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International Journal of Sexual Health logoLink to International Journal of Sexual Health
. 2021 Sep 21;33(4):572–586. doi: 10.1080/19317611.2021.1955802

Sexual Pleasure and Healthcare Settings: Focusing on Pleasure to Improve Healthcare Delivery and Utilization

Jessie V Ford a,✉, Faysal El Kak b, Debby Herbenick c, Christopher Purdy d, Stephen Tellone a, Marlene Wasserman e, Eli Coleman f
PMCID: PMC10903612  PMID: 38595777

Abstract

Sexual pleasure is best attained through facilitating access to the highest standard of health. Today global data show a persistent high burden of sexual health issues. Yet, pleasure remains a sensitive, stigmatized, and unspoken topic in healthcare services. This article examines how to incorporate a value for pleasure into healthcare services, grounded in the assumption that pleasure is a fundamental reason why people have sex and that acknowledging this can support people in creating safer, more pleasurable sexual experiences. Drawing upon examples from the literature and field experience, this article explores how to better address pleasure in healthcare settings.

Keywords: Sexual pleasure, healthcare settings, sexual health, pleasure, sexual health promotion, sexuality

Introduction

Despite increased calls for attention to sexual pleasure in healthcare settings (Ford et al., 2019; Gruskin et al., 2019; Starrs et al., 2018), clinicians and healthcare systems have been slow to incorporate such a focus. The World Health Organization (WHO) recognizes sexual pleasure as fundamental to sexual and reproductive health and rights (SRHR) (WHO, 2017). A growing body of research finds that a focus on sexual pleasure complements existing sexual health efforts and improves outcomes (Hogben et al., 2015; Philpott et al., 2017; Scott-Sheldon & Johnson, 2006; Starrs et al., 2018). Yet, pleasure remains a sensitive, stigmatized, unspoken topic in healthcare services. This article examines how to incorporate a value for pleasure into healthcare services, grounded in the assumption that pleasure is a fundamental reason why people have sex and that acknowledging this can support people in creating safer, more pleasurable sexual experiences (Gianotten, 2021; Meston & Buss, 2007).

In 2016, the Global Advisory Board for Sexual Health and Wellbeing (GAB) developed the following working definition of sexual pleasure and its link to sexuality, sexual rights, health, and freedom of expression (Ford et al., 2019; GAB, 2016):

Sexual pleasure is the physical and/or psychological satisfaction and enjoyment derived from solitary or shared erotic experiences…. Sexual pleasure should be exercised within the context of sexual rights, particularly the rights to equality and nondiscrimination, autonomy and bodily integrity, the right to the highest attainable standard of health and freedom of expression.

As referenced in this definition, sexual pleasure is best attained through facilitating access to the highest standard of health. Sexual rights—supported through broader policies, norms and structures—are critical enablers to support sexual pleasure (Gruskin et al., 2019; Kismödi et al., 2017; Starrs et al., 2018). Building upon this definition, in 2019, the World Association of Sexual Health (WAS) officially recognized theimportance of sexual pleasure through the release of their Declaration on Sexual Pleasure at the Mexico City World Congress (WAS, 2019).

Decades of research show that many people of all backgrounds and interests—including adolescents, refugees, and those undergoing palliative care—are interested in discussing sexuality and sexual pleasure (Fuzzell et al., 2016; Perz et al., 2013). However, many healthcare providers and the institutions in which they practice are not adequately trained, prepared, or supported to take on this task (Ford et al., 2013; WHO, 2011). Current medical, nursing, and healthcare education does not adequately teach providers to address sexual health, let alone pleasure (Coleman et al., 2013; El-Kak et al., 2004; Parish & Clayton, 2007). Healthcare professionals report increasing time constraints, client load, and even fear of litigation, which all make it difficult to discuss and include sexual pleasure in healthcare services, interventions, and treatment. Stigma continues to be an obstacle for providers and their clients to effectively discuss pleasure (Fuzzell et al., 2016; Higgins & Hirsch, 2007; Kingsberg et al., 2019; Knerr et al., 2008; Perz et al., 2013)

Beyond provider-client interactions, many structural challenges relevant to sexual pleasure remain globally—including settings that are low in resources, international health crises such as war, mass migration, natural disasters, and global pandemics, as well as entrenched forms of gender inequality including high rates of sexual violence, child marriages, and female genital mutilation. These immense challenges may obfuscate the need for attention to sexual pleasure. Moreover, perceptions of pleasure and expectations around it differ across sociodemographic and sociocultural factors including gendered, racial, political, geographic, religious, and economic lenses (Starrs et al., 2018; Tumwine et al., 2020). Thus, addressing pleasure in relation to healthcare services is not only extremely sensitive, it is complex and difficult. Creative ways of educating and training healthcare practitioners, clients, and systems about the importance of pleasure need to be formulated (Tumwine et al., 2020).

