both municipal
and private day care centres. There are attempts to develop the training of children’s
nurses and kindergarten teachers to provide information about a child’s sexuality.
Fortunately, today most teaching and supervision are of high quality. In the best case,
people in day care institutions and parents work together to support each other in
261
facilitating children’s development. The question of the day is whether the personal
background of people entering the field of child and youth care ought to be checked,
because paedophiles also seek these jobs. Those who support background checking
argue that it is necessary for the safety of the children.
The services of school health service are an important part of sexual health services for
children. Family members and teachers jointly take care of sexual health education for
children. Sex education was a compulsory part of school curricula from the mid-seventies
to 1994. In many places sex education reached a very high standard, and it has been
continued in many schools in spite of its current voluntary status. Nevertheless, pupils
are in very unequal positions with respect to their opportunities to receive sexuality
education. In some areas sexual health education has been totally eliminated. The school
nurse has traditionally been an important person: she or he is often a sufficiently remote
but trusted adult, whose counselling is easy to accept. In addition to giving personal
guidance, for instance, the school nurse provides contraception information and has
been a source of great expertise in sex education classes. However, the services of
school health care have been strongly reduced in recent years, and this has made the
situation of children and young people worse.
Child psychiatric units devote a large share of their resources to support the psychological
development of the child and also to child psychiatric studies and treatment connected
to cases of child sexual abuse. The situation is very problematic because of the lack of
specialist physicians. The Association of Child Psychiatrists in Finland is preparing
national guidelines for the examination of sexual abuse of children.
Both the police and the hospitals in the Helsinki area have specially trained personnel to
investigate sex crimes against children. It would be good to extend this expertise to the
personnel throughout whole country. The best practice would be to establish public
centres specialising in sexual abuse, where the best possible investigation and treatment
of these cases would be available, including a proper amount of trained personnel. Cooperation needs to be improved among authorities in health care, social welfare, the
schools, and police. Training within these fields should also be increased.
Many non-governmental organisations sponsor projects to help children, such as writing
booklets for children, patrolling streets and counselling families. The Sexual Health
Clinic of the Family Federation of Finland has worked for years to support sexual
health services for children. Open House is the name of the project, which has functioned
already for 12 years, providing sexual health services free of charge for girls under 18
and boys under 20. People working with children have been trained to deal with the
sexuality of children. Models for sex and health education for children have also recently
been developed for the lower level of comprehensive school and day care centres.
Special emphasis is on developing the child’s knowledge and respect for his/her own
body and on providing information about sexual rights and bodily integrity. A new kind
262
of model for sex education has been produced together with the National Board of Education,
called The Nine Steps of Sexuality (Korteniemi-Poikela and Cacciatore 2000). The Family
Federation of Finland has also published the book Bunny Stories and Other Baby Fairy
Tales (Hovatta 1993) aimed at children and telling where babies come from.
The Mannerheim League for Child Welfare operates a telephone hotline for children
and the young. It was founded in 1980 to help people under the age of 22. About 50
000 phone calls are received every year. One per cent of the callers are 7-year-old
children or younger, 10% are between the ages of 8 and 10 and 40% between 11 and
13. Of the phone calls dealing with sexuality received in 1998, 15% came from children
between 8 and 10 and 30% from children between 11 and 13 years of age (KajaaniKurki 1999). This organisation also produces material and sponsors studies about
children’s sexuality. For example the book entitled I Discuss Sexuality With the Child
(Joensuu 1994) was published in 1994 and a study about the role of adults as sex
educators for children was carried out in 1999 (Kajaani-Kurki 1999).
Another organisation, The Central Union for Child Welfare also sponsors studies about
children. One study examined the frequency of child abuse and resulted in the report
The Experiences of Sexual Abuse and Violence of Children (Sariola 1990).
The Finnish Red Cross operates four shelter homes for children under the age of 19.
Children and teenagers can visit or phone these homes to get protection and support.
Informing children about these activities, however, is problematic and information needs
to be more actively disseminated, for example, on television, in child health centres,
day care centres and school, among other places. The personnel of different shelters
and mother and child homes are being trained to identify and alleviate children’s sexual
distress and sexual abuse symptoms.
The SEXPO Foundation’s project of sexual growth produced and translated material
about children’s sexuality.
Skidikantti (Kid’s Corner) is a programme developed by Aila Juvonen which has been
operating for ten years. In this programme children are taught self-defence skills. Children
are taught to cope with different dangerous situations, for instance, how to protect
themselves against sexual harassment and how to defend the integrity of their bodies.
This education model has spread to many communities and used in their own projects.
The Finnish Evangelic-Lutheran State Church has generally taken a positive attitude
toward sexual development and sex education. Valuable counselling is given in
confirmation schools.
The Ministry of Social Affairs and Health established a working group in January 1999
to prepare a programme on the prevention of children’s commercial abuse. The group
263
must submit its action plan within one year. Sex crimes against children and adolescents
registered by the police have increased in recent years.
A new Criminal Code of Sex Crimes was passed in the beginning of 1999, in which the
child’s position was improved by making a sex crime against a child a matter of public
prosecution instead of the responsibility of a private person. In practice, this change
means that whereas earlier the guardian of the child had to press charges before an
investigation could start, now investigation automatically begins when the police become
aware of the suspicions. However, the law does not include a possibility to intervene in,
for instance, a case where a know child molester is preparing his or her actions. Recently,
however, a middle-aged man was sentenced because he had made some phone calls to
a 15-year old girl asking her for a car ride and to his hotel room.
What About the Future?
The sexual health of children and adolescents in Finland has been among the best in the
world according to most indicators. The traditions, attitudes, and high professional
standards of personnel and providers of public health care have ensured high-quality
services. The atmosphere for discussion is still open and decisions are based on both
reliable information and ethical principles.
In the past few years a change for the worse has become evident. In the beginning of
the 1990’s an economic recession occurred in Finland, which led to wide cuts in social
and health programmes. The reduction of funding has not stopped, even though financial
conditions are much better now. Inequity of wealth and resources has increased. Welfare
and other supports have decreased particularly for children and adolescents, those who
are not able to defend their rights.
The media brings sexualised advertisements and pornography to every home, and tourism
makes child prostitution accessible to more people. Communication has become more
and more technical, and money has become excessively valued. Sexuality is often
regarded as a commodity, as offering business opportunities to make money. Drug use,
marginalisation and alcohol have their impact on children. It is not fashionable to work
in the upbringing of children, to be present as a female or male role model or to take
care of family life. Doing well in work life demands more and more from parents. All
this weakens the possibilities for healthy sexuality, development and childhood. Children’s
psychiatric problems are increasing, but there is not enough personnel to provide
examinations and treatment for children.
The promotion of children’s sexual health requires adequate financial support by the
state, proper research, resources and expertise, and strong public advocacy. To fight
against children’s sexual abuse, public specialised centres should be founded, where the
best possible investigation, treatment and research would be carried out.
264
Working with children demands sustained efforts and abilities based on both knowledge
and sensitivity. More men are needed in the field of education. Fathers have the right to
know how important their presence is for the development of their son’s and daughter’s
sexual identity. Children should not be a nuisance in the tightly scheduled everyday life
of adults. Instead, they should be enjoyed and considered a special privilege for the
attention and time of their parents.
References
Aalberg, Veikko and Siimes, Martti A. 1999. Lapsesta aikuiseksi (From a child into an
adult). Nemo, Jyväskylä.
Aigner, Gertrude and Centerwall, Erik. 1999. Lapset ja seksuaalisuus (Children and
sexuality). Kirjayhtymä.
Anttila, A. 1995. Rakkaudesta ne tytötkin ennustaa (Even the girls foretell of love.).
Yliopisto 2/1995.
Atabaki S., Paradise J. E. 1999. The medical evaluation of the sexually abused child:
Lessons from a decade of research. Pediatrics 104: 178-86.
Carrasco, Mary. 1996. Sexual abuse and rape. In Gellis & Kagan (ed.). Current Pediatric
Therapy. 15th Edition. W. B. Saunders Company. pp 56-8.
Fergusson, D.M., Lynskey, M.T., Horwood, L.J. 1996. Childhood sexual abuse and
psychiatric disorder in young adulthood: I. Prevalence of sexual abuse and factors
associated with sexual abuse. J Am Acad Child Adolesc Psychiatry 35(10): 135564.
Finkelhor, D. 1994. The international epidemiology of child sexual abuse. Child Abuse
Neglect 18(5): 409-17.
Heiskanen, Markku and Piispa, Minna. 1998. Usko, toivo, hakkaus (Faith, hope,
battering.). Tilastokeskus, Tasa-arvoasiain neuvottelukunta. Helsinki.
Hobbs, Christopher J. and Wynne, Jane, M. 1996. Physical Signs of Child Abuse, a
Colour Atlas. Saunders Company Limited.
Hovatta, Outi. 1999. Pupujuttuja ja muita vauvasatuja (Bunny stories and other baby
fairy tales.). Väestöliitto. Painatuskeskus Oy, Helsinki.
Huttunen, Matti, O. 1999. Ihmiseksi (As a human being). Duodecim kustannus.
Joensuu, Jyrki. 1994. Keskustelen seksistä lapsen kanssa (I talk about sexuality with
the child). Mannerheimin Lastensuojeluliitto.
Kajaani-Kurki, Kristina, Mannerheimin Lastensuojeluliitto. 1999. Henkilökohtainen tiedonanto (Personal communication, The Mannerheim League for Child Welfare).
Kontula, Osmo and Haavio-Mannila, Elina. 1995. Matkalla intohimoon (On the way to
passion). WSOY, Porvoo-Helsinki.
Kontula, Osmo. 1987. Nuorten seksi (Sex of the young and adolescents). Otava, Keuruu.
Korteniemi-Poikela, Erja and Cacciatore, Raisa. 1999. Seksuaalisuuden portaat (The
nine steps of sexuality). Opetushallitus, Helsinki.
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Mäenpää, Jorma and Siimes, Martti. 1995. Lasten ja nuorten seksuaalisuus (The sexuality
of children and adolescents). In Seksuaalisuus (Sexuality). Kustannus Oy Duodecim, Pieksämäki. pp. 55-68.
Nykänen, Maija. 1996. Näkemyksiä ala-asteen seksuaaliopetuksesta (Views about sex
education at the lower level of comprehensive school). Jyväskylän Yliopisto, Terveystieteen laitoksen julkaisusarja 4/1996.
Sariola, Heikki. 1990. Lapsen seksuaalisen hyväksikäytön ja väkivallan kokemukset
(The sexual abuse of a child and experiences of violence). Lastensuojelun Keskusliitto.
STAKES 45/2000, http://www.stakes.fi/tiedotteet/2000/45.htm
Virtanen, L. 1975. Lasten lääkärileikit (Children’s doctor plays). Suomen Lääkärilehti
30: 1711–15
266
Appendix 1. When is a child’s sexual behaviour a symptom of a disturbance
or a problem?
Normal behaviour
Symptom of what?
•
even fetuses have erections, boys touch their
penises at all ages to have an erection
•
•
the touching of all parts and openings of the
body, including the genitals
The most common reason for excessive or
compulsive masturbation is the child’s fear of being
left alone in the day care centre, separation anxiety,
depression or stress.
•
a delighted, enthusiastic, investigative curiosity
about everything connected with sexuality; open,
unabashed questions about different body parts,
an unabashed wish to get to touch and see other
people’s bodies and how they function
A common cause is also a lack of sexual
boundaries in the home: the child may have seen
sexual activities between the parents, porno videos
etc. and is trying to deal on a level of action with
what s/he has experienced
•
Sexual abuse is the least common reason. An
indication of this could be, for example, a sudden
change in behaviour: the child may become
depressed, timid, withdrawn and apprehensive or
aggressive towards other children. On the other
hand, the child may start to cling to an adult and
become afraid of going home. Sometimes the child
has symptoms with sexual overtones or the child
tells through the means of play what has happened
or what s/he is afraid of. The sexual descriptions of
the child may be unusually detailed considering the
child’s age. The child may try to push object into
the anus or vagina. Larson (1994).
•
•
a proud and bold wish to exhibit one’s body, a
wish to be the centre of everything
•
a periodical lack of modesty at least up to the
age of 3 to 5
Symptom
What to do if there are suspicions that the child’s
sexual behaviour deviates from normal?
•
The child exhibits the sexual areas of her/his
body in a compulsive, exaggerated, anxious
way, for example, to all visitors
•
•
The child touches her/his genitals in a
compulsive way and does not listen to advice to
do that only in privacy
•
The child continually talks to adults in an
explicitly sexual way, for example, by telling two
adults to ”fuck each other” and asks very
intensively about the sex life of adults. On the
other hand it is very common for children to
discuss adult sex life among themselves.
The child’s activities should be commented on and
described, for example, masturbation or playing
with one’s genitals. The child should be told that
picking one’s nose or touching private parts should
not be done in the presence of others. There is
nothing bad in these activities as such but they are
supposed to be done in privacy. Limits should be
given to the child: if you have difficulties controlling
yourself, I will have to intervene. The child should
be told what is proper language and behaviour, and
let the child clearly know about the rules. (Aila
Juvonen: The Kids’ Corner programme.)
•
The child continually and without any inhibitions
touches an adult, for example by squeezing the
genitals of an adult, or rubs her/himself against
the adult in an unpleasant manner
•
•
Forcing or hurting other children in a sexual
way, impulsive and aggressive way playing
sexual games
Avoiding closeness to adults and becoming
anxious, for example, when washing or going to
bed
It is good to discuss the question with the team of
the child’s day care centre: Have others noticed
strange behaviour? Are others worried? It is
important for the counsellor that s/he can have the
support of the team. To become aware of one’s
own helplessness is the first step toward
understanding the situation. (Aila Juvonen: The
Kids’ Corner programme.)
•
Contact the caretaker of the child: Has this kind of
behaviour been noticed also at home? Is there a
reason for the child to be stressed or anxious about
something? If necessary, the support of a family
counselling centre is recommended
•
If talking with the parents or the caretaker of the
child doesn’t help or the symptoms continue to be
alarming, the child should be referred to child
welfare authorities.
267
Elise Kosunen
21. Adolescent Sexual Health
Introduction
When evaluated from a medical perspective using statistical data, adolescents’ sexual
health has developed favourably in Finland during the last two or three decades. Teenage
pregnancies and abortions have decreased by fifty percent since the 1970s, and these
declining trends continued until the mid-1990s. Because these trends in pregnancies
and abortions cannot be explained by changes in sexual activity, they are indications of
more effective use of contraceptives. Age of initial sexual intercourse has remained
fairly constant since the late 1980s. Sexually transmitted diseases have decreased among
adolescents. Gonorrhea is rare and chlamydia infections decreased during the first half
of 1990s. So far, HIV has not gained a foothold among Finnish adolescents. This can
be considered an achievement in the promotion of sexual health.
Promotion of sexual health also includes components of psychological and social health.
We know substantially less about the status of adolescents’ psychosocial sexual health
than we know about their physical health. So far, less attention has been given to
studying and describing these aspects of their health. In addition, adolescents have
seldom been studied as users of health services, not to mention as users of sexual health
services. We know very little about adolescents’ experiences and needs as clients.
International comparisons have shown that low teenage pregnancy and abortions rates
are associated with sex education and easy access to contraceptive services (Jones et al.
1985). This means that services must be located close to young clients and that the cost
of using these services is low. In addition, it is important to adolescents that services are
confidential. A prerequisite for carrying out effective sex education and providing sexual
health services is an accepting attitude, one which acknowledges sexual experiences as
a normal part of adolescent growth and development.
In Finland, many of these criteria were met to a large degree during the last two decades.
In this chapter, I describe in more detail those factors that have created prerequisites for
favourable development of adolescent sexual health, as well as its present status. In
addition, the topic of adolescents’ sexual and reproductive rights in Finland will be
addressed. Sex education, which is necessary for the promotion of sexual health, is
discussed in other chapters of this book.
268
Adolescents’ Health Services
Provision of Sexual health services
A major part of adolescent health services is carried out within the system of public
services, that is, as a part of primary health care services. Unlike many other European
countries, Finland has not founded a specific organisation of youth clinics; only the
health centres of the large cities have separate clinics for teenagers.
In practice, when in need of sexual health services, adolescents mostly use services
provided by their own health centre. They can make an appointment with a general
practitioner or they can visit a family planning clinic or school health care unit.
Providing health services at schools has a long tradition in Finland, originating at the end
of the 19th century. In 1972, the Primary Health Care Act included school health care as
a part of services provided by health centres. A school nurse carried out age-specific
physical examinations for all children and adolescents and was available at school at
specified times for counselling and treatment of minor health problems. A school physician
also participated in this work, but with clearly less time resources. From the viewpoint
of promoting sexual health, school health care has had an important role as a provider
of sex education and as a first contact with health care organisations. When adolescents
begin their sexual activity and are in need of contraception, it is easier for them to first
contact a school nurse to get advice. Mostly the school nurse helps the adolescent in
making an appointment with a family planning clinic. In many schools, it is possible for
a school nurse to give out the first package of oral contraceptives on advice of the
school doctor, and thereafter, the girl is guided to a family planning clinic for follow-up.
A school nurse probably has the more important role as an information channel and a
guide to family planning services in the bigger towns and health centre organisations. In
1998, a questionnaire study was conducted among youth clinic clients aged less than 18
in the city of Tampere. One of the questions asked the clients how they received
information about youth clinic services. Friends were the most important source of
information (63%), but almost as often (58%), clients got the information from their
school nurse (Kosunen 1998).
Family planning clinics in health centres have provided services to adolescents using the
same principles that are used for the adult population. Direct access to services without
making an appointment, which would lower the threshold of obtaining services, has
been used in only a few clinics. Sex education directed to large groups of adolescents
has not been included in services of family planning clinics, but information and education
has mostly been given in a counselling session with a client. Some municipalities have
269
had the staff of the family planning clinic participate in sex education at schools, while
in others, whole classes from schools have visited the family clinic to learn about its
services.
Besides public services, “Opened Doors” of the Family Federation of Finland (Väestöliitto) has provided sexual health services to adolescents since 1988 in the capital of the
country, and Folkhälsan has provided some services in the Swedish speaking areas on
the coast. Use of private services is minimal among adolescents.
Costs of sexual health services
Visits to family planning clinics as well as services in schools and student health care in
health centres are free. The circular letter given by the National Board of Health in
1982 stated that the first method of contraception should be given free of charge. In
practice, this meant that adolescents got their first oral contraceptives cost-free for 3 to
9 months, but after that, they had to pay the full price for the pills.
Currently, the price of a one-month package is about seven dollars; in larger packages,
the price per month is a bit lower. Nurses working in family planning clinics have found
that even the price for one month is a problem, at least for those girls who try to pay
this expense from their pocket money, without any support from their parents. Besides
oral contraceptives, adolescents also pay the full price for condoms, and so far, the
delivery of condoms for adolescents has not been organised at a subsidised price.
Confidentiality of services
In Finland, there has been hardly any public discussion about prescribing oral
contraceptives for minors without parental consent. For instance, in the USA and England
there have been trials about such prescriptions, and even currently in England, the lack
of confidence in teenagers complicates obtaining contraceptives by adolescents less
than 16. However, court decisions in England have been consistent with The International
Convention for the Rights of Children which stipulates, If a minor is considered mature
enough, she or he has a right to decide about his/her own business without parental
consent. In Finland, the Act on the Status and Rights of Patients that has been in effect
since 1993 correspondingly places emphasis on the developmental level of a child or an
adolescent, when it stipulates, a minor has the right to make the decision on his or her
care or on releasing information about his/her health. The law does not stipulate any
age limits that could be generally applied.
Adolescents themselves find confidentiality of services very important (Scally 1993).
This issue has also emerged in countries, which are generally considered to have an
open-minded sexual culture (Jones et al. 1985). Regardless of adolescents’ insistence
on confidentiality, parents often know about their use of contraception. The Finnish
270
practice allows prescription of oral contraceptives without parental consent, and no
minimal age limit has been set. However, a young client is advised to tell her parents,
because eventually they will find out. In practice, the youngest clients of family planning
clinics are 14-year-old girls, of which some one to two percent are using oral
contraception. This proportion has remained about the same since the mid-1980s, and
contrary to public opinion, the users of oral contraceptives are not getting younger and
younger (Kosunen et al. 1999a). According to a Finnish study, 15 year-old girls who
use oral contraceptives have a steady relationship; they are sexually active and like
adults need contraception (Kosunen 1996).
Current Situation of Adolescent Sexual Health
Initiation of Sexual Activity
Sexual experiences in adolescence are important for the discovery of one’s own sexuality
and formation of ones sexual identity. Even children as young as 9 to 11 try to find out
how it feels to be close to somebody of the opposite sex by slow dancing “ at school
discos or home parties. In adolescent surveys, pupils of the 7th grade (between 13 and
14 years old) report quite frequent experiences of kissing and fondling. Real dating
relationships become more common after age 13. Girls are more active in dating than
are boys, and this difference can be seen even several years later.
According to the School Health Survey in 1996-97, about 60% of 8th grade boys and
girls have experienced their first kiss, and about half of them have experienced fondling
with clothes on (Table 1). Experiences of intimate fondling (under clothes or naked)
sharply increase between 15 and 16, among boys and girls (Kosunen et al. 1998).
By the end of the last year of comprehensive school (mean age 15.8) about one quarter
of adolescents have experienced sexual intercourse (Table 1). Girls are a bit more active
than boys, if total number of coital experiences or the frequency of sexual intercourse
during the past month are used as criteria for sexual activity. This is mainly due to the
difference in biological sexual maturation, which starts two years later in boys than in
girls. On the other hand, compared to girls of the same age, experienced boys reported
having had more sexual partners. In the second year of high school (mean age 17.8)
girls are still more active than boys in terms of the frequency of sexual intercourse
during the past month. Forty percent of sexually experienced girls and 23% of boys,
respectively, reported having intercourse during the last month. There was no longer a
difference in the number of sexual partners at this age.
Finnish adolescent surveys between 1986 and 1997 have provided very similar results
on the proportion of adolescents having experienced sexual intercourse. Contrary to
popular belief, the age at which sexual experimentation begins has not decreased during
271
the last few years. From the viewpoint of promoting sexual health, this is an important
finding. Although sex education has been provided in Finland since the 1970s and
contraceptive methods are quite easy to obtain for adolescents, this has not led to a
younger age of initial sexual intercourse.
Table 1. Proportions (%) of adolescents reporting sexual experiences by
gender and grade at school according to the School Health Study 1996 and
1997 (Source: Kosunen et al. 1998).
Girls
Gender
8 grade
9 grade
USS*
8 grade
9 grade
th
USS*
17 627
16 765
10 649
17 814
16 841
7 321
Going steady
16
25
39
12
16
22
Kissing
64
77
89
58
69
81
Fondling with clothes
on
50
67
84
48
62
76
Fondling naked/under
clothes
30
49
73
27
43
61
Sexual intercourse
15
29
53
14
24
42
Sexual intercourse
during the last m onth
8
18
36
8
13
21
Sexual intercourse at
least ten tim es
5
14
36
4
8
19
grade
N
th
th
Boys
th
*upper secondary school (high school)
Contraception
General points of adolescent contraceptive methods
Contraceptive methods suitable for adolescent use are few compared to those of the
adult population. A condom is the most important method that teenagers use. It is a
coitus-dependent method and suitable particularly if sexual intercourse occurs infrequently
and irregularly, as often happens in the case of adolescents. The strong point for using
condoms is that, if used properly, they protect relatively well against both pregnancy
and sexually transmitted diseases. The weak point is that condom use requires great
care and proper use to be reliable. This is important for young and inexperienced users
to understand. A shift to oral contraceptive use often happens in a steady relationship
where coital events occur more frequently. At the beginning of a new relationship, oral
contraceptives should be used together with condoms, as methods of double contraception
272
(Table 2). Hormonal emergency contraception is not applicable for regular use because
of its low contraceptive efficacy, but it is a reserve method for a failure or omission of
regular contraception.
Table 2. General outlines for choosing contraceptive method for adolescents
for prevention of unplanned pregnancies and sexually transmitted diseases
according to type /length of couple relationship and coital activity
Type of relationship Length of relationship Coital frequency
Contraceptive method
Occasional
-
Less than 2 per month
Condoms (+ emergency
contraception*)
Occasional
-
At least 2 per month
Oral contraceptives
+ condoms
Steady
Less than 6 months
Weekly
Oral contraceptives
+ condoms
Steady
At least 6 months
Weekly
Oral contraceptives
*advice on emergency contraception for all condom users in case of failures
Condoms
Information and education of condom use targeting adolescents was substantially
increased in the latter half of the 1980s because of a threat of an HIV epidemic. A
survey of adolescent sexual behaviour in 1992 (the KISS Study) showed that teenagers’
opinions of condoms were more positive compared to earlier studies, and proportions
of adolescents using or having ever used condoms increased (Kosunen 1993).
The main contraceptive method used at the first sexual intercourse is a condom; the
second most common option is that no method is used. The figures of the KISS Study
describing the first sexual intercourse indicate that use of condoms between 1986 and
1988 increased: in that period, the proportion of non-use of contraception decreased
from 40% to 27% among girls and form 30% to 20% among boys.
The prevalence of contraceptive use has also been studied by asking which contraceptive
method adolescents used at their most recent intercourse. The results of the WHO
cross-national survey (Health-Behaviour in School Aged Children) suggest that practices
of condom use improved again during the early 1990s. The proportion of girls who had
not used a contraceptive at their most recent intercourse decreased from 25% to 15 %
between 1990 and 1994, and the respective figures for boys were 25% and 11%. When
comparing distributions of contraceptive methods, the proportion of condoms had
increased by ten percent (Pötsönen 1998).
273
Oral contraceptives and double contraception
In Finland, oral contraceptives were recommended for the first time for adolescents at
the end of 1970s. According to the Adolescent Health and Lifestyle Survey in 1981,
about one fifth of 18 year-old girls used oral contraceptives. Among younger girls, the
use was infrequent. During the 1980s, the proportion of users also increased among
younger age groups. Among 16 year-olds, it almost tripled, and one to two percent of
14 year-olds were users (Figure). During the 1990s, the use of oral contraceptives
remained steady. Neither the rise in prices nor the pill scare in 1995 had an effect on
their popularity. According to the Adolescent Health and Lifestyle, in 1997 41% of 18
year-olds, 17% of 16 year-olds and 2% of 14-year-olds used oral contraceptives (Kosunen
et al. 1999a).
Many efforts have been made to promote the use of double contraception during the
era of HIV. The recommendation has been that it should always be used at the beginning
of new relationships for 3 to 6 months. The proportion of such users has been small,
and use of double contraception has not increased during the 1990s. According to a
recent study, five to seven percent of sexually experienced comprehensive and high
school students had used double contraception at their last intercourse. The figures are
somewhat lower than at the beginning of the decade. One reason often given is that the
combination of pills and condoms is far too expensive a method for adolescents at
current unsubsidised prices of contraceptives.
Figure 1. Proportions of oral contracpetive users (%) among girls aged 14, 16
and 18 years from 1981 to 1997.
45
40
35
30
25
18-years-old
20
16-years-old
15
14-years-old
10
5
0
1981 1983 1985 1987 1989 1991 1993 1995 1997
The four-tablet package of hormonal emergency contraception was introduced to the
Finnish markets in 1987. Its sales have risen annually, so that in 1998 about 44,000
packages were sold. According to a study in 1994, the users are mainly unmarried
women under age 25 (Kosunen et al. 1997). Older women knew less about this method
274
than conventional methods. According to the School Health Survey in 1996, almost all
girls in the 8th and 9th grade (mean age 14.8 and 15.8 years) knew about hormonal
emergency contraception. In the 8th grade, the proportion of girls who had ever-used
emergency contraception was 2%, in the 9th grade the figure was 6%, and in high school, it
was 15%. Two thirds of those users had used the method only once, while the proportion
of multiple users varied between 4 and 6 percent in all groups (Kosunen et al. 1999b).
Teenage Pregnancies and Abortions
Teenage pregnancy and abortion rates have decreased by more than half since the mid1970s. Because teenage pregnancies are usually unplanned, the trend of pregnancies
reflects changes in sexual activity or contraceptive use or both of them. Based on
research data it is obvious that changes of adolescent sexual activity do not explain
trends in teenage pregnancies and abortions in Finland.
Around half of pregnancies of girls less than 20 years of age will end in induced abortion.
The younger the girls concerned, the higher the proportion. As in western countries in
general, the trends of pregnancy and abortion rates highly correlate. The only exception
in the Nordic countries is Iceland, where the prevalence of teenage pregnancies is the
highest of these countries. However, most pregnancies are carried to term there, and
the abortion rate has been lower than in other Nordic countries until quite recent years.
However, the situation is changing and the number of teenage abortions is now sharply
increasing in Iceland (Gissler 1999).
Sexually Transmitted Diseases
When HIV became public knowledge in the mid-1980s, versatile campaigns were started
in Finland to increase condom use and prevent an epidemic of HIV (Tikkanen and
Koskela 1992). One form of public campaign targeted to adolescents was a personal
letter mailed to the home address of all young people between 15 and 24 years of age in
1987. The Ministry of Social Affairs and Health sent the letter and it included information
on preventing HIV and other sexually transmitted diseases. The campaign has continued
so that every year all adolescents who will be sixteen years old receive this information
package. Besides a pamphlet, the material includes a condom and a letter to the parents.
Since the very first years, the content of the package has increased so that currently,
different topics of sexual health information are covered more thoroughly.
At the beginning of the 1980s, gonorrhea was still a quite common disease. A decreasing
trend started in the early years of the decade, and this trend accelerated at the end of
the decade, perhaps only as a result of increasing condom use. The incidence of gonorrhea
was 13 cases per 10,000 girls aged 15 to 19 years; the new figure was 2 per 10, 000 in
1994. From 1995 to1998, the total number of cases has been around twenty cases
among adolescent boys and girls combined.
275
Statistics on chlamydia infections have been recorded since 1988. The incidence of
chlamydia decreased simultaneously with the decreasing trend of gonorrhea: between
the years 1988 and 1994, chlamydia infections decreased 41% in girls aged 15 to 19
(Kosunen 1996). After that, the method of compiling statistics changed twice, so that
the numbers of the recent years are probably not comparable with those of earlier
years. However, the statistics of 1997 and 1998 suggest that chlamydia infections are
increasing in young age groups. Twenty-three percent of all reported venereal chlamydia
infections in 1998 were found in adolescents aged between 15 and 19 years. Altogether,
the proportion of young people‘s (aged 15 to 24) infections was two thirds of all chlamydia
infections in 1998 (source: www.ktl.fi/ttr). So far, HIV transmissions have not spread
among the teenage population in Finland. The total number of HIV transmissions found
in adolescents aged 15 to 19 is eleven, but the figure is 137 in 20-24 year-olds by June
2000 (National Public Health Institute, unpublished information). Now, HIV is spreading
as an epidemic among users of intravenous drugs in the capital area. Therefore, more
effective preventive measures must be taken in the very near future.
Psychosocial Sexual Health
The concept of sexual health was created to emphasise, among other goals, that good
sexual health also includes psychosocial well-being. This means that an individual person is free to discover his/her sexuality in that way which is best for him/her, without
any pressure, fear or anxiety, and with respect for other people.
We know very little about the status of psychosocial sexual health among adolescents.
What are those teenagers who are just starting their active sexual life thinking? Sexual
maturation of an adolescent includes powerful and rapid changes, both physically and
psychologically. Events of maturation raise many questions in a teenager, even feelings
of fear and anxiety. Ideally, adolescents should be surrounded by safe adults, adults
adolescents feel comfortable with and with whom they can discuss their problems
freely and openly. Relevant knowledge will lessen misunderstandings and unnecessary
fears. For example, masturbation is still associated with hiding and feelings of shame,
even with severe feelings of guilt. Therefore, it is important that adolescents get relevant
information through school sex education lessons, which include information about a
variety of topics including masturbation and its role in a young persons sexual
development.
The KISS study in 1992 showed that during the HIV campaigns in the late 1980s
adolescents’ knowledge about sexuality improved, but, on the other hand, their sexual
fears increased. These kinds of studies have not been carried out in the latter half of the
1990s. Studies among young clients of family planning clinics show, however, that
adolescents need discussion, and they would like to talk about sexuality and couple
relationships during their visit to the clinic.
276
Gender socialisation is a developmental process that begins in early childhood. In spite
of the trend of increasing equality between genders, old sex-related attitudes still influence
the sexuality of young people. Sexual activity is “macho” for boys, but for girls
expressions of sexuality can still mean stigmatisation and loss of reputation.
In very recent discussions, some public health nurses working in family planning clinics
have expressed concern about sexual pressure on young girls. In particular, a question
has been raised about the possibility of the misuse of emergency contraception for
pressing girls to engage in sexual intercourse. Research data on this topic is non-existent
for the 1990s. The KISS Study in the late 1980s showed that between five percent and
ten percent of girls had reluctantly agreed to their first sexual intercourse after persuasion
(Kontula and Meriläinen 1988).
Increasing commercial sex and its visible role in all types of mass media can also be
regarded as a threat to adolescent sexual well-being. This probably shapes teenagers’
understanding of sexuality and may cause unnecessary pressures for both genders. As
an alternative to commercial information, adolescents need additional sources of relevant
information about dating, human relationships, and sexuality.
We know very little about growth and development of those adolescents whose sexual
orientation is different from the majority. Homosexuality and bisexuality are seldom
addressed in sex education lessons at school. Although attitudes towards homosexuality
have changed and become more open and accepting in Finnish society, the dominance
of a heterosexual perspective is obvious in the society and among different service
providers.
Adolescents’ Sexual Rights in Finland in the 1990s
Finland and other Nordic countries are among the leading countries in both the realisation
and promotion of adolescents’ sexual rights. It is not purely by chance that the trends of
different indicators of adolescent sexual health (e.g., induced abortions, HIV
transmissions) are favourable here. However, during the 1990s, some changes occurred
which may have a deteriorating effect on the realisation of adolescents’ sexual rights.
In 1994, curricula of comprehensive schools were changed so that the municipalities
had more power to decide about what was taught in their schools. Sex education, which
used to be an obligatory subject at school, was no longer included in the required
curriculum of a school. Consequently, comprehensive sex education and sufficient level
of sexual knowledge are not provided in every school any more, thus compromising the
foundation for the successful promotion of sexual health later in life.
School and student health care funding was substantially reduced during the early 1990s
in many municipalities because of the economic depression (Latikka et. al 1995). These
277
reductions are very significant because the Finnish organisation of primary health care
does not provide any other services targeted for young people in particular. Although
the economic depression is now over and there are many signs of improved health and
well-being among adolescents, no improvement in the provision of services is scheduled.
The changes in services and education provided by the health and education systems
are important from the viewpoint of sexual health; promotion of adolescent sexual
health requires services tailored for adolescents’ needs with easy accessibility and
availability. Those who counsel adolescents must have specific requirements: they must
have a broad understanding of bio-psycho-social development and good communication
skills. At its best, school health care has provided this kind of service. Developing, not
cutting off these services would be the easiest and most economical way of meeting
adolescents’ increasing needs for health services.
Occasionally, there have been discussions about limiting adolescents’ access to
contraceptive services, for example, by setting an age limit. However, this is very difficult,
not only because of individual rate of growth and maturation, but also due to the large
variation of normal development. Putting strict age limits for access to contraception
would also be against international recommendations and agreements concerning sexual
and reproductive rights. Commitments and legislation related to such rights include the
International Convention for Children’s Rights and the Act on the Status and Rights of
Patients, which both give the right of self-determination to a child if he/she is mature
enough to understand them.
If an exceptionally young teenager comes to ask for oral contraceptives, she should not
be given them automatically. Rather the girls’ life conditions should be examined more
thoroughly than usual. Need of contraception at an early age (in Finland this usually
means younger than 14 years) is often associated with a wide range of social problems.
When a child or young adolescent comes for a visit to a family planning clinic, she may
need assistance with other problems. If access to contraceptive services were limited by
enforcing a strict age limit, it would be the end of one way to identify and help children
and adolescents with serious problems
Several indicators during the last two or three years suggest that the favourable
development of adolescent sexual health has levelled off. Trends of induced abortions
have turned upwards since 1994. Laboratory reports indicate that chlamydia infections
have statistically increased. Increased use of intravenous drugs, in particular, has already
created a small epidemic of HIV in the capital area, which can easily spread through the
rest of Finland. Society must react soon to the worsening conditions by increasing
information and education directed to individuals and communities, as well as by
developing sexual health services that more adequately reflect their current needs.
278
References
Gissler, M. (ed.). 1999. Aborter i Norden-Induced Abortions in the Nordic Countries.
Tilastoraportti-Statistical Report 10/1999. Helsinki
Jones, E.F., Forrest, J.D., Goldman, N., Goldman, N., Henshaw, S.K., Lincoln, R.,
Sosoff, J.I., Westoff, C., and Wulf, D. 1985.Teenage pregnancy in developed countries:
determinants and policy implications. Family Planning Perspectives 17: 53-63.
Kontula, O., Meriläinen, J. 1988. Nuorten kypsyminen seurusteluun ja seksuaalisuuteen (Adolescent maturation to courtship and sexuality). Lääkintöhallituksen julkaisuja. Terveyskasvatus. Sarja Tutkimukset 9/1988. Valtion painatuskeskus, Helsinki.
Abstract in English.
Kosunen, E. 1993. Teini-ikäisten raskaudet ja ehkäisy (Teenage pregnancies and
contraception). Stakes. Raportteja 99/1993. Jyväskylä: Gummerus.
Kosunen, E. 1996. Adolescent Reproductive Health in Finland: Oral Contraception,
Pregnancies and Abortions from the 1980s to the 1990s. Academic dissertation.
University of Tampere. Acta Universitatis Tamperensis ser A vol. 486.
Kosunen, E., Sihvo, S., Hemminki, E. 1997. Knowledge and use of hormonal emergency
contraception in Finland. Contraception 55: 153-157
Kosunen, E. 1998. Nuorisoneuvolapalvelut Tampereella (Youth clinic services in the
city of Tampere). Abstract. In XI Yleislääketieteen päivät 22.-23.10.1998 Tampereella. Lyhennelmät. Tampere.
Kosunen, E., Rimpelä, M., Liinamo, A., Jokela, J., Vikat, A., Rimpelä, A. 1998. Nuorten seksuaalikäyttäytyminen Suomessa 1996-1997 (Adolescents’ sexual behaviour
in Finland 1996 - 1997). Suomen Lääkärilehti 53: 3353-60.
Kosunen, E., Rimpelä, M., Vikat, A., Rimpelä, A., Helakorpi, S. 1999(a).
Ehkäisytablettien käyttö Suomessa 1990-luvulla (Use of oral contraceptives in Finland in the 1990s). Suomen Lääkärilehti 54: 163-167
Kosunen, E., Vikat, A., Rimpelä, M., Rimpelä, A., Huhtala, H. 1999(b). Questionnaire
study of use of emergency contraception. British Medical Journal 1999: 319:91.
Latikka, A-M., Perälä, M-L., Hemminki, E., Taskinen, S. 1995. Kouluterveydenhuollon
muutokset 1992–1994 (Changes in school health care from 1992 to 1994). Suomen
Lääkärilehti 50: 349-353
Pötsönen, R. 1998. Naiseksi, mieheksi, tietoiseksi. Koululaisten seksuaalinen
kokeneisuus, HIV/AIDS-tiedot, -asenteet ja tiedonlähteet (Growing as a woman,
growing as a man, growing as a concious citizen. Adolescents’ sexual experiences,
HIV/AIDS knowledge, attitudes and the source of information). Academic dissertation.
Studies in Sport, Physical Eduction and Health 59. University of Jyväskylä, Jyväskylä. Abstract in English.
Scally, G. 1993. Confidentiality, contraception, and young people. British Medical
Journal 307: 1157–58.
Tikkanen, J., Koskela, K. 1992. A five-year follow-up study of attitudes to HIV infection
among Finns. Health Promotion International 7: 3-9.
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Jukka Lehtonen
22. Non-Heterosexual and
Transgendered People in Finland
In Finland as in most cultures a heterosexual gender system exists. This system includes
norms about how people should express their sexuality and enact gender roles. These
norms discourage sexual intimacy and love between people of the same gender. In
addition, it is against cultural norms for females to behave in highly stereotypical
‘masculine’ ways or for males to display highly stereotypical ‘feminine’ behaviour.
Finnish lesbians, gays, bisexuals and transgendered people have been trying for a long
time to find their place in society which promotes heterosexuality and restricts crossgender behaviour.
Non-heterosexuals are people, who have sexual feelings toward and/or who engage in
sexual activities with persons of their same gender and /or who have sexual identities
which are linked to these feelings and behaviour. Non-heterosexuals include lesbians,
gays, and bisexuals, individuals who to varying degrees are motivated by a definite
erotic desire for members of the same gender. Transgendered persons are men or
women who in some way surpass the limits of normative gender behaviour. The gender
identity of a transgendered person is different from the normative gender identity
associated with the person’s biological sex. Transgendered people include transsexuals
and transvestites.
First I discuss homosexuality, bisexuality, and transgenderism from a historical-cultural
perspective. I explain how ideas associated with these constructs have become part of
Finnish culture and emphasise their pluralistic nature. Next I concentrate on heterosexism
and homophobia in Finland. I describe how these cultural stereotypes and labels have
had an overwhelming detrimental effect on the sexual health and general well being of
homosexual, bisexual and transgender people. I also highlight problems and dilemmas
these people have because of their marginal positions in society.1
Lesbian, gay, bisexual and transgendered
people in Finnish culture
The concepts of heterosexuality, homosexuality and bisexuality have only been used to
describe people’s sexuality for about one hundred years. This trichotomy was used
1
I thank Kaija Kurkela (social worker of SETA), Jussi Nissinen and Olli Stålström for
their comments.
280
mainly in medical journals. In 1882, a case study of a Finnish woman who had sexual
interests in women was published in a medical journal (Löfström 1991). In the 1950’s
the term homosexuality started to become more common in everyday use but the word
heterosexual has only been in common use since the 1980´s. Previously, heterosexuals
were and still are today referred to as ‘normal’or ‘ordinary’. In the 1960´s nonheterosexuals adopted the word homosexual. Before that the word ‘meikäläinen’ (meaning
‘one of us’) was used in the company of others with a similar same gender attraction.
That term is still used in older generations of homosexuals. At the end of the 1970´s and
the beginning of 1980´s, the word lesbian started to be used to mean a woman erotically
attracted to another woman. About the same time the word ‘homo’ (gay) became
widely used and it began to refer only to men who have a same gender erotic preference.
Less has been written about the origin of the term bisexuality, but currently in Finland a
bisexual woman is called ‘bi-nainen’ or literally bi-woman and similarly, a bisexual man
is called ‘bi-mies’ (bi-man). (Lehtonen 1997).
Because Finland remained a predominately rural country later than most Western nations
and homosexual culture is concentrated in cities, common use and meanings of the
terms heterosexual, homosexual and bisexual are relatively new to Finnish culture. In
Finnish rural, culture good work was valued more than sexual performance and the
emphasis on the value of work reduced the incidence of homosexual labelling (Löfström
1997; 1998). Sexuality, in general, was not much talked about and men did not have to
depend upon their heterosexuality for the construction of a positive male identity to the
degree that is common in many other cultures. It was only after the second world war
that the increased urbanisation made it possible for new terms and ideas relating to
homosexuality to spread among the ordinary people.
The history of transgender terms is even shorter. In Germany in 1910 research was
published on transvestites and after that the term became more widely used. Transexuality
was differentiated from transvestism only in the 1950´s in the United States. In Finland
these words did not become popular until the 1970´s and 1980´s. The existence of
biological women who had male gender identity was not acknowledged until the 1990’s.
Previously transgenderism was understood to apply only to biological men. Today it is
common to speak about trans-women or trans-men.
The meanings and importance of the constructs of homosexuality, bisexuality and
transgenderism vary in people’s lives. Those with sexual interests toward members of
their own gender define themselves in many different ways and use a variety of words
to describe themselves. The process of defining one’s gender identity and sexuality is
often a difficult process for nonheterosexuals. Interpretations and understandings of
their sexual orientation and gender often undergo change and variations in different life
stages. In the last decade some young people especially have questioned traditional
categories of gay and lesbian and seem to deal more pragmatically with sexual and
gender issues than those from earlier generations (Lehtonen 1998a; 1998b). Recently,
281
some have tried to accept and promote a philosophy of individualism and empowerment
that encourages people to develop and define their own categories to describe themselves.
The self-defined sexual orientation of those who engage in same sex interactions varies
greatly. Some people can have same-gender sexual feelings and occasionally engage in
same gender sex and not define themselves as lesbian, gay or bisexual. Thus a man in a
heterosexual marriage, who occasionally has sex with men, does not need to create a
gay identity. Others can define themselves as lesbian or gay even if they have not
engaged in sexual behaviour with or even feel a sexual attraction toward someone of
their same gender. Some radical feminists, for example, might find a lesbian rather than
heterosexual identity more consistent with their political or ethical ideology. There are
numerous possibilities for combinations of sexual feelings, behavioural enactment, and
self-definition. Educators and health professionals need to be aware of the
oversimplification and inadequacy of conventional categories used to describe
nonheterosexuals as well as heterosexuals.