This article discusses the intersection between pleasure and the health services that people seek, need and use. We explore best practices and identify current gaps where healthcare professionals and clients could be better educated, enabled, and supported within health systems to discuss pleasure in a productive and compassionate manner (Coleman et al., 2013; WHO, 2011). We argue that a value for sexual pleasure could expand opportunities for clients and their providers to talk about how they can maintain or enhance their sexual lives in pleasurable ways, even against the backdrop of sometimes challenging health conditions and treatments for those conditions.

Background

Why do we need to address sexual pleasure in healthcare? Simply put, pleasure is one of the primary reasons for sexual engagement and therefore must be incorporated into any discussion of related healthcare issues. Global data show a persistent high burden of sexual health issues including sexually transmitted infections (STIs), unintended pregnancy, unsafe abortion, sexual violence, and sexual dysfunction. Over 350 million people are diagnosed with an STI annually and over 200 million women currently lack access to modern contraception (S. Singh et al., 2010; WHO, 2015b). Some 70 million women terminate pregnancies each year (Starrs et al., 2018) and an estimated 38 million people continue to live with HIV (UNAIDS, 2020). Studies show that as many as 70% women have experienced physical and/or sexual violence from an intimate partner in their lifetime (WHO, 2013). Consequences of this violence include higher rates of depression and anxiety as well as physical and emotional effects.

In terms of chronic disease, research shows that common chronic illnesses such as diabetes mellitus, cardiovascular diseases, cancer diagnosis and treatment, and psychiatric disorders can lead to sexual dysfunction, and individuals who experience sexual dysfunction report worse self-rated health (Lewis et al., 2010; Sabanciogullari et al., 2016). Adverse Childhood Events (ACE’s) can profoundly impact adult sexuality—leading to higher rates of sexual dysfunction—as a result of consequent mental and physical illnesses. In other words, Developmental Trauma Disorder is a major factor that leads to sexual dysfunction (DePierro et al., 2019; Van der Kolk, 2005). Likewise, declines in sexual frequency are associated with higher rates of depressive symptoms and lower life satisfaction in older adults (Jackson et al., 2019). In other words, pleasure is important to people and to their health and well-being. Pleasure is a central motivation for sexual behavior (Gianotten, 2021; Meston & Buss, 2007). Yet, adverse outcomes—with emphasis on fear, risk, disease, and death associated with sexual behavior— remain the focus of much sexual and reproductive healthcare (Ford et al., 2017; Philpott et al., 2017; Purdy, 2019; Singhal & Rogers, 2003). The more pleasurable aspects of sexuality are infrequently addressed in healthcare settings.

When pleasure is included in sexual and reproductive healthcare interventions, these efforts have been primarily fueled by private sector actors—not the public sector. For instance, pharmaceutical companies and Fast-Moving Consumer Goods (FMCG) advertising, as well as NGOs, have been the main drivers on products and conversations around pleasure to date (Maddison, 2010; Tiefer, 2000). There have been a few exceptions to this (e.g., more pleasure-inclusive national health plans in Europe (Clutterbuck et al., 2018; Wellings & Johnson, 2013), which we describe in our best practices section. However, for the most part, healthcare systems and the providers within them have been slower to respond to global calls for the inclusion of pleasure and sexuality in sexual and reproductive health. In this article, we argue that focusing on the pleasure incentive (e.g., the orgasm premium1) is a sound and effective way to increase people's use of and the effectiveness of sexual and reproductive health services (Ford et al., 2019; Philpott et al., 2006, 2017; Purdy, 2011, 2019). In what follows, we draw upon examples from literature and our own field experience to explore how to better address pleasure in healthcare settings and how to strengthen sexual and reproductive health services with pleasure as a built-in component.