Sexual orientation is a multidimensional construct and includes sexual dreams, fantasies,
desire, feelings, sexual behaviour, self-defined sexual categorisation, sexual attitudes,
gender identity, and sexual orientation linked life style (Lehtonen, 1995). Dreams,
fantasies, feelings and sexual orientation are usually kept private. Behaviour, life style
and attitudes are more visible, at least to some people. It s also common for people who
define themselves as heterosexual to occasionally have a sexual dream about or erotic
feeling toward someone of their same gender. Not all people who have same gender
feelings and sexual experiences construct a gay, lesbian or bisexual identity. However,
some do live gay or lesbian lifestyles characterised by living with or dating someone of
their gender and taking part in the activities of gay and lesbian communities. Although it
is common for gays and lesbians to have tolerant attitudes toward diversity, this is not
always the case. For example, gay men with a traditional gender role identification may
be prejudiced against effeminate men. Among people of all major orientation groups —
homosexual, heterosexual and bisexual— a great deal of variation exists with respect to
almost any quality or characteristic.
Because of this plurality and variation it is difficult to determine the number and
proportion of non-heterosexuals and transgendered individuals. Depending on the research
method it has been estimated that homosexuals and bisexuals make up 1-15 % of the
Finnish population or between 50 000 and 750 000 people (see Kontula & HaavioMannila 1993; Sievers & Stålström 1984; Kontula 1987; Diamond 1993). The proportion
of sexual minorities changes depending on the question asked and the sample. If the
question requests respondents to identify themselves as gay, lesbian, bisexual or
heterosexual, the answers will differ from those to a question about ever having had
erotic feelings for a person of the same gender. For example, in a 1993 survey of
students at the University of Helsinki, 9% reported that they were either often or
sometimes attracted to persons of the same gender, yet 3% of the respondents described
282
their sexual orientation as bisexual, gay or lesbian (personal communication, Elina HaavioMannila). It is estimated that there are about 50,000 transvestites and about 5000
transsexuals in Finland. Not all transsexuals want to have surgical treatments.
Lesbians, gays and bisexuals in Finland are often grouped together and referred to as a
sexual minority, and recently transgendered persons have been referred to as a gender
minority. These minorities do not form a coherent well-defined group with clear
boundaries. Variations in age, residence, gender, religion, education, language, background
and cultural heritage as well as possible disabilities and social status influence how they
as nonheterosexual or transgender people live and create images of themselves. Although
nonheterosexuals look for models and materials from their environment and culture to
aid in the construction of their self concept, they can also be considered active agents
involved in this construction process. Finland is a small country with only a small
immigrant/foreign population. About 99% of the population of Finland consists of racially
white-looking Finns, and the income distribution is not great, among the smallest in
Europe. The culture is fairly homogenous and similarity and conformity are valued
more than plurality and difference. The needs of minorities are often not accepted and
frequently discussions about the human rights of lesbians and gays are considered a
demand for special advantages.
Heterosexism and Homophobia in Finland
Historically, public discourse about homosexuality and transgender issues has been
linked to religious, medical and legal considerations (Foucault 1984; Weeks 1986).
These discourses posit the views that heterosexual relationships and marriage including
the nuclear family are better for society’s well-being and more “natural“ and healthier
for the individual than are other lifestyles. Christianity labelled sexual activities outside
heterosexual marriage as sins against God. Medical doctors defined individuals who
engaged in same gender sex as sick and psychologically degenerate and laws defined
this activity as a crime. Those who engaged in transgender behaviour were subjected to
similar negative reactions by religious, medical and judicial institutions.2
Attention should not be directed only towards social institutions but also to heterosexist
ways of thinking about sexuality and gender. Heterosexism operates on many levels
(Herek 1990). Cultural heterosexism includes negative labelling and exclusion of nonheterosexualities by major societal institutions in all basic areas – the economy,
government, the family, education, religion and medicine. Psychological heterosexism
is a way of thinking adopted by an individual, which can result in homonegative prejudices.
Heterosexism or heteronormativity can also be defined as a belief in the superiority and
self-evidence of heterosexuality in which non-heterosexuality or non-heterosexual persons
2
These labels and reactions are discussed more in the chapter of this book by Olli
Stålström and Jussi Nissinen
283
are consciously or unconsciously shut off from programmes, happenings or other activities
(Sears & Williams 1997). A common heterosexist assumption is that everyone is
heterosexual. Other options are not considered or even silenced. Instead of speaking of
psychological heterosexism, some have used the term homophobia which can be defined
as irrational fear of homosexuality in others, the fear of homosexual feelings within
oneself, or self-loathing because of one´s homosexuality. Homophobia can be expressed
in many ways, silently and covertly (exclusion and avoidance) as well as blatantly and
obviously (jokes, name-calling, violence) (Epstein & Johnson 1994).
The general population accepts numerous myths and stereotypes about nonheterosexuals
and transgendered people. One such belief is that there are major biological and physical
differences between nonheterosexuals and others. A common stereotype is that gay
men are always effeminate and lesbians masculine. In heterosexist thinking children of
transgendered or non-heterosexual persons will develop gender and sexual disorders.
Research has not found children raised in these nontraditional families to have a higher
incidence of such problems (e.g., King & Pattison 1991). Sexual minorities are often
judged and thought about primarily with respect to their “perceived“ sexual behaviour
instead of according to the wide range of qualities and activities that are commonly used
in reference to their heterosexual friends and acquaintances. (See Heikkinen 1994;
Lehtonen 1996)
A typical homophobic reaction is the violence towards men who are thought to be
homosexuals by men unknown to their victims. For young non-heterosexuals, schools
can be unsafe places and name calling and bullying linked with homosexuality is common.
Research in the 1980´s (Grönfors et al., 1984, N=1051) indicated that overall every
sixth gay or bisexual man had experienced violence based on his sexual orientation. For
men over 35 years, the proportion who experienced such violence was 25 %. This type
of violence usually occurs outside gay restaurants and in parks which are places for
men to meet a sex partner. The aggressors are usually groups of young men. Violence
towards women is more often committed by acquaintances and by men who propose
that sexual intercourse with them will ‘cure’ them of lesbianism.
Researchers have found that boys´ attitudes towards homosexuality are especially
negative in comprehensive school when they are 13 to 15 years old (Kontula 1987;
Lehtonen 1995). Findings from research indicate that only a small minority of boys
reacted positively to homosexuality. Despite the fact that most homosexuals hide their
sexual identity, 12 % of women and 21% of men reported that they had been teased,
discriminated against or called names in school or university because of their sexual
orientation (Grönfors at al. ,1984). In my own survey research involving adult lesbian,
gay, and bisexuals most of the young (under 30 years old) respondents had heard
negative stories about homosexuality from their class mates. Boys much more often
than girls, told these stories. Boys also frequently used references to homosexuals as
swear words or to degrade or make fun of another boy. Homophobic bullying is not
284
always directed towards gays or bisexuals, but works as a control mechanism as ‘ordinary´
boys are growing up to be ‘ordinary´ men. This homophobic culture in schools seems
to be used to construct a distinct type of heterosexual masculinity (see also Mac An
Ghaill 1994, Nayak & Kehily 1997).
Despite the stereotypes and heteronormative attitudes on transgender issues and
homosexuality, general attitudes in these areas have improved (Kontula & HaavioMannila 1993). In a large national survey, two thirds of Finns regarded homosexuality a
private matter that authorities should not interfere with. However, the majority of
adolescents report negative attitudes towards homosexuality (Kontula 1987). On the
other hand, as they grow older their attitudes become more positive and in general,
adults between 18 and 44 and especially women have accepting attitudes toward nonheterosexualities (Kontula 1991).
Silence and lack of recognition of sexual minorities are more common than overt
prejudice and homophobic action. In schools, for example, gay and lesbian artists,
writers and historical figures are portrayed in a heterosexual context. Consideration is
not given to the possible influences of their same sex eroticism on their creative works
and accomplishments. In addition, many public discussions of nonheterosexuality and
transgender issues have a narrow focus, concentrate on negative aspects, or deal with
sensational topics. Nevertheless, some attempts have recently been made to expand the
curriculum in school sex education and to sensitise social and health care workers
(Lehtonen 1995, 1998c)
Lesbians, gays, bisexuals and transgendered persons have had to deal with sickness,
sin, crime and other labels as well as heterosexist attitudes. Some have adopted these
negative stereotypes. Some have resisted them but these labels and attitudes impact
their life in many ways and contribute to feelings of low self-worth, suicidal thoughts
and attempts, and excess drinking. Sexual and gender minorities have in the past tried to
hide these problems. Recently the mental and alcohol problems of non-heterosexuals
and transgendered people have been acknowledged. This is an important first step for
now health and education systems can begin to provide services and information to
help these minorities.
Out of the Closets or Not?
Only a small minority of lesbians, gays, bisexuals and transgendered people are living
their life openly which means that they mention their sexual or gender identities to
general acquaintances. Most, however, do talk about their identities, feelings or
relationships to some other people: most commonly to those whom they feel would be
understanding of their situation such as lesbians, gay or transgender individuals, family
members, and close friends. Most keep this information from their school, study or
work mates or tell only a very small group of people in education and work environments
285
(Grönfors et al., 1984; Lehtonen 1995, 1999). Because the general societal expectation
is that people are heterosexual, being open about sexual orientation is an on-going
process and continually presents dilemmas. There are three ways to deal with openness
about one´s sexual orientation: the first is to live as heterosexual, the second is to adopt
a lesbian and gay life style and the third is a combination of the other two— to sometimes
speak honestly about sexual orientation and to sometimes keep it a secret (Davies
1992). The same type of patterns apply in most situations for transgendered people.
The situation of transsexuals is slightly different from that of the homosexuals, especially
if they are living the gender role they want and if they have started the sex correction
process. If transsexuals are accepted in their new role, they do not need to face other
people´s amazement or disgust. In situations where transsexuals need to tell their
identification number or reveal their body, problems can occur if their name and social
security number have not been changed or if the sex correction process is incomplete.
Some transsexuals hope to be “ordinary“ women or men and choose not to disclose
their previous gender. Others want to acknowledge their transsexualism publicly with
the view that their story will help others in a similar situation. Some find openness
easier because they do not have to make efforts to hide their past.
The situation of transvestites varies depending on whether they are always living the
opposite gender role, or only on certain occasions, or only in their own home privately
and alone. There are also motivational differences. Some want to behave in a variety of
ways not expected to their gender and others are mainly interested in getting sexual
satisfaction by wearing clothes of the opposite gender. Only a few transvestites always
dress in opposite gender clothing. (Pimenoff 1997; Toivonen 1997).
Reasons for hiding sexual and gender identity vary greatly. Some are unsure about their
personal issues but most are simply afraid of the negative reaction they would receive
from honest disclosure. Sexual and gender minorities fear that revealing their identities
would result in teasing, exclusion and loss of friends. Some of these minorities still choose to
be open in order to live honestly as themselves, to avoid the effort needed to hide personal
matters, or to work to improve the social situation of individuals like themselves.
Open or known non-heterosexuals or transgendered people can be models for either
their communities or a larger public. The characteristics of these open individuals often
become stereotyped and generalised to all sexual and gender minorities. The current
view of most therapists as well as members of the minorities themselves emphasises
acceptance of pluralities and differences rather than limited categorisation of sexual and
gender groups (Lehtonen 1996).
Although discussions about openness versus secretiveness of sexuality and gender are
major topics for many non-heterosexuals and transgendered persons, issues involving
relationship problems and loneliness are also common topics of conversation.
286
Professionals in the health, education and social welfare professions need to be sensitised
to the special problems that confront sexual and gender minorities.
Social Change
The social and legal situation of nonheterosexuals has greatly improved in Finland,
largely due to the work of SETA (see chapter 9). The Ministry of Health and Social
Affairs has also helped by supporting research projects (such as the study on HIV risks
of men having sex with men) and appointing committees to work on issues of concern
to sexual and gender minorities. In addition, this ministry has included information
about homosexuality and the risk of HIV infection in the magazine sent yearly to all 16
year olds. Problems that still exist for sexual and gender minorities involve discrimination
at work, and teasing, harassment and violence or its threat in schools and elsewhere.
These minorities still frequently encounter situations where their needs are ignored,
more often because of the assumption of heterosexuality rather than intended exclusion.
Major goals for the beginning of the 21st century include not only legal equality based
on sexual orientation and gender identity but also equality in the services and benefits of
society. Education of social and health care workers, teachers, members of parliament,
police, and lawyers about minority issues is needed. Financial support of services,
education, and research must be continued in order to improve the sexual health of
sexual and gender minorities. Research has consistently supported the view that these
minority groups can contribute a great deal to the betterment of society. Indeed many
have argued that a more accepting and tolerant view of sexual and gender roles would
benefit both heterosexuals and nonheterosexuals. It has been difficult to change the
long established and widely held beliefs and practises that have denied minorities their
sexual rights. Yet substantial progress has been made. If present trends continue, we
may be able to consider Finland a model country in promoting good sexual health for
sexual and gender minorities. Societal and community efforts do not change our
heteronormative culture easily. Old ways of thinking and traditional practises do not
change in one moment, but without these activities human rights and equality do not
even have a chance to become a reality.
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Kaija Karkaus-Rikberg
23. The Sexual Health of Disabled
Persons
The starting point in discussing the sexuality of disabled persons should be the fact that
the sexuality of disabled and healthy people has more similarities than differences. All
human beings have the same sexual needs, rights and problems; disabled people have
additionally some disability that influences their lives and activities in one way or another.
Sexuality is a basic need of every human being, and this need includes feelings of
tenderness, sensuality, belonging, contact, warmth, closeness, physical satisfaction,
openness and safety.
Sexuality involves feelings, sexual activities and, additionally, possible impediments for
experiencing sexuality. Common impediments are beliefs and thoughts, which include
myths, prejudices, attitudes, taboos and stereotypes. Disability is connected with
functional obstacles or limitations caused by the mental, anatomical or physiological
deviance or handicap of the disabled person. The myths and attitudes connected with
sexuality and disability form a kind of double sensitivity, because both sexuality and
disability arouse many kinds of feelings and thoughts in the disabled person, in his/her
closest family and friends, and in those working with him/her. When someone becomes
disabled or the parent of a disabled child, he/she is faced with many sensitive issues
caused by interactions of both positive and negative beliefs of the disabled person,
relatives of the disabled person, and others with whom they come in contact. Correct
information is needed by both by the disabled and non-disabled, in order to change
attitudes to a more positive direction toward both disability and sexuality.
A disabled person should have the same sexual rights as other people. The energetic
defender of the rights of disabled persons in Finland and disabled himself, Kalle Könkkölä, defined disability and sexuality in the following way: “The human being is a sexual
being and a disabled person is a human being, therefore a disabled person is a sexual
being“. Martti Lindqvist, a leading Finnish ethicist and a doctor of theology, writes in
his book The Human Being as a Profession: “A disabled person is a human being with
a unique life of his/her own. His/her boundaries are externally different from those of
the majority but he/she is a whole human being. He or she cannot be separated from
his/her disability“.
The relationship between disability and sexuality is crystallised in the principle of the
National Association of the Disabled in Finland: “Every disabled person is personally
responsible for his or her own life“. A disabled person also makes decisions about his/
her own sexuality and sexual needs. The human being is not a machine which can
change its functioning and characteristic nature with the help of a new part. The sexuality
of disabled people is not realised simply by changing positions or using physical props.
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Sexuality is part of a human being and the totality of his or her life. Understanding
sexuality always requires personal experience and understanding. Without knowing and
accepting one’s own sexuality one can not accept the sexuality of other people.
Who Are Disabled?
The United Nations Declaration of the Rights of Disabled Persons (1975) states: “The
term ‘disabled’ means any person who is not able to completely or even partially satisfy
the needs associated with normal individual and/or societal life because of the lack of
either inborn or other physical or mental properties“. Guidelines for the equality of
disabled persons were accepted by the United Nations in 1993. The guidelines define, in
addition to other rights, the right to family life and personal integrity. According to the
guidelines a disabled person has the right to establish a family, the right to sexuality and the
right to experience parenthood. A disabled person has the right to choose his or her lifestyle
and way of living whether he or she lives in his/her own home or in an institution.
The 1987 Finnish law on services and support activities for disabled people defines a
disabled person as someone who has long-term special difficulties to cope with
conventional activities of life. Disabled does not mean ill, because in an illness the
defence mechanisms of the body are activated and start a fight for a balance. An illness
does not necessarily limit the performance of normal tasks and various treatments are
available for illnesses. An illness may, however, lead to a disability. Disability is a
permanent anatomical or physiological deviance or defect. The defence mechanisms of
the body are not able to correct a disability. Various functional impediments or limitations
are connected with disability and living with it is supported by physical and mental
rehabilitation.
Various groups of disabled people are:
•
intellectually disabled persons whom the law defines as persons whose
development or mental activity is hindered or disturbed because of an
inborn illness, defect or disability or one obtained at a later age; the most
significant group of disabilities are the developmental disturbances of the
nervous system (especially the brain), which are called intellectual disability
•
persons with disabilities of movement, whose disabilities may be either inborn (such
as cerebral palsy), caused by an accident (for instance, defects of the spinal cord),
or caused by an illness (such as polio)
•
•
persons with disabilities of the senses (hearing and sight impaired)
•
persons disabled because of illnesses or their complications (different forms of reumatism, diabetes, heart disease, cancer, multiple sclerosis and other diseases of the central
nervous system, lung diseases, surgical removal of organs or parts of the
body)
mentally ill persons
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Development of the Acknowledgement of the
Sexuality of Disabled People in Finland
Discussion about the sexuality of disabled people began in Finland in the 1970s. The
Finnish Association for Sexual Policy (SEXPO) drew attention to sexual rights of various
minorities in addition to sexual rights of the general population. The most important
goal of this organisation was to remove obstacles preventing the realisation of sexual
rights in society and provide every Finn a possibility to enjoy a happy sex life.
Sex counselling for disabled persons was apparently given for the first time in the
summer of 1973, when SEXPO’s experts lectured to young people with cerebral palsy
(CP) in the adjustment training courses organised by the Finnish CP Association. The
courses dealt with growing up, becoming independent, and problems associated with
sexuality. The young people attending these courses considered discussing the subject
of sexuality important and demanded that society begin to support research and problem
solving activities for people with disabilities.
Sex counselling for disabled people started to be developed by a working group founded
in 1975 at the joint initiative of The Association of Psychologists in Health Care and
SEXPO. The working group got acquainted with international literature on this topic
and disabled people themselves were asked for their opinions in rehabilitation and
discussion events organised for the disabled. The need for counselling was apparent
and in the autumn of 1976 The National Association of Disabled People in Finland
provided the funds for publishing a sex guidebook for people with disabilities. This
guidebook Disability and Sex Life was published in 1978 and it was the first such
guidebook in Finland to be distributed to experts, disabled persons themselves and their
closest relatives.
The development of sex counselling has received a lot of support and information from
Sweden, where an institute has worked for years to provide services to benefit the
sexuality of the disabled. At the same time a general discussion took place in Finland
about the principles to be applied to help disabled people have a sex life.
In 1980 the Finnish National Board of Health issued guidelines in accordance with the
World Health Organisation’s recommendations on sex education. According to these
guidelines sexual matters should be integrated as part of the total treatment of the
disabled, and resources to deal with sexual matters should be developed for caretakers
of disabled people. The guidelines especially emphasise the need for sex education and
counselling for people with disabilities and long-term illnesses. According to law, sex
education should be a part of a municipality’s child and family counselling.
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Access of Disabled to Sex Counselling
As stated earlier, the sexuality of disabled persons was first considered in the 1970s. At
the end of the 1980s the Association for the Mentally Disabled started a research
project on the quality of life, part of which dealt with sexuality. The sexuality of the
mentally disabled had gradually become accepted, and the Association for the Mentally
Disabled jointly with SEXPO trained a large number of people working with the mentally
disabled to become sex counsellors.
Organisations for the disabled and for patients, in general, have drawn attention to the
importance of including sexual issues as part of providing treatment and defending the
interests of the disabled and ill. Nowadays courses and rehabilitation programmes in
almost all organisations for disabled people and people with particular long term illnesses
include at least one lecture about sexuality and the effect of the disability or illness on
sexuality. The Multiples Sclerosis Association has guidebooks, for instance, about the
effect of impotence and spasticity on sexuality. The Association of Finnish Heart
Patients and The Association of Finnish Cancer Patients have published guidebooks on
sex for people with heart diseases and cancer, respectively.
Sexuality is taken into consideration in all stages of rehabilitation in the activities of the
National Association for the Disabled. People who have lost their mobility partially or
totally receive their first information about the effect of their disability on sexuality at
the same time they are informed about how the disability itself produces major life
changes. Information is also given to close relatives and friends of the disabled according
to their needs. There is always a lecture on sexuality in the adaptation training courses
of the National Association of Disabled Persons, and everyone also has the possibility
to receive personal counselling. In partnership courses the focus is on the sexuality of
the couple. In the adaptation training centre it is possible to get practical advice on
learning techniques of masturbation or intercourse.
According to the principles of the National Association of Disabled Persons, every
disabled person is responsible for his/her own life and therefore also for his/her sexuality
and for putting it into practice. Psychological and physical matters relating to sexuality are
discussed, but clients also have the option not to hear information about sexual topics.
Disability is Not an Obstacle to Sexuality
Becoming disabled or having a disabled child are situations that always entail various
crises. Life and the future are in a crisis and one has to consider the new life situation
from many viewpoints. Every person takes the change in life in a different way.
A person who becomes disabled as an adult needs a lot of strength to cope with the
disability and life changes it brings. In this situation it is natural and understandable that
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interest in and thinking about sex seems unnecessary for the disabled. On the other
hand, sexuality becomes a very important issue for some people, and it raises many
questions and causes fears: am I still good for anything, am I good for anyone? Some
people need the support of those near and dear to them, and some want to cope with
the new situation alone.
Having a disabled child is a crisis for the parents. At first they have to learn about how
to cope with the special difficulties of the child and become familiar with the disability
the child has. Later questions arise about what kind of youth and adult the child will
become. Parents have to reflect not only on everyday matters but also on the future.
A disabled child grows into a disabled teenager. A disabled girl becomes a disabled
woman, and a disabled boy becomes a disabled man. A disabled adult becomes a
disabled older adult. Development for the disabled takes places gradually, just like
human development in general. The parents of a disabled child have to get acquainted
with the whole life cycle of the disabled person. There is no way to avoid it at any stage
of the child’s life. When parents think about the future of their child, questions also
arise about the sexual future of the child, falling in love, marriage, and parenthood. If
parents get acquainted with the world of disabled adults, then it easier for them to think
about the future of their own child.
Development of disabled children into teenagers and adults also requires a great deal of
effort from children themselves. Getting to know oneself and achieving independence
demands a lot of strength from any teenager. The rebellion associated with the teenage
years may be difficult if the disabled child is dependent on the constant help from
parents or nurses. Possibilities for a life of one’s own and to experiences of one’s own
are important from the beginning. They provide resources for adulthood, and they
teach how to cope with various life circumstances.
The disabled child and teenager should have a possibility to examine her/his own limits
and to find her/his own life in spite of the disability. Nevertheless, many children who
have been disabled from birth complain that as a child and teenager, they did not have a
possibility to test their own limits and look for adventures. Often moving difficulties
were due to a lack of devices to help a child move or fear by caretakers that the child
would hurt her/himself in her/his surroundings, in testing her/his limits, or even at times
in playing rough-and-tumble games with peers.
Myths and Taboos of about Sexuality
When an adult becomes disabled or when a disabled child is born, beliefs and views on
sexuality do not change. During past decades and even centuries people have held
different beliefs associated with sexuality. These beliefs and taboos can be different in
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different cultures but they are present everywhere. Beliefs and taboos also influence all
people’s attitudes toward their own and other people’s sexuality.
Beliefs and taboos are formed gradually without our paying any attention to them. A
taboo is something that is rarely spoken about. This silence supports the view that
speaking about the taboo is forbidden. Various beliefs often persist even though they
may not have any significance for everyone’s own life. When they were first accepted,
they may have had some practical significance. For instance, belief in bogeys has
prevented children from going to the dark forest, and the fear of the lake monster
prevented them from swimming in too deep water. Advertisements and other media
constantly create new beliefs and taboos. Many myths and taboos promote the power
of educators, society and the church to control people.
Beliefs associated with sexuality often originate in an atmosphere of non-verbal
communication, and these beliefs are also influenced by the negative or contradictory
attitudes of parents, peers and others. Our attitudes toward our own sexuality are most
clearly visible in how we react to nudity and accept our own body. One myth associated
with sexuality is the view that sex is only meant for young, beautiful and healthy people.
The entertainment industry makes us feel that someone needs to have a perfect body in
order to enjoy sex. Accepting one’s own bodily imperfections is part of accepting one’s
sexuality.
The effects of beliefs and myths associated with sexuality can be subtle. Examples of
myths include: “Sex is dirty. Save it for marriage when it will be clean“, “Sex is
beautiful but don’t talk about it in the presence of children“, “A man always has to be
ready for sex“, “A woman does not love a man if she is not willing to have sex with
him“, and “Sex is more passionate for the neighbour than for me“. Such myths can
create pressures and problems. On the other hand, some myths may offer protection.
Myths operate in basically the same way for disabled and healthy persons, with the
exception that the number of myths is just larger when sexuality and disability are
combined. However, there is no such thing as “sex for the disabled“.
It is not easy for most people to discover their sexuality and its various forms while at
the same time accepting myths and stereotypes about sexual behaviour. Therefore, one
must attempt to look behind the myths and stereotypes in order to understand one’s
sexuality. Getting permission to try various acts that have been considered forbidden is
important, because then one can see how the myth operates and how changing the
myth can influence experiences and feelings. Every individual has the right to her/his
own sexuality and to putting it into practice under her/his own conditions and with her/
his own means. Everything accepted by both parties and which does not hurt anyone is
permissible and lawful.
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Disabled People Also Have Sexual Rights
In the past two decades significant progress has been made in Finland toward granting
disabled people their sexual rights. Sexuality is now seen as an integral part of the life
and activities of the disabled person. On the other hand, these rights and the realisation
of these rights have not been accepted in all places.
The right to get information and guidance
All human beings have the right to get information about the biological and sociopsychological facts related to sexual behaviour. Information should continually be available
in different stages of an individual’s life cycle. Various problems related to the disability
can be obstacles when a disabled person looks for information. For instance,
communication problems affect the way a disabled person can receive information:
physically disabled persons need their information in a different form than, for instance,
deaf and blind persons. Using pictures or relaying information through touch and
experience are alternative ways to disseminate information.
Sex education requires permission from the parents, teachers and the nurses of disabled
children and teenagers. People who regularly interact with the disabled should be
acquainted with and accept their own sexuality. In addition, they should have a broad
understanding of the sexuality of people in general. After this, they can formulate ways
to provide sex education for each group of disabled people in a way most suitable for
them and according to the needs and wishes of the group. A disabled person has to be
seen as a whole person and her/his sexual identity should be given a chance to develop.
The right to sexual expression
The sexual expression of a human being develops with the help of imagination through
masturbation to sexual play. Disabled people should also have a right to this development
and compared to others, this development generally does not require extreme courage
or great efforts. Disabled people who get help with everyday activities should also be
able to get help in satisfying their sexual needs.
The right to partnership and parenthood
Sexual experiences, a partnership and marriage are also rights of disabled persons.
They should have the possibility to form partnerships in spite of, for instance, living in
an institution or needing continual care. The rights of disabled persons to have and adopt
children should also be guaranteed, because disability is not an obstacle to being a good
parent. And becoming disabled is not an obstacle for continuing to be a good parent.
The right to get services from society
Possibilities to get sexual counselling and therapy have gradually increased in Finnish
society. These possibilities also apply to disabled persons. This counselling means
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particularly that a disabled person can get equipment to aid in sex. In Finland such
equipment is provided in accordance with the law on services for disabled people.
Sexual Problems and Their Origin
With respect to sexuality and disability there are five areas which should be considered
when determining sexual problems of disabled persons and the origin and background
of these problems:
·
·
·
The body-image of the disabled person which emerges when society continually
emphasises perfection, youth, beauty and good physical condition
Low self-esteem which may be partly caused by dependence on other people’s help
Difficulties in decision-making and responsibility which become apparent in a
partnership when one partner becomes disabled. For instance, the issue of having
children becomes problematic in a situation where both or one are seriously disabled.
The disabled person has the right to have a near and dear person, whose role is not
that of a nurse. If the partner becomes mainly a nurse, both the partnership and the
sexual relationship suffer.
·
Sexual identity and variations in sex roles. According to myths and gender
stereotypes related to sexuality, a woman or man is expected to behave in a certain
way in certain social and sexual contexts. These expectations do not take into account
a disability and the limitations it causes. Myths and gender stereotypes do not take
into consideration the differences among human beings and do not give possibilities
for variation.
·
The extent and character of the sexual experience. A disabled person may become
the object of sexual abuse because of her/his lack of experience or a disabled person
may use her/his disability to get sexual satisfaction from friends, companions or nurses.
Assistance, Advice and Support for Sexuality
As Finns have noticed in meeting their colleagues in international conferences and
training sessions, the sexual rights of disabled persons have been realised quite well in
Finland. The sexuality of disabled persons is considered in many ways. However,
special sex education and therapy are not offered to any particular group. People in
need of advice or help must find these services themselves. Sex counselling for disabled
persons is offered as part of other rehabilitation or treatment.
The PLISSIT scheme (see chapter 10) is commonly used in Finland for sex counselling
and therapy. The “P“ (for Permission) in this scheme means giving permission or
information, and “LI“ (for Limited Information) means giving some general advice.
The “SS“ (for Specific Suggestions) includes giving specific advice, and “IT“ (for
Intensive Therapy) means providing actual psychotherapy. Giving advice and general
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instructions about sexuality are among the services of the primary health care system.
The goal is to provide this information in order to prevent problems from arising and
becoming worse. If these services are provided, the need for specialised services and
sex therapy should decrease.
Giving permission and information requires that the permission giver - the professional
meeting the client – is acquainted with and accepts her/his own sexuality and the
associated feelings, needs, fantasies, attitudes and norms. Getting acquainted with one’s
own sexuality is therefore an important part of the sex education for personnel in the
teaching, social and welfare fields. The professional needs permission for her/his own
sexuality in order to give permission to the client. It is difficult to talk about sexuality if
the counsellor her/himself feels anxious or embarrassed. Professional sex counsellors
should have feelings toward sexuality that are neutral or positive. Such attitudes make it
easier to deal with a client’s sexuality and problems related with it in a natural and
positive way.
Giving permission means that the counsellor will convey a verbal or non-verbal message
assuring the client that feelings related to her/his sexuality are permissible and natural.
At the same time a client can get factual information and a possibility to try, for instance,
masturbation or sex aids.
The normalisation of matters related to sexuality is also important. It is often sufficient
to tell a client that many others have similar problems and questions at some stage of
their life. The information also helps to confirm beliefs and to put into perspective
expectations associated with sexuality.
Giving special suggestions requires a better knowledge of a client’s life situation and
problems. Suggestions can be given to reduce performance pressures and direct the
disabled person and her/his partner to get acquainted with each other in a new way and
according to the demands of the new life situation.
The aim of sex therapy is to solve sexual problems. There are several methods used but
currently sex therapy in Finland means the brief therapy method developed by Masters
and Johnson, especially intended for the treatment of functional disorders, such as
erection problems in men and problems with orgasm in women.
The Effect of the Life Situation on Sexuality
Becoming disabled, growing up disabled, or having and bringing up a disabled child are
continually changing life situations. Many aspects of life situations influence how a
disabled person and how the partner of a disabled person experience sexuality and are
able to realise their own sexuality.
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Social expectations of those in the surroundings of a disabled person strongly affect the
realisation of sexuality by either limiting or supporting it. The situations are quite different
in private homes, apartments where services are regularly provided, and institutions.
Where a disabled person lives influences the type and number of contacts of a disabled
person and whether he or she has the possibility to interact with his/her partner in
intimate ways. Possibilities for travel also influence the quantity and quality of the
contacts. Long and inconvenient distances can, at worst, prevent the formation and
maintenance of new contacts. Even one’s income level has an impact on realising one’s
sexuality and, for instance, obtaining sexual services.
The attitudes of society and the immediate surroundings do not support romances of
disabled persons and the realisation of their sexuality. They usually reflect the narrow
view of sexuality, for instance, that the only proper sexuality is a heterosexual relationship
with simultaneous orgasm in vaginal intercourse. This view allows almost no individuality
or variation of sexual expression. For some, it is enough to hold hands and to touch a
partner in various ways to get adequate satisfaction; others want and need daily intercourse.
Sexuality is experiencing and feeling, which are not hindered even by a serious physical
disability. A disability does not lead to difficulties that make it impossible for disabled
people to enjoy their sexuality. The disability is always personal, and each person needs
to understand what effects it has on sexuality and sex life. The disability may cause
problems, but many of these problems have practical and technical solutions.
Disabled people do not have greater or more frequent mental problems than others. All
people experience crises and problems associated with human relationships, sexuality
and changing life situations. A disability or illness can, however, emphasise these
problems. On the other hand, a satisfying sex life can also solve other problems and
reduce psychological stress.
Importance of Asking, Getting Answers and
Understanding
Asking questions about sexuality can easily solve many problems that concern a disabled
person or those closest to him/her. Possibilities of asking these questions depend on how
aware the personnel working with disabled persons are of the importance of sexuality.
Difficulties in communication are the biggest problem in asking the questions and
obtaining the answers. In talking about sexuality it is important that all parties are using
the same language, i.e., that the meanings of the words used are the same. The meaning
of words and terms should be explained and checked because Latin-based names, for
instance, for the genitals or intercourse may not be understood. Answers should always
be given in a language the client can understand. Drawings, pictures and other aids can
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be used to make sure that the message is understood. It is always advisable, however,
to check that a term or concept has been correctly understood. Distorted information is
more likely to make a situation worse than to improve it.
Those who work with disabled people first encounter direct questions, which are usually
the following:
·
·
·
·
·
·
·
·
·
How does my disability affect my masculinity/femininity?
What part of my body has been damaged and how does/will it affect me (bone
structure, muscular structure, blood circulation, nervous system, brain functioning,
hormonal functioning)?
Can I be operated on or can I get medical treatment to correct the damage?
How does the disability affect my sexual arousal?
Can I have an erection?
Can I have an ejaculation?
Can I get an orgasm?
Can I menstruate?
Can I fertilise a woman / become pregnant and give birth to a child?
All disabled people should get answers to these questions. The most natural person to
give the answers is the treating physician, but other health care personnel and persons
working with disabled persons should also be prepared to answer these questions. The
situations in which these questions emerge can be unexpected. Asking these questions
and understanding the answers depends very much on the particular disabled individual.
Indirect questions often emerge gradually and in different treatment and rehabilitation
situations. Asking them presupposes a trusting relationship and confidence that these
matters are considered appropriate to discuss. Myths can be an obstacle to asking crucial
questions. Obtaining answers to some questions can greatly influence solutions to sexual
problems and affect the future of a disabled person’s sexuality. These questions can be dealt
with in discussion groups where they can remain on a general level or where participants
can exchange experiences. The following are common indirect questions:
·
·
·
·
·
Can I have sexual intercourse?
Can intercourse create problems or cause difficulties, for instance make the disability
worse?
Are technical aids and equipment (for instance stoma sacs) obstacles to intercourse?
What kind of positions and technical aids can I try?
How do others with similar disabilities act?
Unexpressed questions are those which are difficult to ask. They touch most closely
one’s own personality and cause fears and doubts about oneself and one’s possibilities.
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It is often easiest to discuss these questions with, for instance, a psychologist if other
qualified people are not available. The following are silent questions:
·
·
·
·
·
·
·
Does anyone care about me? Can I find a partner?
Can anyone consider me attractive?
How do others experience my disability?
Am I good enough for my partner? Will our relationship continue? How will it
change?
How can I satisfy myself, my partner?
How does my disability affect our life together – physically and mentally?
How much importance does sexuality have in our life together?
Different Disabilities Have Different
Consequences and Solutions
The problems related to sexuality, love and partnership that disabled people have are
similar to those of other people. Difficulties and fears in forming friendships and love
relationships for disabled people are very similar to those for people without any visible
disability. In the background there are often problems of self-esteem and fears of not
being attractive enough or of being somehow unfit because of the disability.
No disability in itself is an impediment to sexuality and enjoying sex. No disability
presents challenges so great that all sexual expression is impossible. Each person just
has to find his or her personal way of enjoying sexuality. Disabled people should be
advised to talk with an expert (for instance a sex counsellor, sex therapist or physician)
to get the information and permission necessary for them to have a sex life.
It is most important when discussing the sexuality of disabled people, that the disabled
person become acquainted with her/his own body and its reactions in various
circumstances. Becoming disabled causes changes which are very important to identify
and accept. Learning masturbation is part of getting to know one’s own body and
various forms of pleasure and orgasm. After becoming disabled it is important to learn
that there is no single way to enjoy sexuality that is the only proper one. Intercourse and
orgasm are not even necessary if mutual interaction otherwise is enjoyable and brings
satisfaction.
Each disability is unique and the solutions for each disability are also unique. For instance
in paraplegia (paralysis of the lower limbs) or in tetraplegia (paralysis of all limbs) the
effects of the disability on sexual functioning depend on the location and severity of the
disability and vary from total impotence to a lack of symptoms. A reflexive erection in
men often remains intact. In some cases there is an inability to ejaculate or a reduced
tactile sensitivity. In women menstruation may cease for a few months after the onset
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of disability, but later return to normal. Women may have difficulties with lubrication.
Difficulties already stated above in finding an appropriate position for sexual activity
also occur. Spasticity and decreased sensitivity can cause problems as well as the stoma
sac, but they are not insurmountable problems. Paraplegia and tetraplegia are not
hereditary, and they form no obstacle to conceiving and giving birth to children.
It may take a person with lowered mobility and weak muscles a long time to find a
suitable position for intercourse. It is important for the disabled person to learn to know
the functioning of her/his own body as well as possible and, for instance, to find out
which position is best for pelvic mobility. Different positions and the use of pillows as
supports provide new possibilities for intercourse.
A person with sensory defects can search for erogenous areas of his or her body with a
vibrator. For instance, a person with a damaged spinal cord may find that areas usually
considered to be sensitive to sexual arousal are unresponsive to touch. If tactile sensitivity
is totally missing in the genital area, one has to find other areas of the body that produce
sexual arousal and pleasure. In spite of a lack of tactile sensitivity it is possible to have an
erection and orgasm, even though the sensations may feel different after becoming disabled.
One can prepare for the effects of incontinence by emptying the bladder and the bowel
before interacting with one’s partner. Emptying the bladder is a personal choice because
in some cases the orgasm is stronger when the bladder is full. It is advisable for a
disabled person to discuss the matter with the partner to prevent an involuntary emptying
of the bladder from disturbing enjoyment from intercourse.
Congenital disabilities and deformities, that have not damaged the genitals, do not prevent
intercourse but may cause problems of self-esteem. People with serious disabilities may
often have to undergo corrective surgery, and children with disabilities may have to
hear insensitive and unkind remarks about their disabilities. These remarks are
experienced as criticism of themselves and their body, and people with serious disabilities
may react to them by refusing to accept certain parts of their body.
Adaptation Training, Guidance, Technical Aids
and Medicines
Different adaptation training courses are organised in Finland for disabled people, people
who have become disabled, and people who have a disabled child. These courses often
deal with sexuality and partnership concerns. The participants also have the possibility
to talk individually with an expert (physician, nurse, sex counsellor or sex therapist)
about their own situations and related matters. The purpose of adaptation training is to
help clients accept themselves. Sexuality is not regarded as a separate entity but as an
integral part of the human being and his/her personality. Sex is part of the need to love
and be loved.
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Sex counselling has been offered in various courses for couples and in rehabilitation.
Sex counselling consists of verbal advice and suggestions for new positions for intercourse
and getting acquainted with technical sex aids and medicines alleviating sexual problems.
Numerous technical sex aids are available and their number is increasing. Attitudes
toward technical sex aids have gradually changed. Previously they were considered
perversions, although their use is an old custom and totally accepted in many cultures.
In the past few years the number and availability of technical sex aids have increased
and negative attitudes have decreased. There are technical sex aids for both men and
women for various purposes.
The use of medical treatment for problems with orgasm, for instance, has considerably
increased. Injection treatments have been supplemented with oral medication, of which
Viagra is the most famous. It is advisable to discuss the use of technical aids and
medication with the treating physician. Technical aids prescribed by the physician are
fully subsidised by the state in accordance with the law on services for disabled people.
However, solutions vary for each individual case and finding the best possible technical
aid or medicine may require time. More medical methods are being developed all the
time for both men and women.
Interviews
Ilmonen, Tuisku, Training Supervisor, Sex Therapist, SEXPO Foundation.
Johansson, Tiina, Director, Physiotherapist, The Adjustment Training Centre for Disabled
Persons, Lahti.
Kuusisto, Tiina, Rehabilitation Planner, Special Nurse, The Adjustment Training Centre for Disabled Persons, Lahti.
Moilasheimo, Tapio, Director, Sex Therapist, SEXPO Foundation.
References:
Vammautuminen ja sukupuolielämä (Becoming disabled and sex life). Invalidiliitto National Association of the Disabled in Finland 1979.
Vammaisuus ja seksuaalisuus -seminaari (The seminar “Disability and sexuality“ on
November 6-7. 1991. Helsinki: Invalidiliitto - National Association of the Disabled in
Finland 1992.
Seksi ja spastisuus (Sex and spasticity), Maskun Neurologinen Kuntoutuskeskus 1991.
Sydämelliseksi - tietoa sydänsairauksien vaikutuksista seksuaalisuuteen ja seksitoimintoihin
(Cordial sex – information about the effect of heart disease on sexuality and sexual
activities). Sydäntautiliitto 1997.
Syöpä ja seksuaalisuus (Cancer and sexuality). Suomen Syöpäpotilaat ry 1993.
Tuisku Ilmonen. 1994. Siivekäs Sillanrakentaja (Winged bridge-builder). Helsinki: TSLopintokeskus.
Tuisku Ilmonen. 1987. Rakkaudella sinun (Yours, with love). Helsinki: InvalidiliittoNational Association of the Disabled in Finland.
I have also used the final reports written in SEXPO’s training sessions by various
authors
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Pirkko Kiviluoto
24. The Sexual Health of Aging
People
The Sexuality of Aging People
Sexuality is an integral part of the personality and it does not diminish or disappear with
age. Often it is connected with youth and beauty, and the thought of the sexuality of
someone who is old and wrinkled can be strange or surprising. On the other hand,
attitudes toward the sexuality of older people have become more permissive in recent
times. It is evident, for instance, by noting that recent sociological surveys on sexuality
have been extended to include older age groups than were in earlier surveys. As the
population grows older and quality of life expectations become greater, the significance
of the sexual health of aging people will increase. The sexual attitudes and expectations
of those who are middle-aged today, that is the old people of the future, are also quite
different from those of previous generations of old people.
There is no unequivocal definition of how elderly people are “aging“ or “old“ in the
area of sexuality. Generally one speaks about an aging person by using as a yardstick a
decrease in general ability to function, which is often associated with the need for help
in everyday activities. This kind of aging is usually defined with respect to older age,
rather than with respect to sexuality.
In sex guidebooks for aging people the lower age limit is often 60 or 65. A project of the
Family Federation of Finland to provide services for people having problems in the area
of sexuality was targeted for members of the adult population over 40. Men between
the ages of 60 and 70 were the most frequent users of these services, but there were
also people older than 80 among the clientele. Women used these services less than
men did. The gender difference in use of services was at least partially attributed to the
fact that women often seek treatment for their sexual problems in connection with
gynecological examinations or in regular tests to diagnose other health problems. Special services intended solely for retired or old people are not available in Finland. In the
summer of 1999 the municipality of Kangasjärvi organised jointly with many organisations
the Kutemajärvi sex festival. This festival’s theme was aging and sexuality, and it
attracted a large number of retired people as participants.
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The Sexual Activity of an Aging Person
The following factors influence the sexual activity of an aging person:
•
•
•
•
the level of sexual activity throughout the entire previous lifetime
physical and mental health and illnesses
self-image and self-respect
social factors
The level of sexual activity during a person’s whole lifetime influences her/his sexuality
in later years. It has been shown that beginning sexual activity at an early age predicts a
greater sexual activity and satisfaction in middle age. A person who has continued to
have an active sex life through middle age is likely to still have an active sex life in old
age, providing a partner is available. Someone, for whom sex has always been in the
background or less important, will probably also be less sexually active as an older
person. If the lack of sex has been caused by inhibitions, one may become more
liberated with age and take a stronger interest in sex. The quality of sex techniques
learned during one’s previous life also influences the ability to enjoy sex as an old
person. Versatile sexual techniques are important especially to aging people, whose
sexual reactions are slower than those who are young or middle-aged.
Another factor influencing activity is physical health. Chronic illnesses become more
common with aging, and they influence both sexual desire and sexual reactions. Illnesses
that hinder the ability to move, the movement of joints, and health, in general, also
influence sex life. Illnesses focussing on the genital area, such as incontinence, also
impede lovemaking.
In addition, psychological and social factors greatly influence sexual behaviour for those
at an advanced age. Sex appeal is often associated with youth and beauty. Thus, the
changes caused by aging can lower sexual self-confidence. Loneliness increases with
age and the loss of a partner may also cause a great change in life that includes the area
of sexuality. It is more difficult for old adults compared to young adults to find a new
partner. The attitude of grown-up children toward the sexual expression of their elderly
parents can also be problematic for many wanting to remain sexually active.
The Sexual Health of an Aging Woman
Quality of life factors are highlighted in the sexual health of an aging woman. Older
women no longer need to worry about contraception. Prevention of sexually transmitted
diseases must still be a concern, especially if the woman or her partner has sexual
contacts outside the stable partnership. The sexual health of a woman is influenced by
her own ageing pattern, menopause, illnesses, her partner’s health, and changes in her
social relationships. When informing women about health issues and treating their illnesses,
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health professionals need to include sexual concerns and consider how a woman’s
sexuality may be affected.