Methods

In order to identify current best practices related to the inclusion of sexual pleasure in healthcare delivery and service utilization, we conducted a literature review that included a series of formal and informal searches using combined terms of “sexual pleasure;” and “healthcare/health care” in PubMed and google scholar (Figure 1). We also identified resources through correspondence with colleagues. Initial literature searches identified over 1,400 articles, websites and resources (802 from google scholar, 584 from PubMed, and roughly 50 from colleagues). We narrowed down to 60 items after first retaining examples if (a) the abstract and or summary/overview included a focus on healthcare settings, services or utilization; (b) the example had relevance to sexual pleasure and sexual health. Next, two raters independently read each of these 60 remaining resources and judged fit for final inclusion based on the GAB definition of sexual pleasure above. We considered a resource aligned with the sexual pleasure definition if raters independently judged that its content overtly incorporated the possibility for sexual pleasure to contribute to sexual health and wellbeing. If both raters agreed, the study was retained. When the raters disagreed, both raters met to achieve consensus. Our final search resulted in 21 examples that we highlight as best practices.

Figure 1.

Figure 1.

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Inclusion flowchart of sexual pleasure in healthcare articles/resources.

After reviewing these resources, we identified four thematic areas of best practices that each pertain directly to the WAS Declaration on Sexual Pleasure (WAS, 2019). The Declaration urges all governments, private and public institutions, media, and society at large to integrate sexual pleasure into “service delivery,” “research,” “health promotion,” and “education,” in all parts of the world. Thus, building from the Declaration, we organized best practices into the following four areas: Sexual Health Education, Service Delivery, Research and Interventions, and Health Promotion.

Results

Sexual health education best practices

To identify best practices related to sexual pleasure in terms of education, we examined resources that aimed to address pleasure for healthcare providers and their clients. The Pleasure Project, for instance, includes a pleasure map highlighting a range of smaller organization globally that encompass best practices related to sexual pleasure. In this section, we first review three excellent resources for providers. Next, we examine a series of examples for self-education for individuals and couples, which have relevance to practitioners in healthcare settings who can direct clients to these sites. While this list is not exhaustive, it exemplifies how pleasure is a rich and fertile paradigm in which to educate clients as well as providers about healthy love, relationships and sexuality, as well as the link between wantedness, consent and pleasure. Such an approach adds another lens to the usual authoritarian and fear-based messaging in much sexuality education.

  • WHO Brief Sexuality Communication for healthcare providers. The difficulty of sexuality-related communication frequently comes up as a key barrier to effective care in research and at consultations. While clients consistently express a desire to talk about sexuality (including pleasure) in clinical settings, providers report being underprepared and lacking skills to provide comprehensive sexual and reproductive health care and services. There is also a general lack of clarity in the field regarding the role of primary care for discussions of sexuality. In response, WHO developed this brief sexuality communication document for healthcare providers, which includes the right to sexual pleasure as a motivator toward sexual health behavior (WHO, 2015a). This guide, which is easily downloaded online, gives practitioners, policymakers, and decision-makers in training institutions and health settings advice for how to support providers in addressing sexual health concerns in primary care. It heavily emphasizes the need for sexuality and pleasure to be included in sexual and reproductive health (SRH) services.

  • SRH Provider Training Toolkit and Pleasuremeter. In 2018, the Global Advisory Board for Sexual Health and Wellbeing (GAB) developed a training toolkit that incorporates sexual pleasure into SRH services, counseling, and education with clients (GAB, 2018). The toolkit introduces the Pleasuremeter, a tool designed for to guide providers through sexual history taking by exploring individual-level experiences around sexual pleasure with recognition of GAB’s working definition of sexual pleasure (Castellanos-Usigli & Braeken-van Schaik, 2019).

  • National Coalition for Sexual Health. This organization has developed guides for healthcare providers and clients/beneficiaries to encourage helpful conversations regarding sexual health, which put particular emphasis on talking about pleasure and sexual satisfaction. These materials can be retrieved from their website.

  • A Woman’s Touch Sexuality Resource Center. Run by two women—a healthcare professional/sex educator and a counselor—this innovative resource center and website presents in inclusive approach to achieving pleasure and providing access to health information while linking physical and mental health to sexuality and sexual health. Educational brochures provide detailed information about subjects ranging from a good sex diet, healthy sexuality after cancer, sex-toys, post-partum sexuality, etc.

  • OMGyes. As another excellent example of pleasure-focused education, this website was developed as a resource for women, men, and couples—or—“for everyone who cares about women’s sexual pleasure and wants to make it even better.” Among other things, the site includes a menu of evidence-based techniques and tactics (e.g., detailed demonstrations) for enhancing women’s sexual pleasure (Hensel et al., 2021). The site includes extensive information for self-education including current research conducted on sexual pleasure, with an emphasis on women’s pleasure and information on women’s health as well.