The most common factors affecting women’s sexual health are the following:
•self-image and self-respect
•menopause
•aging of the genitals
•illnesses and their treatment, especially operations
Self-image and self-respect
It is very important for a woman to think of herself as desirable and attractive. External
changes associated with aging cause anxiety for many women. The sexual interest of
men is often aroused by visual stimulation. An enormous industry is supported by
attempts to slow down, cover or treat changes connected with aging, such as the
slackening and wrinkling of the skin. Cosmetic products become more and more expensive
as a woman ages. The make-up products of young people are inexpensive, but wrinkle
creams for older women are very expensive. Even then their effect has not been reliably
demonstrated. Cosmetic surgery, available in some countries like the United States, is
another method available to upper class aging women to help themselves appear more
attractive.
Taking care of themselves, including their appearance, is an important way for elderly
people to promote their well-being and self-respect. Self-esteem should be based on a
healthy lifestyle, which includes exercise and nutritious food, as well as psychological
care, adequate relaxation and rest. In addition, the use of cosmetics and other devices
help many. Nevertheless, it is important for people to accept themselves, including their
age. That is the basis of a healthy self-respect, not external beauty. One does not have to
be young and beautiful in order to enjoy sex and to be sexually appealing. The media and
entertainment industry have, however, created a myth that sexy people are young, slim and
good looking. Only a very small fraction of people looks like the loving couples in movies.
It is also important that old, wrinkled and institutionalised women have a possibility to
feel attractive. Health care personnel can help by making sure that old people dress
attractively and by taking care of their hair and general appearance. Positive feedback is
pleasant to hear and supports everyone’s self-esteem.
Menopause
Some decades ago it was generally thought that a woman’s obligation to provide sex for
her husband ended with menopause, if not earlier. Today we see the matter differently.
A woman has the possibility to enjoy sex regardless of age. How this possibility is
realised depends on many factors. Factors that influence a woman’s sexual vigour,
desire and sexual reactions include her values and beliefs, her social life situation, her
self-confidence, and her state of health.
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An adequate hormone level is not the only condition for satisfactory sex, and certainly
hormone replacement will not eliminate all problems connected with a woman’s sex
life. It is true, of course, that menopause has an effect on sexual health. The rapid
decrease of estrogen production by the ovaries causes changes in a woman’s body.
Many of these affect sexual functioning. However, menopause does not have to mean
the end or decline of a sex life.
During menopause changes take place in the structure and functioning of the genitals.
Menstruation ends when there is no estrogen to thicken the mucous membranes of the
womb. The mucous membranes of the vagina gradually become smoother and thinner.
Pelvic floor muscles become weaker. These changes can lead to urinary infections,
incontinence and dyspareunia. These problems often appear years after the end of
menstruation. During menopause most women also have general symptoms such as
night sweats and mood changes.
The most efficient treatment for menopausal problems is to take estrogen in pill form or
through the skin. The side effects and contraindications of the treatment somewhat
limit its use. Most Finnish women use hormone treatment at least for some period. The
proportion of hormone users is highest among highly educated and urban women. The
availability of hormone treatment is also better in cities. It is also possible to get treatment
in the countryside but its use is sometimes limited by negative attitudes of the population
or physicians. Locally applied hormone treatment in the form of creams is often sufficient
for the treatment of genital symptoms such as vaginal dryness. Suitable preparations
are available from pharmacies without prescription. Modesty and a lack of knowledge
are impediments for their use, however.
In principle, treatment for the physical difficulties of menopause and post-menopause is
widely available. However, treatment especially directed to help a woman with her sex
life during menopause and post-menopause is uncommon. A patient may ask her
physician for help with general menopausal symptoms or problems in the urogenital
area. Physicians do not routinely ask older women questions about their sex lives and
sexual intercourse. Thus, opportunities for counselling and treatment directly aimed at
the patient’s problem are often lost. On the other hand, it is good that a woman can get
indirect help with sexual problems without having to discuss intimate matters with her
physician. In some cases, modesty prevents a woman from getting help.
Pelvic floor muscles
The muscles surrounding the vagina, urethra and anus affect the functioning of these
organs. Childbirth predisposes a woman for weakness in the pelvic floor muscles.
Problems may not become apparent for many years after menopause. Weakness of
these muscles leads to incontinence. Additionally, a woman’s feelings of orgasm may
not be as intense, and her vagina may not feel as tight during intercourse. The functioning
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of the pelvic floor muscles should be routinely checked as part of the medical examination
after childbirth. The present service system in Finland makes such an examination
possible. However, information and counselling about problems linked to poor pelvic
floor muscles currently are not generally provided. Usually, attention is only paid to
serious symptoms that have already appeared at the time of the check-up.
Health-care personnel and physicians should actively ask both menopausal and older women
about possible symptoms associated with the pelvic floor muscles. Incontinence is often a
problem that women are ashamed of. Thus, it tends to be kept silent and not reported.
In addition many women do not know that these problems may be considerably alleviated
by actively and regularly exercising their muscles. It is possible to strengthen the muscles
with physiotherapy and exercises carried out according to instructions. In this way later
problems can be prevented. Muscle exercises help even if they are started when a
woman is older. Learning the right technique requires careful guidance and often the
help of a physiotherapist. A woman can use small metal balls inserted into the vagina in
the exercises. These can be bought in health care shops and in sex shops, which sell the
metal balls at a considerably lower price.
The vagina and erectile tissues
As a woman becomes sexually aroused, her vaginal wall expands and gets moist. This
moisture comes from the expansion of a woman’s erectile tissues, which are located in
the clitoris, around the urethra, around the vaginal opening and in the front wall of the
vagina. A woman’s erectile tissues function similarly to those of the man in connection
with an erection. Good blood circulation and adequate distribution of nerves are
preconditions for the normal functioning of the tissues. The reaction of the erectile
tissue also requires sufficient stimulation. The physical arousal of a woman usually
occurs more slowly when she is older compared to when she was young. If lubrication
does not occur in spite of attempts at arousal and pleasant caresses, vaginal dryness
may be caused by problems in blood circulation. There is significantly less medical
information about the functioning of a woman’s erectile tissues than male erection
problems, which have been actively investigated in recent years. In the future it is likely
that the functional problems in women’s erectile tissues will be able to be treated with
medication which directly affects these tissues. Vaginal dryness can also be caused by
hormonal imbalance. The administration of estrogen often helps to alleviate the dryness.
Local lubrication gels also reduce symptoms.
After menopause a woman’s vagina gradually becomes shorter, if she does not have
sexual intercourse. If intercourse is resumed after a long pause, a woman should be
careful. The lengthening of the vagina takes place slowly. Estrogen treatment also helps
in this situation.
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A regular sex life also maintains the physical conditions for sex. The changes caused by
reduced hormonal action appear more slowly in those women who have a satisfactory
sex life and regular intercourse. Resuming a sex life after a long pause can cause the
problems described above and can require treatment. As a woman ages she should try
to understand her sexual needs and make her own choices concerning sexual activity.
Celibacy may be the option chosen by some women.
Operations
Many operative and surgical treatments used to treat women’s illnesses affect both a
woman’s subjective experience of her own sexuality and her sexual functioning. Cancer
of the breast or uterus, myomas and excessive or frequent menstruation are common
illnesses that are often surgically treated. Surgical operations of the genitals and the
breasts naturally affect sexuality. Other procedures such as operations requiring a stoma
or hip replacement involve factors affecting sexuality.
Hysterectomy is a common operation, which often involves the removal of the ovaries
in menopausal or older women. The ovaries produce small quantities of testosterone
that affect sexual desire. After removal of her ovaries a woman may experience a lack
of desire, that is partially caused by hormonal factors. Operations can also have a
significant effect on a woman’s body-image and self-respect, and thus may significantly
affect her sex life. Some women report that hysterectomy has definitely affected their
feelings of orgasm.
In the counselling connected with operations it is important to discuss the sexual dimension
of life after the operation. A woman should be given written information and a possibility
to talk with a nurse or physician. It is important that a patient be informed of the effects
before the operation. An open discussion between a woman and her partner is
recommended as the best way to resolve possible problems. A woman should also be
given an opportunity to receive guidance jointly with her husband or partner
In cancer operations it is possible that such a large part of a woman’s genitalia must be
removed that intercourse no longer is possible after the operation. Such situations
emphasise the importance of counselling, and it is especially important that women get
professional help at this time, preferably with their partner. Sexual matters usually remain
in the background in the acute stage of cancer, but later it is important that members of the
couple communicate with each other and find new ways of gaining satisfaction.
After an operation requiring a stoma, where the intestine is discharged though the
stomach into a sac, the patient may feel dirty and unpleasant. Sexual self-esteem may
decrease. There may be fears about the stoma opening during intercourse. A patient
with a stoma should be given the opportunity to discuss sexual concerns with a health
professional.
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Social situation
The end of sexual activity for an aging woman is more often caused by the lack of a
partner or her partner’s sexual problems than a woman’s own unwillingness to have
sex. Many consider loneliness the worst sexual problem of aging women. The lack of a
partner becomes more common with age because due to the higher mortality of men,
there are more female widows than there are men. The sexuality of a lonely aging
woman may occasionally be expressed in erotic dreams. That may cause anxiety and
fears of abnormality for some women. Providing factual information can make the
situation easier for a woman. Masturbation is a natural way to give oneself sexual
satisfaction, and this activity is possible for people of all ages. Older people may still
have unnecessary feelings of shame and guilt about fondling themselves.
Finding a new partner may be difficult, but problems may ensue even if one is found.
The relatives of the elderly person, especially grown-up children, may have a negative
attitude toward the intimate relationship of their old parent. Many people lack an
understanding of the sexuality of aging persons.
Without privacy it is difficult to realise one’s sexuality in any way. There is often very
little privacy in institutional surroundings. Some years ago a study of psychiatric institutions
was carried out in order to investigate the possibilities for long-term patients to have
privacy and sex. The results indicated that the staff had a relatively positive attitude
toward patients’ right to have sex, but in practice, opportunities for privacy had not
been organised. There is no empirical data on the sexual expression of elderly people living
in institutions. Elderly people living in institutions providing long-term care often develop
serious health conditions. Nevertheless, it would be worthwhile to consider sexual needs
when planning treatments and living arrangements of aging people in institutions.
The Sexual Health of an Aging Man
As a man ages, the following areas need to be considered:
•
•
•
•
performance pressure
problems with erection
illnesses and their treatments
male menopause
In the same way as for women, aging and illnesses associated with them affect the
sexual health of men. The interest in sex remains in men as they age. Sexual activity,
however, generally decreases. This decrease is often connected with problems of sexual
health, such as disturbances in erections.
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Performance pressures
The sexuality of men is often perceived to be performance-centred. Thus, men feel
pressure to “be capable“ of intercourse and this “capability“ is considered an important
property. The more frequent illnesses associated with the aging process threaten a
man’s capability to perform. These pressures can be eased if sexuality is perceived in a
broader and different way; the focus should not be on intercourse, its duration and the
stiffness of the penis. Changing the emphasis from performance to pleasure and toward
receiving and giving pleasure in versatile ways can compensate in many situations for
what the aging person often misses in the number and quality of erections.
In our society erection not only means the capability for sexual intercourse for a man,
but it is also perceived as a “measure of manhood“. A decrease in erections often
diminishes a man’s sexual self-esteem and general self-confidence. Factual information
about the causes of problems with erections can help a man understand that the underlying
problem is a reaction with physical preconditions and that an erection problem does not
mean the loss of sexuality or masculinity. A decrease in performance pressure and
increased knowledge about sexual reactions help to create a more open discussion
between a man and his partner. Discussion can prevent many misinterpretations about
the causes of reduced intimate interaction.
Problems with erections
A precondition for the stiffening of the penis or an erection is a normal functioning of
the erectile tissues of the penis. The causation mechanisms of erection problems are
well known, and considerable research has been done concerning male erections in
recent years. New, easily used and effective medical treatments have brought this
problem into public discussion. It has also been found that problems with erection are
more common than had earlier been assumed.
A physical illness often underlies a problem with an erection. Blood pressure problems,
heart disease, diabetes, a disease of the prostate or its treatment, a neurological or a
psychiatric disease often contribute to erectile dysfunction. Also many drug treatments
for the above mentioned diseases have side effects, which include erection problems.
The frequency of erections (less frequent) and especially the time period to achieve a
new erection (increase in time) after orgasm also change with advancing age.
An increased openness and discussion about erection problems has made it easier for
men to seek help for these problems. Naturally, the availability of an efficient medical
treatment has also been important. Physicians and other personnel providing basic
health care services encounter the largest share of men needing treatment for problems
with erections. It is important for health professionals to be able to openly discuss
matters associated with sexuality in connection with treatments and to give basic sexual
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counselling. Another important consideration involves an older man’s partner. The
partner’s sexual concerns as well as the partner’s possible need for sexual counselling
or treatment should be discussed. Sexual counselling also includes information about
ways of caressing or other means of stimulation to promote erection. Elderly couples
may be very penetration-oriented in their sex habits. Erection may have occurred without
foreplay at a younger age, but requires more caressing for older men.
Specialised treatment for impotence can be obtained from urologists. They treat patients
needing surgical operations and other patients as well. The Sexual Health Clinic of the
Family Federation of Finland provides specialised services, including telephone
counselling, teaching injection treatment and, when necessary, couple therapy or other
psychotherapy. Physicians in basic health care have been given a great deal of information
and further training about problems with erection.
Sildenafil, with the common name Viagra, is the first efficient, orally administered
medicine for erection problems. It is only intended for patients who suffer from erection
problems and should not be used to prolong or strengthen normal erections. This medicine
functions in the erectile tissue is such a way that the erectile cavities dilate and are filled
with blood. This effect is mediated though nitrogen oxide. Viagra, if taken at the same
time as nitrate can produce dangerous side effects. A patient who simultaneously uses
Nitro medication or other long-effect nitrate medicines and Sildenafil can suffer a
significant or even life-threatening loss of blood pressure. The medicine also has other
milder side-effects.
Illnesses and their treatments
Diseases of the heart and blood-vessels and elevated blood-pressure are common national
illnesses, especially affecting men. Many of these illnesses are associated with erection
problems, but also many drugs used in the treatment of these illnesses have side effects
that influence sexual response. In selecting and monitoring drug treatments, a physician
should actively ask about these matters, because patients often do not voluntarily mention
them. Patients often do not consider a connection between their medication and their
sexual response. In addition, many men feel too ashamed to talk about their sexual problems.
A sudden heart disease, such as a heart attack, is a frightening experience after which
resuming sex life may be regarded as too frightening to attempt. Intercourse may be a
considerable physical strain, and the thought of a new episode of the illness may interfere
with the enjoyment of sex. It is important that a person who has had a heart attack be
unambiguously counselled on when sexual intercourse can be safely resumed. It would
be good to discuss what kinds of positions are least stressful.
Illnesses of the prostate, such a benign growth of the prostate and cancer of the prostate,
initially cause symptoms associated with urinating. Problems with erection may also
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appear. These problems can also appear in connection with the treatment of these
illnesses. It is advisable for a patient to discuss the possible effects of medications and
of any operation on erection beforehand with the treating physician. When congestion
of the urethra caused by a growth of the prostate is surgically treated, the result often
causes the ejaculation to turn into the bladder (retrograde ejaculation). This symptom
in itself is harmless but can feel disturbing or puzzling if the patient has not been
informed about it.
Male menopause
The production of testosterone in the man’s testicles does not suddenly stop but decreases
evenly and steadily with advancing age. The decrease begins before middle age. Some
men have symptoms around the age of sixty resembling women’s menopause. The men
may experience hot flashes, unusual perspiration and feelings of irritation and depression.
Erection problems are often associated with this state. As a syndrome the male menopause
is still rather poorly understood, and there are no established forms of treatment. Hormone
treatment has been tried and some are clearly helped by it. The side effects of the
treatment, especially the increase in the size of the prostate, limit its use.
Finnish physicians have not been systematically trained to treat symptoms of male
menopause and service and treatment procedures are not available. In bigger cities
there are specialists acquainted with the problem in private practice. In the future it is
probable that if the need to treat male menopause symptoms grows and knowledge in
the field increases, then methods of treatment will develop and become established.
The Sexual Rights of Aging Persons
As part of human rights, sexual rights include the right for individuals to define their
sexual needs themselves and to strive for a satisfactory sex life taking into consideration
the needs of a partner. Every person should have the right to obtain information that
supports sexual health, and, in particular, to the information and health services he or
she needs. It is important that an elderly person’s sexuality is not denied, and that
information or services that he or she needs for sexual health are not ignored solely
because of age. Sexuality should be dealt with in a comprehensive way within the
health care system, and aging people should be able to get counselling and treatment
they need. Counselling should be easily available from the same person who treats
aging people with their illnesses.
Also elderly people persons in long-term institutional care and people otherwise very
dependent on others have sexual needs that should not be ignored. Elderly people
should have enough privacy to make their sex life possible. The sexual needs of
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elderly people should be among the considerations of those in charge of planning
treatments and those responsible for daily care of this patient group.
Although basic health care and specialised nursing are most important in taking care of
the sexuality of aging persons, they also need special services targeted specifically for
them. In addition, special services have an important function in the dissemination of
information and in opening discussion on the sexuality of aging people.
References
Kontula, Osmo, Haavio-Mannila, Elina. 1993. Suomalainen seksi (Finnish Sex). WSOY.
Butler, Robert N., Lewis, Myrna I . 1993. Love and sex after 60. Ballantine books
Wright, Helen J. 1998. The female perspective: Women’s attitudes toward urogenital
aging. American Journal of Obstetrics and Gynecology 178: 50-253.
Jaarsma, T., Dracup, K., Walden, J., Stevenson, L.W. 1996. Sexual function in patients
with advancedheart failure. Heart & Lung: The Journal of Critical Care 25: 262270.
Read, J. 1999. ABC on sexual health: Sexual problems associated with infertility,
pregnancy, and ageing. British Medical Journal 318: 587-589.
314
Ilsa Lottes and Osmo Kontula
25. Conclusion: The State of Sexual
Health in Finland
In this final chapter, we present methods to evaluate the sexual health of a country and
then apply them to Finland. We base our methods of evaluating sexual health on principles
of the new approach described in chapter 1.The authors of previous chapters have
already discussed strengths and weaknesses of the provision of sexual health services
and information for specific organisations and populations groups. We now summarise
important aspects of service and education provision described by the authors and add
our own observations in highlighting both effective programmes and areas of concern.
We end the chapter with a discussion of how Finland can continue to offer leadership in
sexual health expertise and promote sexual health throughout the world.
An underlying assumption in this discussion is that there is general agreement with the
principles upon which the new approach to sexual health was based. Thus, it is assumed,
for example, that we should work to promote equality of sexual standards, and in
particular to promote policies that do not discriminate on the basis of class, race/ethnicity,
religion, age, disability, gender, or sexual preference. We also assume that policies should
be directed toward increasing sexual skills and knowledge and providing quality sexual
health services for all. Of course, these assumptions are problematic for people with
non-egalitarian views and for governments that either can not or choose not to assume
the responsibility of providing universal sexual health services and sex education in
schools. Yet, we strongly endorse these assumptions, based on a human rights approach
to sexual health.
Our evaluation criteria are guided by listings of sexual rights (Tables 1, 2, and 3 of
Chapter 1), Coleman’s ways to promote sexual health (Table 4, Chapter 1), definitions
of sexual health arrived at through international consensus, and the sexual health models
described earlier (Chapters 2 and 3). We continue to provide arguments for the view
that countries most closely approximating the actualisation of the aforementioned sexual
rights also have the best records on many indicators of sexual health such as rates of
sexually transmitted diseases and unplanned pregnancy.
One way to evaluate the sexual health of a country is to determine the degree that
sexual rights are realised by the citizens of a country. Any one of the lists of sexual
rights presented in Chapter 1 provides a framework for such a determination, i.e., one
of the listings of rights formulated by the International Planned Parenthood Federation,
the World Association of Sexology, or the subgroup (HERA) of the International Women’s
Health Coalition. A second approach is to use the list of ways to promote sexual health
315
suggested by Eli Coleman as evaluation criteria. A third way is to consider the models
of sexual health described in chapters 2 or 3 and develop criteria of evaluation from one
of those models. A fourth way is to use the components of the definition of sexual
health to guide construction of indicators for evaluation. Because all four of these
methods are based on the same principles, those adopted by international consensus at
the Cairo and Beijing conferences, evaluation criteria developed from these methods
would be similar.
We chose the fourth method to organise indicators and areas to examine in evaluating
the sexual health of a country. Table 1 contains a list of these indicators and areas for
each component of sexual health, and we use this table to summarise the state of sexual
health in Finland. Because the three direct determinants of sexual health are sexual
information, services, and ideology, these three determinants also need to be discussed
in an evaluation of sexual health. Finally, aspects of reproductive health also need to be
examined because of their relationship to sexual health.
Unwanted and Unplanned Pregnancies
Finland fares well with respect to unwanted and unplanned pregnancies. Women in
Finland have access to traditional and most new contraceptive methods including
emergency contraceptives. Teenagers are well acquainted with this as well as other
older methods of birth control. In one list provided by the United Nations of teenage
birth rates for 44 of the better industrialised countries for the first half of the 1990s,
Finland had the 11th lowest rate (United Nations, 1996). Countries such as Japan,
Switzerland and the Netherlands were among the countries with teen birth rates lower
than Finland, and the USA reported the highest rate. In a comparison of Finland’s 1995
teen birth rate with other countries, only Japan’s rate was lower (Mackay, 2000).
Although many surveys of sexual behaviour have been conducted in Finland, apparently
few have asked women to report the number of unplanned and unwanted pregnancies
they have ever experienced. Myhrman (1992) found that from1966 to 1985/86, rates
of unwanted pregnancies (not wanted at all) decreased from 12% to 1% in Northern
Finland. Helmig (1997) reported that in this same regional study, the unplanned pregnancy
rate (pregnancies that occurred earlier than desired or was not wanted at all) was 12%
at the later date. A major study by the Alan Guttmacher Institute (Jones et al., 1989)
found that more than 50% of all pregnancies were unplanned in Finland in 1978, a
figure comparable with other Western countries at that time. Recent international data
on this topic is limited although Helmig emphasised that Finland’s rate is considerably
lower than that in the United States, where the unplanned pregnancy rate is nearly 60%
(Brown and Eisenberg, 1995). The decrease in rates of unwanted and unplanned
pregnancies since the 1960’s can be attributed to the high quality and free family planning
services that became available to Finnish women in the early 1970’s.
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Table1. Indicators and areas to examine for the evaluation of a country’s
sexual health
Sexual Health Component
Indicator or Area
1. Planned and wanted pregnancies
- Contraceptive prevalence
- Percent using effective methods
- Cost, accessibility, and quality of family planning and abortion
services including general and emergency contraceptives
- Legality of abortion
- Abortion mortality and morbidity rates
- Teenage pregnancy, birth and abortion rates
2. Low risk of contracting a sexually
transmitted disease (STD)
- Rates of major sexually transmitted diseases including
HIV/AIDS by gender
- Cost, accessibility and quality of STD diagnosis and treatment
- Impact of prostitution
3. No sexual coercion, abuse, harassment,
assault, rape, or mutilation
- Rates of sexual coercion, abuse, harassment, assault and rape
- Extent of female genital mutilation
- Cost, accessibility, and quality of services for victims and
treatment for abusers
4. Lack of discrimination
- Extent of empowerment of and services for women,
nonheterosexuals and transsexuals, and other groups
who tend to be marginalised
- Degree to which laws promote political, economic and
social equality for all groups irrespective of gender, race,
age, ethnicity, class, sexual preference or religion
- Extent of social harassment based on gender, race, etc
- Cost, accessibility, and quality of sexual health services
for special population groups such as the disabled,
elderly, sex workers and teenagers
5. Sexual enjoyment and pleasure
- Extent of sexual dysfunction
- Degree of sexual satisfaction
- Cost, accessibility, and quality of medical treatment and
sex therapy for physiological and psychological sexual
problems
- Extent of sexual dissatisfaction due to lack of a partner
- Degree of sexual knowledge and skills of the general
population
- Acknowledgment and consideration of the influence of
diseases and treatments on sexual functioning by health
professionals
- Knowledge of sexuality based on scientific,
multidisciplinary research
6. Sexual knowledge and education
- Comprehensiveness and quality of sex education in
public schools
- Uniformity, comprehensiveness, and quality of sex
education of educators and health professionals
- Extent of continued education for sex educators and
health professionals
- Extent of media coverage of sexual health issues with
consideration of wide range of experts as well as topics
7. Reproductive health
- Infant and maternal morbidity and mortality rates
- Extent and treatment of infertility problems
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Several large-scale national surveys since 1971 have asked women to indicate their use
of contraceptives. Rehnström (1997) emphasises two trends that emerge from these
surveys: first, an increasing use of contraceptives, even among the young and second,
the use of more reliable contraceptive methods. In one survey, Erkkola and Kontula
(1993) found that only five percent of women who are in need of contraception use no
contraceptives at all. Thus, the risk of having an unplanned pregnancy seems small in
Finland for a majority of such pregnancies occur in women who use no contraceptive
method. The most recent surveys indicate that the pill and IUDs are common methods,
and that 25 to 35 percent of women rely on condoms. Some Finns use the condom for
protection against sexually transmitted diseases as well as another method for birth
control. Väestöliitto (1998) and Mackay (2000) note that condom use is widespread,
and that Finland is second only to Japan in its use of condoms. Thus, contraceptive
prevalence rates and the use of reliable methods are high. These favourable rates can
be attributed to a high level of contraceptive knowledge by women and also to the easy
accessibility of services.
Rimpelä (1998) attributes Finland’s success in reducing abortion and unplanned pregnancy
rates to the following five factors: (1) use of preventive approaches in public health (2)
change of focus from abortions to the prevention of its main cause, unintended pregnancy,
(3) good co-operation and co-ordination between the health and education sectors, (4)
strong and skilled guidance from the national health authorities, and (5) professional
attitudes of nurses and doctors in sex education and family planning.
Nevertheless, there are some reasons to be concerned. Väestöliitto (1998) has noted
that the cost of some contraceptives likely inhibits their use by members of low-income
groups, especially disadvantaged youth. Lowering the price of contraceptives would be
an effective measure in increasing their use. One reason for the exceptionally low rates
of abortion and unplanned pregnancy in the Netherlands is the free or low cost of
contraceptives.
A few cases of violations of confidentiality of services to adolescents have recently
caused concern (Dan Apter, personal communication, July, 2000). In one incident, a
bill was sent to the home of a teenager who had obtained emergency contraception, and
this caused family conflict when her mother read the description of service on the bill.
In addition to violating the right of privacy, such publicised incidents may prevent other
young people from seeking needed sexual health services. Besides teenagers, other
population groups that need special attention with respect to contraceptive use are
women intravenous drug users, the disabled, and the growing number of refugees and
other foreigners.
Because abortion services are legal and provided by skilled professionals, Finland does
not have a problem with health complications or deaths due to illegal abortions. A major
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goal of health professionals has been to keep abortion rates low by supporting policies
that promote contraceptive use. STAKES is currently conducting research on how to
make abortion services better meet the needs of women. A world wide investigation by
the Alan Guttmacher Institute (1999) revealed that in 1996 Finland had the 6th lowest
abortion rate for women between the ages of 15 and 44 in a ranking of 28 countries
where abortion statistics were considered complete. In 1994, Finland’s abortion rate for
those 15 to 19 was 9 per 1000. This is lower than corresponding rates in most other
industrialised countries (this rate was 32 per 1000 in the USA, for example) (Henshaw,
1999; Kosunen and Rimpelä, 1996).
Some sexual health professionals fear that the decrease in sexual health services in
some areas of Finland due to budget cuts and increased decision making powers of
municipalities will cause the teen pregnancy rate to rise. These cuts have meant that
some family planning clinics that have been staffed by specially trained nurses are no
longer operating. Such clinics were popular with young women because of the highly
trained personnel and reduced fears of anonymity violations. Currently, more family
planning services are expected to be offered by primary care providers where some
young people have greater concerns about privacy. Another cause for alarm is that the
cost of obtaining an abortion as an outpatient has recently more than quadrupled
(Kosunen, Chapter 5).
A major strength of the Finnish health care system had been the sexual health services
provided by school nurses in the comprehensive schools. Since the recession of the
early 1990’s, school nurses have had less time to provide sex education and counselling
in sexual matters. Services of these nurses to young people should be restored if Finland intends to emphasise prevention of health problems and avoid higher health costs
of treating STDs and abortion services later.
Health providers in Finland are actively involved in collaborations with other countries
that have good records in sexual health. Thus, frequent consultations, seminars, lectures,
and conferences are arranged with other countries, especially with the Netherlands and
their Nordic neighbours. Such international co-operation ensures that those providing
sexual health services continue to be aware of high-quality and effective programs.
Sexually Transmitted Diseases
The next area to consider in Table 1 concerns sexually transmitted diseases. Professionals
in this field in Finland agree that their country has excellent diagnostic and treatment for
the major sexually transmitted diseases. For most of these diseases, including HIV/
AIDS, treatment is low cost or free and confidentiality is protected. Treatment can be
obtained from both public and private services.
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Until recently, professionals thought rates of sexually transmitted diseases were low and
under control. Fifteen percent of adult men and 12 percent of adult women acknowledged
they had had some sexually transmitted disease (Kontula, 1994). In this same survey
less than 2% of both men and women reported they had such an infection during the
past year. Furthermore, Finland has been known for its exceptionally low AIDS rate
and for its effective information campaign about this disease.
In the last couple years, higher rates of some diseases have caused health experts grave
concern. First of all, the rate of HIV infection has increased alarmingly due to a new
method of transmission in Finland – intravenous drug use (57% of new HIV cases in
1999). Response to this situation has been quick, and new strategies are continually
being developed to deal with this growing problem. Clean needles and syringes are
available for drug users at easily accessible safe places in major cities. Increased treatment
programs including those using methadone have been arranged. Groups at higher risk
of becoming drug users – the young, immigrants, and prisoners – have also been targeted
for special programs and attention.
Another area of concern is the high rate of STD transmission from foreigners to Finns.
With the increased travelling and mixing with members of states of the former Soviet
Union, particularly to and from Russia and Estonia – where rates of STDs have increased
dramatically in the 1990s –more and more Finns, men especially, are getting an STD
from a foreigner and subsequently giving their partners an STD. Syphilis has slightly
increased among the adult population, for example. So, further educational campaigns
as well as additional components in school sex education need to be developed to help
contain STDs in Finland. All population groups need to be considered, and people can
not assume that they will not get a STD from their regular partners. A shortcoming
mentioned by Väestöliitto (1998) in efforts to reduce STDs is the need for better followup of people treated for a sexually transmitted disease.
When determining how STDs are transmitted, one important factor to examine is the
influence of prostitution. More information about the role of prostitution in the spread
of STDs in Finland is needed. However, at a 1999 meeting of professionals in the field,
the general agreement was that risk of getting a STD in Finland is greater from one’s
regular partner than from a sex worker.
Another problem requiring attention is the rate of chlamydia. There were more than
10,000 new cases in 1999. Infertility is now recognised as a growing problem in Finland, and chlamydia is one of its major causes. Public health information campaigns
have attempted to reduce the incidence of this disease. Experts now believe that extensive
screening programs for those at risk would be a cost efficient and effective way to
reduce the incidence of this problem.
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More versatile teaching methods – those requiring student participation and role practising
of sex education would also help in giving adolescents better interaction skills with their
peers. In a recent Finnish study, Papp et al. (2000) found that good social interaction
skills reduced sexual risk taking for the young.
Sexual Abuse, Assault, and Coercion
As Riitta Raijas and Raisa Cacciatore (chapters 11 and 20) have emphasised, problems
of sexual abuse and assault need to be addressed in Finland. In this regard, it is
important that issues relating to the abuse of children be addressed more comprehensively
in the sex education programs of schools as well as by parents. Raisa Cacciatore
already stressed the need for children to understand their rights to control who touches
them and when and how they are touched. Sexuality programs need to also address
issues relating to consent and mutuality in all sexual relationships. If a rights approach
to sexuality is used in schools, then perhaps more people will adopt a norm of mutual
consent and reciprocal respect.
Results of surveys of the general population also indicate that problems of sexual abuse,
harassment, and rape are present in Finland. Kontula and Haavio-Mannila (1993) report
that 18% of women and 7% of men had experienced sexual harassment (defined as the
receiving of an unwanted/one-sided physical or verbal sexual approach) before they
were 17. In this same survey, 9% of adult women and 3% of adult men reported they had
experienced unwanted offensive touching with a sexual intent in the last five years. One and
a half percent of women reported they had been the victim of rape or attempted rape.
In the United States, social scientists (e.g., Lottes, 1988; Lottes, 1991a) have argued
that rigid gender roles which link ideal masculinity with high numbers of sex partners
and femininity with submissiveness and lack of sexual experience encourage dishonest
communications between men and women. Thus, men often disregard a ‘no’ response
for sexual interaction. Research (Hofstede, 1983; Löfström, 1997) suggests that these
types of gender roles have less influence on Finnish women and men. Thus, Finnish
men seem more likely than American men to interpret a ‘no’ as really meaning no and
thus, not push for sexual intimacy. Another traditional difference between Finnish men
and American men involves their patterns of communication in heterosexual relationships.
American men are quick to say ‘I love you’ to a potential partner, and many American
women believe that if they are in love, then a sexual relationship with their ‘love’ is
morally acceptable. In fact, verbal sexual coercion by men toward women is common
in the USA (Lottes, 1991b). A Finnish man generally does not tell a woman he loves her
just to convince her to have sex with him.
Furthermore, sex among the unmarried is widely accepted in Finland. Women do not
have to pretend they are not interested in sex or justify their sexual involvement by
love.
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Thus, it seems that some of the sexually coercive situations due to psychological coercion
and pressure may be less in Finland than have been commonly reported in the USA.
Nevertheless, Riitta Raijas (chapter 11) stressed that even though rates of sexual violence
do not appear to be higher than rates in other European countries, such violence is a
serious problem in Finland. The importance of mutuality to engage in sexual interactions
needs to be stressed in sexuality programs, and young people need to be taught and
given the opportunity to practice interactional competence skills. Research has supported
the view that good interactional competence skills reduce the risk of sexual coercion and
abuse by both psychological and physical means (Vanwesenbeek, 1999).
Female genital mutilation is not allowed in Finland but due to the increasing number of
immigrants from countries where this is practised, policies will need to be developed to
prevent its occurrence and also to sensitise health professionals in their treatment of
women who have undergone this procedure.
In chapter 11, Raijas highlighted some promising trends that have the potential for
reducing sexual violence. First, educational and informational campaigns have brought
this problem to the attention of the public and illustrated the need to find ways to reduce
sexual violence and provide support for its victims. These campaigns helped ensure that
the rape crisis centre in Helsinki is now operating as a permanent provider of services
for victims. Raijas also described many crucial areas of sexual abuse and assault that
need to be investigated in future research. In this regard, it is worth repeating that the
Academy of Finland has allotted a substantial sum of money for research on violence
and gender topics. Policy makers, service providers, and educators need to learn more
about contextual dynamics of sexual violence, coercion, and assault in Finland.
Sexual Discrimination
The harmful effects of discrimination on the sexual health of individuals are difficult to
determine. Even listing all groups that are subject to this type of injustice is not an easy
task. The obvious groups are women, gays, lesbians, and transsexuals. Other groups
facing discrimination and in need of sexual health care and support services include the
elderly, the sick, disabled, children, victims of sexual abuse and assault, prostitutes,
immigrants, and people in institutions. Some may even include individuals having
serious difficulties in finding a partner as a group that deserves special attention. Elderly
women and marginalised men are in this group and the number in the latter category
has increased in Finland during the economically hard years of the 1990s.
Nevertheless, in our evaluation of the discriminatory damages suffered by the citizens
of a country, we can make some definite guidelines to follow. First, norms, attitudes,
laws and policies with respect to these groups, as well as the services and education/
information available to them, of course need, to be examined. The official policies in
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Finland generally support equality between the genders and between heterosexuals and
non-heterosexuals. Yet with respect to gender equality, particularly in regard to issues
involving economic and political resources, more work needs to be done (see chapter
2). Certainly, gays and lesbians are still victims of cruel acts of discrimination, starting
at young ages (Stålström and Nissinen, chapter 9 and Lehtonen, chapter 22). These
acts of harassment throughout the school period have devastating long-term effects on
the self-esteem and sexual health of many gays and lesbians.
Despite, these acts of intolerance, we must emphasise that non-heterosexuals enjoy
more rights and better sexual health in Finland than their counterparts in most other
areas of the world. The main official areas of legal inequality for same gender couples
involve: (1) the right to have their relationship legally registered, (2) the right to receive
inheritance from a partner under the same rules that apply to heterosexual couples, and
(3) the opportunities to have children through adoption or using reproductive technologies.
With respect to the sexual health of other groups, it is important to listen to and take
action concerning the recommendations of those who provide services to them (see
chapters 21 to 24). At least in Finland, the need for sexual health services for the
elderly, disabled, adolescents, and children has been acknowledged. Health authorities
at the national level have also facilitated the work of many of the sexual health support
groups by providing both funding and expertise.
Effective public campaigns can reduce sexual discrimination. An example of one such
campaign aimed at improving attitudes about the sexuality of older people took place in
1999 and 2000 in central Finland (at Kutemajärvi) and was advertised as a “sex festival
for the over 40”. This three-day event attracted both young and old and received media
attention all over Finland. It combined informational activities like films, educational
exhibits, and lectures on sex and love with opportunities to enjoy art, craft
demonstrations, singing, music and dancing. In a similar way, “sex festivals“ targeted
primarily for the young have been organised annually since 1996 and are characterised
by both educational and recreational activities.
Sex workers comprise another group that requires special sexual health services, and
we have not focused on them in this book. The major reason for this is that important
research on prostitution is currently in progress, and much of the information that we
could include at this time would be outdated. The nature of prostitution has changed
greatly since the break up of the Soviet Union. For example, in the last decade, many
women from Russia and Estonia have come to Finland to make money as sex workers.
Whereas earlier prostitution was largely hidden, in the early 1990’s it became more
visible as new sex workers sought clients in the streets and other public places. Thus,
policy makers and those who provide services for sex workers have responded to the
need to carry out research on prostitution in order to form a basis for future policy. We
now give a brief description of the research and describe a support centre for sex
workers.
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One research project entitled “Prevention of Prostitution 1998-2002” is sponsored by
STAKES. A major goal of the research is to find ways of reducing prostitution and its
harmful effects on both sex workers and the society in general. The other major project
– EUROPAP – involves all the European Union countries. EUROPAP stands for
European Intervention projects AIDS prevention for prostitutes. The goals of EUROPAP
are to support and develop interventions to reduce HIV, STD and other communicable
diseases in prostitution and to assess the most successful and appropriate approaches
for sex workers. Major goals of the Finnish part of EUROPAP are to learn from
interviewing sex workers ways to design programs and services that better meet their
needs and also, of course, to help guide political and policy decisions on prostitution.
In Helsinki, there is a Prostitutes’ Counselling Centre (PCC) which provides support
services for sex workers and their friends and family members. The primary goal of this
organisation is to promote the health, well being and safety of sex workers. Services
provided are confidential and free of charge, and the will to stop sex work is not a
condition for service. The PCC employs 2 full time and 3 part time workers, including
a social worker, psychiatric nurse, and a doctor with a speciality in STDs. These highly
trained professionals take personal appointments, offer help by telephone, provide
information about safer sex techniques, and perform STD diagnosis and treatment,
both at their centre and through outreach activities in sex bars and the streets.
Prostitution is linked to sexual health problems and has been a major area of concern
for Europe. In this regard it is worth noting that the two countries Sweden and the
Netherlands have recently adopted diametrically different policies. Sweden has chosen
to punish the clients of prostitutes with fines and short imprisonment, whereas the
Netherlands has now lifted bans on prostitution while still keeping strong restrictions on
the trafficking of individuals for sex work, the forcing of individuals into prostitution,
and the participation in prostitution by those under 18.
After the Finnish research findings are known, it will be interesting to see which approach
Finland favours. Prostitution has never been criminilised in Finland. Attitudes among
men toward prostitution are favourable (Kontula and Haavio-Mannila, 1993), and during
the 1990’s they have become even more tolerant (Haavio-Mannila, Kontula and Kuusi,
2000). It is interesting that the different approaches to prostitution in Sweden and the
Netherlands were both motivated by the desire to reduce violence against women. One
attempts to do this by strict punishment and the other by trying to regulate and control it.
Sexual Enjoyment and Pleasure
Finland is one of the rare countries for which national survey data exist that provide
some measures of sexual satisfaction. We do not claim that these data tell the whole
story, but they are certainly worthy of examination and may help professionals in other
countries in their planning of evaluations of sexual health. One major finding supported
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by the longitudinal survey analyses (from 1971 to 1992) was that the sexual health of
Finns – or at least the sexual enjoyment component of sexual health – has improved in
the last 20 years. This seems to be true especially for young adults. Kontula and
Haavio-Mannila (1993) report that compared to 1971, the sex life of Finns has become
more versatile, sexual intercourse is rated as more pleasurable and satisfying by a higher
proportion of adults, intercourse orgasms are more frequent for women, the amount of
foreplay is rated better, discussions of sexual matters with a partner are easier, relationships
are happier, and sex life is rated as more satisfying.
Findings from the survey analysed by Kontula and Haavio-Mannila also indicate that
sexual attitudes of Finns are moving away from endorsing a double standard of sexual
behaviour for men and women and toward an egalitarian sexual ideology. A similar
proportion of men and women in the 1992 survey thought that temporary sexual
relationships could provide happiness and satisfaction. The vast majority of respondents
in all age groups reported that women should be able to initiate sex rather than simply
giving the control and responsibility to men in sexual interactions. About three-quarters
of both men and women agreed that ‘a decent woman can openly show interest in sex’
and this proportion was highest for younger adults. Although half the total sample
reported that the sex drive was greater for men than for women, among the young, the
more common view was that the sex drives of men and women are equal. Experiences
of men and women have become more similar since the early 1970s. Thus, the stronger
societal position of women with respect to their power in basic institutions seems to
have contributed to greater equality in their sexual lives.
Some additional positive findings from the survey include the following: Over 80% of
men and women report that their sex life is at least somewhat satisfying. Over a quarter
report their sex life as ‘very satisfying’ and 6% or less report their sex life as
‘unsatisfactory’. Over 90% of women rated their last intercourse ‘at least fairly pleasant’,
almost half of both men and women rated their last intercourse as ‘very pleasant’, and
90% of both men and women rated their permanent relationship at least ‘fairly happy’
and less than 2% rated it as ‘unhappy’. The majority reported they were in a steady
relationship. Some 39% of men and 30% of women rated themselves as ‘sexually very
skilled’ and 66% of men and 44% of women rated themselves as ‘sexually active’.
Despite these rosy statistics, problems were revealed in the 1992 survey. For example,
19% of men and 23% of women had no steady sexual partner. Women over 50 were
especially likely to be without a partner. Lack of sexual desire was a problem for
significant proportions of men and women. Of men, 50% and of women, 26% reported
no sexual desire problems in the last year. Lack of vaginal lubrication, inability to have
an orgasm and painful intercourse were reported frequently by women. About one third
of women of all ages had continual difficulties in having an orgasm. Similarly, erectile
dysfunction and coming too quickly were problems for men. In addition, relationship
problems also contributed to an unsatisfactory sex life for many couples.
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Thus, the ability to enjoy sex has not been possible for many Finns. Nevertheless, it
seems unlikely that Finns have more sexual problems than people from other countries
have. Indeed, the probability is that they are more able to enjoy sex for many other
components of sexual health are more problematic in most other countries. Possibilities
for sexual pleasure are increased when other aspects of sexual health are not a concern,
that is when worries about unwanted pregnancy, sexually transmitted diseases, force,
coercion, and discrimination are minimised.
Sexual Knowledge and Information
An important influence on the sexual pleasure and satisfaction of individuals is their
degree of sexual knowledge and skills. Adequate knowledge is, of course, important for
every aspect of sexual health. As discussed previously in several chapters, Finns seem
to have an adequate knowledge of sexual issues. Nevertheless, it has also been stressed
that sex education in the schools needs reform (see Lähdesmäki and Peltonen, chapter
15 and Liinamo, chapter 17). It is alarming that the subject is no longer compulsory,
that there are no specific requirements for its content, that there is not much co-ordination
of teaching of this subject, that there is great variability in the amount and
comprehensiveness of sex education curricula across schools and municipalities, that
the training and competence of those who teach it varies greatly, and that many who are
assigned to give sex education regard their skills as inadequate to do so properly.
Of concern as well, as mentioned earlier, is the reduction of opportunities by school
nurses to provide sex education. Thus, we urge that educational professionals take
action to improve sex education in their schools, and thereby work to improve the
aforementioned conditions. The first step is for each school to assign someone in charge
of the co-ordination of teaching sexual topics. Second, comprehensive sex education
should be offered, if not required at every school. Third, teachers who feel they need
more skills to adequately give instruction in sexuality should have opportunities to do
so. Such training is offered throughout Finland in special seminars and at polytechnics.
Teachers should also be made aware of the many new sex educational materials recently
developed with the support of STAKES and Väestöliitto.
The 1992 survey of the Finnish population indicated that over 60% of adults had
received some information about sex from their parents. These respondents also said
they preferred to be informed of sexual matters in the school, and less than one third
(half of the youngest generation) considered the information learned in school adequate.
Thus, these findings also support the view we have stated earlier that sex education
curricula need to be more comprehensive.
The training and knowledge of those in the education and health sectors has a great
impact upon the quality of information and services provided to people. As contributors
to this volume have indicated, there is a need for professionals in these two sectors to
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increase their knowledge and acquire skills that enable them to deal more effectively
with sexual issues and problems of students and clients in their work. Part of the
instruction to these professionals needs to include training in communication and listening
skills. They must feel comfortable in talking about sexual matters and topics that often
cause embarrassment.
Some polytechnics started in the 1990s to give sexological training at the basic level (10
credits) and specialized level. Specialized level (40 credits) leads to a further professional
degree which complements an earlier degree of at least an institutional level. The need
for training is indicated by the number of applicants which is many times larger than the
training places. At the moment these specialized studies are attended by, among others,
nurses, midwives, physicians, health workers, teachers, psychologists, as well as
professionals and researchers in the social and welfare fields. There are plans to establish
a higher degree in the sexuality field in order strengthen professional expertise.
The specific title of a sexologist has not been used in Finland. The situation is changing
for in 1999 the Nordic countries approved a common specialized education program
for sexologists. There are three levels in this training model. The first level of 20 credits
provides a sexological “general education“ or the information to give sex education.
The second level of 20 credits prepares one to be a sex counselor. After completing the
third level of 40 credits, one can claim the competence of a clinical sexologist in either
sexual medicine or sexual therapy.
Finland will begin to formally establish the above education and titles starting in 2001
together with other Nordic countries. Training modules at least on level three will be
produced which can be attended by students from various countries. The professional
titles (sexual counselor/therapist and clinical sexologist) will have to be applied for from
the Nordic Association of Clinical Sexology (NACS). Applications for professional titles
in Finland will first be sent to the Finnish Association for Sexology for review. The
similarity of other previous sexological training and work experience to the new training
program will be assessed. The new sexology programs will lead to the significant
development of professional special expertise and thus improve the sexual health services
for the population.
Statistics Finland and other information gathering organisations provide very accurate
records and data on sexual health. The efficient registrars and tabulations of statistics
and other information are valuable sources for researchers in academia, educators,
health policy experts, and health professionals. They provide a means for identifying
needs and problems and for monitoring services and programs throughout Finland.
Many involved in sexual health have suggested that a multidisciplinary sexological
department be established in one of Finland’s universities. The duties of this department
would be to educate sexual health professionals and co-ordinate research projects that
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relate to sexuality and sexual health. To support this research, a section for sexology
could be established within the Academy of Finland. Members of this proposed
department could offer clinical services in sexual health and develop materials for school
sex education.
Despite the fact that universities do not offer much sexological training, many health
and academic professionals are involved in research that includes sexual topics.
Departments of Public Health, Sociology, Psychology, Medicine, Social Policy, History,
Education, Communications, Philosophy, and Literature have all been involved in research
overlapping with or focusing on sexual topics.
The first national survey of the sexual attitudes and behaviour of Finns was carried out
in 1971 (Sievers et al., 1974). This research was quite an accomplishment for it was
only the second time any country had attempted to conduct a sex survey representative
of its population. The Academy of Finland which funds research in universities all over
Finland financed two (1971 and 1992) of Finland’s three sex surveys. The most recent
one (1999) was funded by the Ministry of Social Affairs and Health. Such support for
sex surveys by a government is uncommon for most countries. The National Research
and Development Centre for Health and Welfare has also funded numerous projects to
guide development efforts and evaluation of sexual health programmes and needs.
Thus, there has been much support to increase the knowledge in sexual health by
educational and governmental institutions. Nevertheless, there is still a need to continue
government funding of sex research and to broaden the range of topics examined.
Opportunities to bring new sexual knowledge to Finland are also facilitated by the active
participation of Finns in many sexuality-related professional organisations. Finns have
regularly attended the meetings of the Scientific Study of Sexuality in the USA, sexuality
sessions of the European Association of Sociology, the European Federation of Sexology,
the International Lesbian and Gay Association, and the World Association of Sexology.
In addition, of course, they attend meetings of Nordic organisations whose members
are STD specialists, sex therapists, clinical sexologists, and gynaecologists with a special
interest in adolescent or women’s health. In 1997 two Finns were nominated to join
the International Academy of Sex Research.
The media has been an important sex educator for all age groups. As discussed in
chapter 18, the media often provides important information about sexual health issues.
Finns follow the media keenly and learn about sexual matters from international as well
as national perspectives. Television, radio, and newspapers can be given credit for their
good coverage of important developments or happenings related to sexuality, including
even interviews and panel discussions with those doing sex research or providing sexual
health services. For example, if STAKES sponsors a national seminar on some aspect
of sexuality, the media will cover this. If a new book on sexuality appears, there will be
a press conference that is well attended by reporters. Even graduate students get press
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coverage such as a TV interview when they complete a major project on a sexual topic.
Nevertheless, the scope of coverage could be extended to take better advantage of the
wide variety of expertise in Finland on sexual matters. For example, more attention is
always needed to highlight inequities of health service or problems of groups that are
victims of abuse, harassment and discrimination.
The Internet provides a great deal of information about sex, and promises to be an
increasing source of knowledge about sex in the future. However, there is great variability
in the accuracy and value of material presented in Internet sites. Some guidance is
needed to help users distinguish between reliable and non-reliable information. At times,
media presentations may overly generalise, simplify sexual issues, or create pressures
and conflicts involving sex and gender roles. Criticism of the sources of sexological
information is often missing. For example, users of the Internet may get answers to
their questions that many in the sexual health field in Finland would regard as harmful.
Other examples of sex-related material provided by those lacking sexological training
are sex magazines and videos sold in sex shops. Internationally and within Finland,
there is a debate among social scientists about whether these types of sexually explicit
materials promote views that are in conflict with the principles of sexual health and
sexual rights that we advocate in this book. A discussion of possible benefits or harm
from these materials is, however, beyond the scope of this book (see Lottes et al., 1993
for the range of views and their support).
Health Services for Sexual Problems
Although some physicians are well trained and sensitive to sexual needs and problems
of their patients, many are not. Jukka Virtanen (chapter 6) pointed out that formal
medical education in Finland does not require or include many courses on sexual health.
Currently, those with expertise in sexual problems have had to get their training abroad
or in special programmes in Finland organised by a special agency such as the Ministry
for Social Affairs, SEXPO, or the Family Federation of Finland. Thus, the formal
training of doctors should be revised to include more about sexual problems and should
provide greater opportunities to specialise in clinical sexology or sexual medicine. Doctors
need to at least understand that patients should be told in advance about how medications
they prescribe might affect sexual functioning. Physicians should also regularly inquire
about possible sexual side effects in their monitoring of medication. For example, depression and anxiety disorders are common in Finland. It seems likely that many Finns
have noticed changes in their ability to have an orgasm and fail to understand that this
change is due to the medication they are taking.
A long-term goal to improve services for sexual problems is to establish sexological
units, each comprised of a team of experts, that can offer clinical services in several
hospitals around Finland to treat sexual problems. Then those with sexual problems
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would have more options for treatment and would also know where appropriate
treatments are provided.
The World Health Organisation as early as the 1970’s considered sexual health important.
At that time WHO listed the following as basic and essential services needed for adequate
sexual health care: (1) basic information on the biological and psychological factors of
sexual development and procreation, the various forms of sexual behaviour, and sexual
functional disorders and diseases, (2) a positive attitude toward sexuality and a possibility
to objectively discuss sexual matters, (3) personnel that shows understanding and
objectivity toward the wishes related to sexuality and gives advice and information
about sexual matters and problems, (4) adequate sexological training of the health care
personnel, and (5) adequate knowledge and resources to deal with the often complicated
problems related with sexuality.
From a comparative perspective, Finland does a good job in the above areas. But as has
been pointed out, there are many improvements are needed in order to provide better
sexual health care for Finns.
Reproductive Health
In Chapter 1 reproductive and sexual health were discussed. Certainly women should
be able to control the timing and spacing of their pregnancies. Women who are always
worried about an unwanted pregnancy would have trouble having enjoyable sexual
relationships. Furthermore, if women and their babies are confronted with serious health
problems resulting from their pregnancies, then the quality of their life including their
sexual health will be adversely affected.
In the chapter 4, many measures of reproductive health are listed and with respect to
other countries, Finland fares remarkably well on these indicators.
The one issue we need to highlight here is the influence of infertility problems on the
sexual health of a couple having difficulty conceiving a child. Research both within and
outside of Finland has confirmed the negative impact of infertility on the sexual enjoyment
of infertile couples. Sex becomes a task, a duty. Men feel they must perform during the
short time period when their partner is fertile, and women are motivated by the pressure
to have sex only for the purpose of getting pregnant. Thus, sexual interactions become
associated with stress, pressure, and other unpleasant emotions. Couples who have
gone through this tense experience often find it difficult to return to an enjoyable sex life
after the infertility problem has been resolved or after they have given up their attempts
to have a child. In far too many cases, the sexual relationship ends and satisfactory
sexual relations can only be experienced with new partners, who are not associated with
the unpleasant and sad traumatic period of their lives.
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Unfortunately, infertility problems are not decreasing in Finland and there is a waiting
period for treatment. In this regard, we re-emphasise the need for better screening for
chlamydia. Due to the increased decision making power of municipal health care centres,
the cost and availability of infertility services varies across Finland. This inequity also
needs to be addressed in health policy.
One of the most alarming trends in Finnish health care in the 1990s, due to lack of
adherence to national guidelines and the greater autonomy given to municipalities, is the
decrease in diagnostic tests for both breast and cervical cancer (Helsingin Sanomat, 6
August 2000). (The Helsingin Sanomat is the most respected and widely read newspaper
in Finland.) Apparently, in efforts to save money, fewer women have been encouraged
to have the important diagnostic mammogram and pap tests and costs for these tests
have increased. In Turku, for example, when mammograms were free, about 90% of
women called had these tests. When payment was required, this figure dropped by
nearly 30 percent. The failure to ensure these important preventive health measures
varies throughout Finland. Of course, the general physical and psychological health, as
well as sexual and reproductive health, of women has been seriously threatened by
these oversights of municipal decision-makers. Public campaigns need to take immediate
action to correct this neglect of the welfare of women.
Conclusion
Finns have a favourable attitude toward sexual matters and understand that sexual
health contributes to general well being. In 1992, 88% of men and 79% of women
thought sexual activity promoted general health (Kontula and Haavio-Mannila, 1993).
With the exception of elderly women, the vast majority indicated they wanted their
lives to include a sexual relationship. Furthermore, a majority of respondents ( 75% of
men and 70% of women) supported the right of those in institutions to have a private
place for sexual interactions. Only 5% were against such a right for the ill and elderly.
The general positive views about sex make it easier for health officials to offer high
quality sexual health services and for teachers to provide good sex education in schools.
The positive attitudes of Finns toward sexuality are the result of a combination of
characteristics of Finnish society. One is the general acceptance of an egalitarian ideology,
and another is the lack of strong religious forces that associate sexual health problems,
and sex in general, to morality and sin. Although Finns generally do not link their sauna
culture to sexuality (it is just a very pleasant and efficient way for people to wash
themselves in a cold culture), the frequent acts of going nude to the sauna with people
of a different age or gender seem to have given them a comfortable feeling about being
without clothes in the presence of others.
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It is also important that Finns have accepted a rights view of health. Finns regard the
provision of basic health care as the responsibility of government. The Finnish Parliament
has even enacted laws on patient rights. Thus, it is not surprising that Finns have been
among the leaders at internationals meetings in their acceptance and promotion of sexual
rights.
Despite these positive aspects, we offer some cautionary remarks about the future.
Improvements must occur in the basic structure of the Finnish health care system.
Finland has the expertise and resources to rank higher than 31st in the 2000 report of the
World Health Organisation (WHO). Deficiencies in the Finnish healthcare system have
a great impact on sexual health. Changes made during the recession must be re-evaluated.
In traditional Finnish fashion, working and action groups must be organized to help
remedy the weaknesses cited in this book as well as those mentioned by the WHO. In
fairness to those who had to make health policy decisions early in the last decade, we
need to restate that this was a period of recession and there were not enough funds to
adequately fund Finland’s social and health care programs. Yet, we find it alarming that
even today, when economic conditions have improved, some important officials in the
Finnish government support reductions in funding proposals of the Ministry of Social
Affairs and Health.´This seems ill-advised given the deep cuts in funding of social and
health programs that occurred throughout the 1990’s. Outside evaluations by both the
OECD and WHO have already stressed that decreases in health funding should not
continue.
We advocate restoring funds to help correct problems in the delivery of health services
to the Finnish population.´The promotion of sexual health in the future requires more
stable public funding than was given in the 1990’s. Part of the budget of the Ministry of
Social Affairs and Health should be allotted on a permanent basis to fund sexological
training, sex research and sexual health information and education campaigns. Financial
support by the Finnish Slot Machine Association to organizations offering sexual health
services should be evaluated to ensure that such funding is sufficient. In addition,
family planning projects of STAKES need to have permanent status for such projects
have been successful in improving sexual health for Finns. Resources from the Ministry
of Education are also needed to support the new Scandinavian model of training in
sexology. Finally, local municipalities need to be more aware of the importance of
continuing school sex education and family planning services.
As of 2000, even though experts in healthcare both within and outside of Finland have
cited evidence of problems in need of attention, overall, Finland deserves praise for its
high quality of sexual health services and education. In international comparisons, Finland fared well on almost all indicators of sexual and reproductive health in the 1990’s.
Support by the major societal institutions for sexual health has been strong in many
332
ways. There are no signs that a powerful organization working against sexual health and
sexual rights will emerge in the future. Citizen’s rights to health care are acknowledged
by the government, strong and highly skilled expertise is provided by national health
policy makers and health providers, the church supports many sex education and equity
issues, rights of and services for many minorities are accepted, and the principle of
equality between the genders is endorsed by a majority of Finns. The Family Federation
of Finland is an avid advocate of sexual rights and especially works to promote the
sexual health of adolescents. Finns also generally support sex education in the schools
and understand that sexual well-being is part of general well-being.
The first sexological unit of a school for higher education was established in 2000, and
a new organization, the Finnish Association for Sexology, founded in 1997, is yet another
professional group that is working to promote sexual health. International cooperation
by Finnish organizations (e.g., The Family Federation of Finland) in countries with
serious sexual health problems will continue. Positive developments include the integration
of sexual health care into family planning and maternity care services. With new and
existing sexual health services and adequate funding from its government, Finland should
be able to maintain its leadership position in sexual health in the new millennium.
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and Human Sexuality, 4 (1), 37-59.
Lottes, Ilsa. 1991(b). The Relationship between Nontraditional Gender Roles and
Sexual Coercion. Journal of Psychology and Human Sexuality 4(4): 89-109.
Lottes, Ilsa, Weinberg, Martin, and Weller, Inge. 1993. Reactions to Pornography on a
College Campus: FOR or AGAINST? Sex Roles, 29, 645-669.
Löfström, Jan. 1997. Sexuality and the Performance of Manliness. Ethnologia
Scandinavica, 27.
Mackay, Judith. 2000. The Penguin Atlas of Human Sexual Behavior, Sexuality and
Sexual Practice Around the World. New York: Penguin.
Myhrman, A. 1992. Unwanted Pregnancy, its Occurrence, and Significance for the
Family and Child. Oulu, Finland, Acta Universitatis Ouluensis.
Papp, Krista, Kontula, Osmo and Kosonen, Kati. 2000. Nuorten aikuisten
seksuaalikäyttäytyminen ja seksuaaliset riskinotot (Sexual behaviour of young adults
and sexual risk taking). Väestöntutkimuslaitoksen julkaisusarja D36/1999. Helsinki:
Väestöliitto, The Family Federation of Finland.
Rehnström, Jaana. 1997. Reproductive Health and Health Care in Finland: An Overview.
Helsinki: National Research and Development Centre for Welfare and Health.
Rimpelä, Matti. 1998. Interplay of Sexual Education and Health Services: The Finnish
Model. Paper presented at the XII World Congress of Pediatric and Adolescent
Gynecology, Helsinki, May 31-June 3.
Sievers, Kai, Koskelainen, Osmo and Leppo, Kimmo. 1974. Suomalainen sukupuolielämä (Sex life of the Finns). WSOY. Porvoo.
United Nations, UNICEF. 1996. The Progress of Nations. Benson, Wallingford, Oxon,
UK: P&LA.
Vanwesenbeeck, I., van Zessen, G., Ingham, R., Jaramazovic, and Stevens, D. 1999.
Factors and Processes in Heterosexual Competence and Risk: an integrated look at
the evidence. Psychology and Health, 14, 25-50.
Väestöliitto (The Family Federation of Finland). 1998. The Evolution of Sexual Health
in Finland: How we Did It. Helsinki: The Family Federation of Finland.
334
335
Authors
2001) ja Seksin trendit (Trends in sex)
(WSOY 2001). He is the president of the
Finnish Association for Sexology, a Full
Member of the International Academy of Sex
Research, and a Member of the Board of
Directors in The Society for the Scientific
Study of Sexuality.
The Editors
Lottes, Ilsa, Ph.D., is an associate professor
in the Department of Sociology and
Anthropology at the University of Maryland
Baltimore County in Baltimore, MD, USA.
Her research and teaching areas include
quantitative research methods, sexuality, and
gender. Her most recent research interest
focuses on sexual health issues from crossnational perspectives. She has published over
two dozen articles, mostly in refereed
journals and is active in the Society for the
Scientific Study of Sexuality, the European
Federation of Sexology, the World Association of Sexology and the International
Academy of Sex Research. Her decision to
edit a book about sexual health in Finland was
motivated by experiences during her
sabbatical leave from 1997 to 1999 in the
Department of Sociology at the University
of Helsinki.
Kontula, Osmo, docent, Ph.D., Senior
Researcher at The Population Research Institute, Family Federation of Finland. He has
studied sexual issues almost 20 years and has
written and edited alone and in collaboration
with others some 20 books of sexuality and
sexology. Among them are for example Nuorten seksi (Adolescent sexuality) (Otava
1987), Tietoiseksi - Tietoa ja näkemyksiä
seksuaalipolitiikasta (Information and views
of sexual politics)(Gaudeamus 1998), Sukupuolielämän aloittamisen yhteiskunnallisista ehdoista (Cultural terms of sexual
initiation) (Painatuskeskus 1991), Seksistä
- Kuinka puhua nuorille (How to give sex
education to adolescents) (Otava 1991), Suomalainen seksi (Finnish Sex) (WSOY 1993),
Seksiä lehtien sivuilla (Sex on the pages of
the press) (Painatuskeskus 1994), Matkalla
intohimoon (Along the way to passion)
(WSOY 1995), Sexual Pleasures (Dartmouth
1995), Intohimon hetkiä (Moments of
passion) (WSOY 1997), Seksuaaliterveys
Suomessa (Sexual health in Finland) (Tammi
2000), Moments of Passion (McMillan
Other Authors
Apter, Dan, MD (1975), Chief Physician &
Director of the Sexual Health Clinic of The
Family Federation of Finland (from 1997),
Helsinki, Finland. Doctor of Medicine
(1981), Docent (1985). Specialist in
Obstetrics and Gynaecology (1984), and in
Gynaecological Endocrinology (1986). Has
worked previously as gynaecologist at the
Student’s Health Care Foundation in
Finland. President of The Finnish Society of
Pediatric and Adolescent Gynecology.
Member of several international
organisations in his field, for example,
Member of the Board and Secretary General
of The International Federation of Pediatric
and Adolescent Gynaecology. Has published
more than 100 articles about sexual health
and adolescent development.
Brandt, Pia, Registered Nurse (1981),
Midwife (1983), Sexologist (2000), Present
position: Research Nurse at the Sexual Health
Clinic of the Family Federation of Finland.
Previous positions: 1983-1987 City
Maternity Hospital, Helsinki; Family
Planning Policlinic.
Oy Algol Ab,
Pharmaceutical Division 1987-1992. University Central Hospital, University of Helsinki Surgery Clinic 1992-1994. The Family
Federation of Finland; Family planning Clinic
and Sexual Health Clinic 1994-1995, 1996 Cacciatore, Raisa, MD (1985) Helsinki
University, Specialist in Child Psychiatry
(1998). Present position: Expert Physician
at the Sexual Health and Family Clinics of
The Family Federation of Finland. Previous
positions: 1986 General Practitioner in
Maternity, Prevention and Child Health
Centres, City of Helsinki; Since 1989 Parttime Physician-Gynaecologist at The
Adolescent Out-Patient Clinic of
336
Folkhälsan, Helsinki; Since 1990 Part-time
Sexual Health Physician at the Adolescent
Out-Patient Clinic of Aurora Hospital, and
since 1999 the University Central Hospital,
Helsinki University. Since 1994 VicePresident of The Finnish Society of Pediatric
and Adolescent Gynecology. Helsinki University, Children and Adolescent Department.
Since 1994 Vice-President of The Finnish
Society of Pediatric and Adolescent
Gynecology. Has worked as an expert in
various tasks concerning adolescent sexual
health, maternity care and children’s
sexuality. Publications, for example, about
the sexuality of children and adolescents,
contraception, the first gynaecological
examination. Has published sexuality
education material for children and
adolescents (The Nine Steps of Sexuality,
with Korteniemi-Poikela, National Board of
Education, 2000).
Esko, Matti, Doctor of Theology, Secretary
General of the Centre for Family Issues of
the Evangelic-Lutheran Church of Finland,
family therapist (Advanced Special Level),
job supervisor and educator. Published a
dissertation Some Aspects of Fatherhood in
Boston, USA in 1985, several publications
and articles in Finnish.
Hiltunen-Back, Eija, MD (1988), Senior
Dermato-venereologist in the STD Clinic at
Helsinki University Central Hospital, 1996. Epidemiologist in the STD Clinic at the Aurora Hospital, 1988-1993, and at the National
Public
Health
Institute,1994-1998.
Publications on STD epidemiology in Finland.
Ilmonen, Tuisku, MSocSc (Psychology),
Training Director, The SEXPO Foundation,
Psychologist, worked as a Sex Counsellor and
Sex Therapist for over 20 years. Published
Yours with love (The National Association
of the Disabled 1987), Challenges of life
(Workers’ Educational Association WEA Finland 1990), The winged bridge-builder
(WEA Finland 1995).
Kaimola, Kari, BSc (Psychology), Clinical
Sexologist, Sex Counsellor, Trainer; sex
therapy (couples and individuals), sex
education and training for professionals in
health and social care, counselling and
training in rehabilitation (disabled and longterm patients), training in gay, lesbian,
bisexual and transgendered issues. Has
worked previously for the SEXPO
Foundation and Jyväskylä Polytechnic,
School of Health and Social Care; now
working in the Family Federation of Finland
(Sexual Health Clinic), the Organisation for
Sexual Equality (SETA), and the Transgender
Support Centre. Board Member of the
Sexological Association of Finland; Chair of
the Section on Sex Therapy in the Sexological
Association of Finland; Finnish representative
in the group of education in the Nordic Association of Clinical Sexology (NACS) .
Karkaus-Rikberg, Kaija, Journalist, editor
of the 30th Anniversary Book of the SEXPO
Foundation.
Kautto, Sari, Project Secretary in the Family
Planning 2000 project of STAKES (National
Research and Development Centre for
Welfare and Health).
Kiviluoto, Pirkko, MD, Specialist Physician
in General Medicine, Medical Adviser, The
Family Federation of Finland. Works as an
expert in sexual and reproductive health in the
International Affairs Department of the
Family Federation of Finland. Specialised in
the sexual health of aging people especially
while directing the Full Life Project of The
Family Federation of Finland, providing
information and services for aging people’s
sexual health and upheld the rights of aging
people.
Kosunen, Elise, MD, Specialist Physician in
General Medicine, has worked as an Assistant
Lecturer at the University of Tampere from
1991. Worked earlier as a practical physician
during 11 years in a hospital and a health-care
centre. Published her dissertation about
teenage pregnancies and contraception
(1996).
Lehtonen, Jukka, MSocSc (Sociology),
researcher, Department of Sociology, Helsinki University. Finalising his PhD
dissertation in sociology on heteronormativity in school practices.
337
Liinamo, Arja, MSc (Health Sciences),
Public Health Nurse, Lecturer in Health
Care. Works in research and development
projects at the Jyväskylä Polytechnic, Finland. Previously worked in planning tasks in
health education projects and as a researcher
in health study projects on young people as
well as in research and development projects
in sexual health. Articles on school health
education, especially in sex education.
Lähdesmäki, Seija O., MA, Counsellor of
Education for Biology at the National Board
of Education, Lecturer in Biology and
Geography. Several years of experience as
sex educator and trainer. Has edited
educational material for sex education, and
guidebooks supporting the curricula and the
work of teachers. Guidebooks on the
development of adolescents. Edited
(together with Osmo Kontula) the book How
to talk about sex with young people. At
present the Project Leader of the
Development Project of the Teaching of
Mathematics and Natural Science (LUMA).
Mäkelä, Marjukka, MD, MSc (Health
Services Research, McMaster University),
Specialist Physician, Research Professor at
the Finnish National Research and
Development Centre for Welfare and Health
(STAKES). Chairperson of the Expert Group
on Family Planning and Maternity Care from
1992.
Nissinen, Jussi, MSocSc (Social
Psychology), Psychotherapist and trainer in
the SEXPO Foundation. Co-edited (together
with Jukka Lehtonen and Maria Socada) a
basic textbook on gays, lesbians and
transgendered people (From a heteroassumption to pluriformity)(1997) for
students in polytechnics and universities. A
co-founding member of the Finnish
Organisation for Sexual Equality (SETA) in
1974, the Finnish Aids Council (1986) and
the Finnish Body Positive (FBP), The
Organisation for People with HIV/AIDS in
Finland (1989). Previously social worker/
counsellor of the Finnish Organisation for
Sexual Equality (SETA). Articles on lesbians,
gays, transgendered persons and HIV/AIDS.
Nurmi, Tuulikki, LicSocSc (Sociology), M.
Health Care, Senior Officer at the Ministry
of Social Affairs and Health. Previously
Secretary of the Working Group on Sex
Education of the Ministry of Social Affairs
and Health, Chair of the Eroticism and Health
Working Party of the Advisory Committee for
Health Education of the Ministry of Social
Affairs and Health. Member of various
committees, working groups and projects on
sexual topics of authorities and organisations.
Research on the need for sex education on the
population level and the resources of Health
Nurses for sex counselling.
Peltonen, Heidi, MSc (Health Science),
Public Health Nurse. Senior Adviser for
Health Education at the National Board of
Education of Finland, expert on health
promotion, health education and student
services. Many years of experience in
practical health education, and editing
guidebooks and materials supporting curricula
and the work of teachers in comprehensive
schools.
Raijas, Riitta, BA (Psych), Crisis Counsellor,
Rape Crisis Center Tukinainen [Support
Woman]. Previously working in the treatment
project for sex criminals and their victims of
the SEXPO Foundation. Training,
consultation, counselling, and guidance in
groups for women who have experienced
violence. Has participated in various working
groups and projects on violence against
women and children. Research (together with
Jaana Kauppinen) for a television
documentary about pedophilia The Secret We
Share. Has edited the report The treatment
of sex criminals and their victims (1996), and
co-edited (together with Taina Repo) the
project report The Rape Crisis Centre Tukinainen [Support Woman] Project 1993 –
1998, (1999). Research (Master’s thesis in
psychology) on rape trauma and recovery
(2000).
Ranki, Anna-Mari, MD, Professor of
Dermatology and Venereal Diseases,
Department of Dermatology and Venereal
Diseases, University of Helsinki and Helsinki University Hospital. Main research area has
been the HIV infection (AIDS), 1983-1998.
Principal Investigator in research projects
funded by the Academy of Finland and the
338
European Community. Visiting Scientist at the
National Institute of Health, National Cancer
Institute, Bethesda, Maryland, USA, in Dr. Robert Gallo’s laboratory, 1985-87. Research
areas have included the pathomechanism and
cancer association of genital human papilloma
virus infections. Member of the National
Advisory Board for Communicable Diseases.
Ritamies, Marketta, MSocSc, Senior
Researcher, The Population Research Institute
of The Family Federation of Finland.
Ritamo, Maija, MSocSc, Project Leader in
the Family Planning 2000 Project of the Finnish National Research and Development
Centre for Welfare and Health (STAKES).
Soramäki,
Pertti,
Psychologist,
Psychotherapist (Advanced Special Level),
Family and Sex Therapist. Previously Head of
the Tampere Clinic of the Family Federation
of Finland.
Stålström, Olli, MSc (Computer Sciences)
Helsinki University of Technology; Brown
University, USA, ; MSocSc (Sociology) University of Helsinki; PhD (Sociology of
Medicine) Kuopio University , Finland; Cambridge Upper Certificate of Proficiency in
English (English Literature). Founding
member, Finnish Organisation for Sexual
Equality (SETA) (1974) and Finnish AIDS
Council (1987). Studies and research in the
United States, Australia, France, Netherlands.
Senior Research Officer, South Australian
Health Commission 1986. Lecturer in
sociology, Kuopio University 1991–1995,
EU Research Officer, Finnish AIDS Council
1997-1998. Edited (with Kai Sievers) basic
book on lesbians and gays (Many faces of
love) in 1984 and on HIV/AIDS (1987); PhD
dissertation in sociology (The end of the
sickness label of homosexuality) (1997).
Over 40 articles on gays, lesbians and the
sociology of HIV/AIDS.
Articles, interviews and television
programmes. McMaster University, Hamilton, Canada 1973-74. Invited lecturer in
Sweden, England, Mexico and France.
Valkama, Sirpa, MSc (Health Sciences),
Principal Lecturer in the Family Planning
and Sexual Health, Jyväskylä Polytechnic,
School of Health and Social Care, Finland,
Sexual Counsellor. Many years of
experience in practical health education and
as sex educator and trainer. Worked in coordinating and planning national and
international sexual health education and
promotion projects. Board Member of The
Finnish Association of Sexology, Vice
President 1997-1999 in the Finnish Association for Sexology, a Finnish
representative in the Nordic Association of
Clinical Sexology (NACS).
Virtanen, Jukka, Clinical Sexologist, Eira
Hospital, Helsinki, Finland, Unit of Clinical
Sexology. Has studied clinical sexology at
many universities in Europe and USA and
specialised in sexological institutions in
Copenhagen, Paris, New York, San Francisco and London. Worked in many different
tasks from practical physician’s work and
medical research to TV and radio
programme production, educational
computer programme production and business consulting, lectured at dozens of
educational institutes, universities and
polytechnics in the health care and medical
sector. Senior Lecturer of Clinical Sexology
at Helsinki Polytechnic. Head of the Unit
of Clinical Sexology at Eira Hospital.
Member of Finnish Association for
Sexology, Chair of the Section of Sexual
Medicine of the Finnish Association for
Sexology, member of Nordic Association
for Clinical Sexology and World Association for Sexology.
Tukiainen, Sirkku, MSocSc (Social Work).
Psychotherapist (Advanced Special Level).
Chief trainer at Tampere University in Family
therapy training programmes. President of The
Finnish Family Therapy Association 19911998. Co-opted Member of The Board in
EFTA (European Family Therapy Association).
339
Authors
2001) ja Seksin trendit (Trends in sex)
(WSOY 2001). He is the president of the
Finnish Association for Sexology, a Full
Member of the International Academy of Sex
Research, and a Member of the Board of
Directors in The Society for the Scientific
Study of Sexuality.
The Editors
Lottes, Ilsa, Ph.D., is an associate professor
in the Department of Sociology and
Anthropology at the University of Maryland
Baltimore County in Baltimore, MD, USA.
Her research and teaching areas include
quantitative research methods, sexuality, and
gender. Her most recent research interest
focuses on sexual health issues from crossnational perspectives. She has published over
two dozen articles, mostly in refereed
journals and is active in the Society for the
Scientific Study of Sexuality, the European
Federation of Sexology, the World Association of Sexology and the International
Academy of Sex Research. Her decision to
edit a book about sexual health in Finland was
motivated by experiences during her
sabbatical leave from 1997 to 1999 in the
Department of Sociology at the University
of Helsinki.
Kontula, Osmo, docent, Ph.D., Senior
Researcher at The Population Research Institute, Family Federation of Finland. He has
studied sexual issues almost 20 years and has
written and edited alone and in collaboration
with others some 20 books of sexuality and
sexology. Among them are for example Nuorten seksi (Adolescent sexuality) (Otava
1987), Tietoiseksi - Tietoa ja näkemyksiä
seksuaalipolitiikasta (Information and views
of sexual politics)(Gaudeamus 1998), Sukupuolielämän aloittamisen yhteiskunnallisista ehdoista (Cultural terms of sexual
initiation) (Painatuskeskus 1991), Seksistä
- Kuinka puhua nuorille (How to give sex
education to adolescents) (Otava 1991), Suomalainen seksi (Finnish Sex) (WSOY 1993),
Seksiä lehtien sivuilla (Sex on the pages of
the press) (Painatuskeskus 1994), Matkalla
intohimoon (Along the way to passion)
(WSOY 1995), Sexual Pleasures (Dartmouth
1995), Intohimon hetkiä (Moments of
passion) (WSOY 1997), Seksuaaliterveys
Suomessa (Sexual health in Finland) (Tammi
2000), Moments of Passion (McMillan
Other Authors
Apter, Dan, MD (1975), Chief Physician &
Director of the Sexual Health Clinic of The
Family Federation of Finland (from 1997),
Helsinki, Finland. Doctor of Medicine
(1981), Docent (1985). Specialist in
Obstetrics and Gynaecology (1984), and in
Gynaecological Endocrinology (1986). Has
worked previously as gynaecologist at the
Student’s Health Care Foundation in
Finland. President of The Finnish Society of
Pediatric and Adolescent Gynecology.
Member of several international
organisations in his field, for example,
Member of the Board and Secretary General
of The International Federation of Pediatric
and Adolescent Gynaecology. Has published
more than 100 articles about sexual health
and adolescent development.
Brandt, Pia, Registered Nurse (1981),
Midwife (1983), Sexologist (2000), Present
position: Research Nurse at the Sexual Health
Clinic of the Family Federation of Finland.
Previous positions: 1983-1987 City
Maternity Hospital, Helsinki; Family
Planning Policlinic.
Oy Algol Ab,
Pharmaceutical Division 1987-1992. University Central Hospital, University of Helsinki Surgery Clinic 1992-1994. The Family
Federation of Finland; Family planning Clinic
and Sexual Health Clinic 1994-1995, 1996 Cacciatore, Raisa, MD (1985) Helsinki
University, Specialist in Child Psychiatry
(1998). Present position: Expert Physician
at the Sexual Health and Family Clinics of
The Family Federation of Finland. Previous
positions: 1986 General Practitioner in
Maternity, Prevention and Child Health
Centres, City of Helsinki; Since 1989 Parttime Physician-Gynaecologist at The
Adolescent Out-Patient Clinic of
336
Folkhälsan, Helsinki; Since 1990 Part-time
Sexual Health Physician at the Adolescent
Out-Patient Clinic of Aurora Hospital, and
since 1999 the University Central Hospital,
Helsinki University. Since 1994 VicePresident of The Finnish Society of Pediatric
and Adolescent Gynecology. Helsinki University, Children and Adolescent Department.
Since 1994 Vice-President of The Finnish
Society of Pediatric and Adolescent
Gynecology. Has worked as an expert in
various tasks concerning adolescent sexual
health, maternity care and children’s
sexuality. Publications, for example, about
the sexuality of children and adolescents,
contraception, the first gynaecological
examination. Has published sexuality
education material for children and
adolescents (The Nine Steps of Sexuality,
with Korteniemi-Poikela, National Board of
Education, 2000).
Esko, Matti, Doctor of Theology, Secretary
General of the Centre for Family Issues of
the Evangelic-Lutheran Church of Finland,
family therapist (Advanced Special Level),
job supervisor and educator. Published a
dissertation Some Aspects of Fatherhood in
Boston, USA in 1985, several publications
and articles in Finnish.
Hiltunen-Back, Eija, MD (1988), Senior
Dermato-venereologist in the STD Clinic at
Helsinki University Central Hospital, 1996. Epidemiologist in the STD Clinic at the Aurora Hospital, 1988-1993, and at the National
Public
Health
Institute,1994-1998.
Publications on STD epidemiology in Finland.
Ilmonen, Tuisku, MSocSc (Psychology),
Training Director, The SEXPO Foundation,
Psychologist, worked as a Sex Counsellor and
Sex Therapist for over 20 years. Published
Yours with love (The National Association
of the Disabled 1987), Challenges of life
(Workers’ Educational Association WEA Finland 1990), The winged bridge-builder
(WEA Finland 1995).
Kaimola, Kari, BSc (Psychology), Clinical
Sexologist, Sex Counsellor, Trainer; sex
therapy (couples and individuals), sex
education and training for professionals in
health and social care, counselling and
training in rehabilitation (disabled and longterm patients), training in gay, lesbian,
bisexual and transgendered issues. Has
worked previously for the SEXPO
Foundation and Jyväskylä Polytechnic,
School of Health and Social Care; now
working in the Family Federation of Finland
(Sexual Health Clinic), the Organisation for
Sexual Equality (SETA), and the Transgender
Support Centre. Board Member of the
Sexological Association of Finland; Chair of
the Section on Sex Therapy in the Sexological
Association of Finland; Finnish representative
in the group of education in the Nordic Association of Clinical Sexology (NACS) .
Karkaus-Rikberg, Kaija, Journalist, editor
of the 30th Anniversary Book of the SEXPO
Foundation.
Kautto, Sari, Project Secretary in the Family
Planning 2000 project of STAKES (National
Research and Development Centre for
Welfare and Health).
Kiviluoto, Pirkko, MD, Specialist Physician
in General Medicine, Medical Adviser, The
Family Federation of Finland. Works as an
expert in sexual and reproductive health in the
International Affairs Department of the
Family Federation of Finland. Specialised in
the sexual health of aging people especially
while directing the Full Life Project of The
Family Federation of Finland, providing
information and services for aging people’s
sexual health and upheld the rights of aging
people.
Kosunen, Elise, MD, Specialist Physician in
General Medicine, has worked as an Assistant
Lecturer at the University of Tampere from
1991. Worked earlier as a practical physician
during 11 years in a hospital and a health-care
centre. Published her dissertation about
teenage pregnancies and contraception
(1996).
Lehtonen, Jukka, MSocSc (Sociology),
researcher, Department of Sociology, Helsinki University. Finalising his PhD
dissertation in sociology on heteronormativity in school practices.
337
Liinamo, Arja, MSc (Health Sciences),
Public Health Nurse, Lecturer in Health
Care. Works in research and development
projects at the Jyväskylä Polytechnic, Finland. Previously worked in planning tasks in
health education projects and as a researcher
in health study projects on young people as
well as in research and development projects
in sexual health. Articles on school health
education, especially in sex education.
Lähdesmäki, Seija O., MA, Counsellor of
Education for Biology at the National Board
of Education, Lecturer in Biology and
Geography. Several years of experience as
sex educator and trainer. Has edited
educational material for sex education, and
guidebooks supporting the curricula and the
work of teachers. Guidebooks on the
development of adolescents. Edited
(together with Osmo Kontula) the book How
to talk about sex with young people. At
present the Project Leader of the
Development Project of the Teaching of
Mathematics and Natural Science (LUMA).
Mäkelä, Marjukka, MD, MSc (Health
Services Research, McMaster University),
Specialist Physician, Research Professor at
the Finnish National Research and
Development Centre for Welfare and Health
(STAKES). Chairperson of the Expert Group
on Family Planning and Maternity Care from
1992.
Nissinen, Jussi, MSocSc (Social
Psychology), Psychotherapist and trainer in
the SEXPO Foundation. Co-edited (together
with Jukka Lehtonen and Maria Socada) a
basic textbook on gays, lesbians and
transgendered people (From a heteroassumption to pluriformity)(1997) for
students in polytechnics and universities. A
co-founding member of the Finnish
Organisation for Sexual Equality (SETA) in
1974, the Finnish Aids Council (1986) and
the Finnish Body Positive (FBP), The
Organisation for People with HIV/AIDS in
Finland (1989). Previously social worker/
counsellor of the Finnish Organisation for
Sexual Equality (SETA). Articles on lesbians,
gays, transgendered persons and HIV/AIDS.
Nurmi, Tuulikki, LicSocSc (Sociology), M.
Health Care, Senior Officer at the Ministry
of Social Affairs and Health. Previously
Secretary of the Working Group on Sex
Education of the Ministry of Social Affairs
and Health, Chair of the Eroticism and Health
Working Party of the Advisory Committee for
Health Education of the Ministry of Social
Affairs and Health. Member of various
committees, working groups and projects on
sexual topics of authorities and organisations.
Research on the need for sex education on the
population level and the resources of Health
Nurses for sex counselling.
Peltonen, Heidi, MSc (Health Science),
Public Health Nurse. Senior Adviser for
Health Education at the National Board of
Education of Finland, expert on health
promotion, health education and student
services. Many years of experience in
practical health education, and editing
guidebooks and materials supporting curricula
and the work of teachers in comprehensive
schools.
Raijas, Riitta, BA (Psych), Crisis Counsellor,
Rape Crisis Center Tukinainen [Support
Woman]. Previously working in the treatment
project for sex criminals and their victims of
the SEXPO Foundation. Training,
consultation, counselling, and guidance in
groups for women who have experienced
violence. Has participated in various working
groups and projects on violence against
women and children. Research (together with
Jaana Kauppinen) for a television
documentary about pedophilia The Secret We
Share. Has edited the report The treatment
of sex criminals and their victims (1996), and
co-edited (together with Taina Repo) the
project report The Rape Crisis Centre Tukinainen [Support Woman] Project 1993 –
1998, (1999). Research (Master’s thesis in
psychology) on rape trauma and recovery
(2000).
Ranki, Anna-Mari, MD, Professor of
Dermatology and Venereal Diseases,
Department of Dermatology and Venereal
Diseases, University of Helsinki and Helsinki University Hospital. Main research area has
been the HIV infection (AIDS), 1983-1998.
Principal Investigator in research projects
funded by the Academy of Finland and the
338
European Community. Visiting Scientist at the
National Institute of Health, National Cancer
Institute, Bethesda, Maryland, USA, in Dr. Robert Gallo’s laboratory, 1985-87. Research
areas have included the pathomechanism and
cancer association of genital human papilloma
virus infections. Member of the National
Advisory Board for Communicable Diseases.
Ritamies, Marketta, MSocSc, Senior
Researcher, The Population Research Institute
of The Family Federation of Finland.
Ritamo, Maija, MSocSc, Project Leader in
the Family Planning 2000 Project of the Finnish National Research and Development
Centre for Welfare and Health (STAKES).
Soramäki,
Pertti,
Psychologist,
Psychotherapist (Advanced Special Level),
Family and Sex Therapist. Previously Head of
the Tampere Clinic of the Family Federation
of Finland.
Stålström, Olli, MSc (Computer Sciences)
Helsinki University of Technology; Brown
University, USA, ; MSocSc (Sociology) University of Helsinki; PhD (Sociology of
Medicine) Kuopio University , Finland; Cambridge Upper Certificate of Proficiency in
English (English Literature). Founding
member, Finnish Organisation for Sexual
Equality (SETA) (1974) and Finnish AIDS
Council (1987). Studies and research in the
United States, Australia, France, Netherlands.
Senior Research Officer, South Australian
Health Commission 1986. Lecturer in
sociology, Kuopio University 1991–1995,
EU Research Officer, Finnish AIDS Council
1997-1998. Edited (with Kai Sievers) basic
book on lesbians and gays (Many faces of
love) in 1984 and on HIV/AIDS (1987); PhD
dissertation in sociology (The end of the
sickness label of homosexuality) (1997).
Over 40 articles on gays, lesbians and the
sociology of HIV/AIDS.
Articles, interviews and television
programmes. McMaster University, Hamilton, Canada 1973-74. Invited lecturer in
Sweden, England, Mexico and France.
Valkama, Sirpa, MSc (Health Sciences),
Principal Lecturer in the Family Planning
and Sexual Health, Jyväskylä Polytechnic,
School of Health and Social Care, Finland,
Sexual Counsellor. Many years of
experience in practical health education and
as sex educator and trainer. Worked in coordinating and planning national and
international sexual health education and
promotion projects. Board Member of The
Finnish Association of Sexology, Vice
President 1997-1999 in the Finnish Association for Sexology, a Finnish
representative in the Nordic Association of
Clinical Sexology (NACS).
Virtanen, Jukka, Clinical Sexologist, Eira
Hospital, Helsinki, Finland, Unit of Clinical
Sexology. Has studied clinical sexology at
many universities in Europe and USA and
specialised in sexological institutions in
Copenhagen, Paris, New York, San Francisco and London. Worked in many different
tasks from practical physician’s work and
medical research to TV and radio
programme production, educational
computer programme production and business consulting, lectured at dozens of
educational institutes, universities and
polytechnics in the health care and medical
sector. Senior Lecturer of Clinical Sexology
at Helsinki Polytechnic. Head of the Unit
of Clinical Sexology at Eira Hospital.
Member of Finnish Association for
Sexology, Chair of the Section of Sexual
Medicine of the Finnish Association for
Sexology, member of Nordic Association
for Clinical Sexology and World Association for Sexology.
Tukiainen, Sirkku, MSocSc (Social Work).
Psychotherapist (Advanced Special Level).
Chief trainer at Tampere University in Family
therapy training programmes. President of The
Finnish Family Therapy Association 19911998. Co-opted Member of The Board in
EFTA (European Family Therapy Association).
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