  • Make Love Not Porn. This user-generated social sex platform is a first-of-its-kind online resource designed to be a sex-positive and reaffirming; it has been greatly featured in entrepreneurial circles and popular press. What makes the site unique is that it is human-curated (i.e., videos of sex made by users are uploaded and shared). There are different components to the website including social media and philanthropic aspects, however, its focus is on separating the “porn world” from the “real world” through displaying user-made videos. The website includes information on the website that complements the purpose of the platform—promoting communication, body image, individual autonomy, empowerment. The website also shares blogs with stories from external sources for current issues such as a brief overview of porn education and the impacts of porn replacing sex education.

What’s missing in sexual health education best practices

While the aforementioned resources represent a series of bold, accessible best practices, several things are missing. First, existing resources still lack substantive guidance for how to make it “easier” for healthcare professionals to talk about pleasure and sexuality. Likewise, there remains a predominant focus on heteronormative, cisgender, and coupled individuals in these resources. More attention could be given to the link between sexual dysfunction and sexual pleasure. For instance, does pleasure function separately from sexual function issues such as pain, erection, lubrication, desire, and arousal? Likewise, resources are needed to address both use of clinical use of pharmaceuticals to enhance pleasure as well as the role of pharmaceuticals in impairing pleasure.

Pleasure is diverse within individuals and across interpersonal circumstances, cultures, religions, race/ethnicities, socioeconomic groups, genders, sexual orientations, trauma histories, and disabilities (Ford et al., 2019; Fortenberry, 2013; Gruskin et al., 2019). For example, “consensual non-monogamy,” is one of the fastest growing relationship structures(Stephens & Emmers-Sommer, 2019). While these online resources are a good start, they are largely tailored to audiences from the global north. Resources for developing countries and knowledge seekers who are less enabled are absent (ISHQ, 2016; Sekyiamah & Grant, 2009).

In marginalized communities, having knowledge about pleasure may be particularly important as it can increase confidence in claiming the right to pleasure and enforcing consent. For instance, knowing that pleasure is part of intimacy, sexuality, and love might encourage young people to seek more knowledge. People in the majority of the world now have access to cell phones, creating an unprecedented opportunity to promote-pleasure inclusive empowerment and education resources for individuals, couples, and communities.

Service delivery best practices

Creating a value for pleasure in healthcare delivery is not an easy or straightforward task, but one which requires ongoing commitment across broader health systems, hospitals, clinics, offices, refugee camps, etc. In an effort improve healthcare service delivery, we sought to identify current toolkits, guiding documents, and strategies that support the inclusion of pleasure in healthcare services provision. This list is not intended to be exhaustive. Rather, it aims to showcase several ways to address pleasure in healthcare services across diverse settings.

  • Fulfil!. In 2016, the International Planned Parenthood Federation (IPPF) and WAS developed Fulfil!, a document developed to guide policy-makers, healthcare providers, and educators in a global context to implement young people’s sexual rights in practice (IPPF, 2016). This document takes the perspective that sexual pleasure impacts health and wellbeing by shaping the way young people experience and express their sexuality. A value for pleasure is integrated throughout Fulfil!, which employs a three-step model for healthcare provision. Step one maps out a foundation for how to provide care that honors young people’s sexual rights through a focus on sexuality (including pleasure), gender, autonomy, and empowerment. Step two presents an implementation guide with a focus on freedom of sexual expression, access to SRHR services, comprehensive sexuality education, protection from sexual violence, and remedies and redress (e.g., through access to the legal system). Step three presents a series of specific case studies related to “contentious situations related to sexual rights” (e.g., how to support a 14-year old transgender girl who is looking to access hormone therapy). Each case includes step-by-step decision-making models to support the implementation of young people’s sexual rights.

  • The United Kingdom Department of Health’s Framework for Sexual Health Improvement in England. In 2013, the UK Department of Health and cross-governmental bodies developed a guidance document of best practices, providing information and evidence-based strategies to enable sexual health service providers to improve sexual health services comprehensively (Cassell, 2013; FPA, 2015; NHS, 2013). The document includes the following key principles for health providers and commissioners: prevention as priority, leadership, a focus on outcomes, broadening the scope of sexual health (e.g., linkage to other health behaviors and chronic illnesses), effective commissioning of services, and addressing vulnerable populations. This framework serves as an outstanding example for how a holistic national strategy can “set out our ambitions for good sexual health” and wellbeing, positioning sexual pleasure as key factor that influences outcomes.

  • Women’s Integrated Sexual Health (WISH). Housed at the American University of Beirut Medical Center (AUBMC), the WISH Program incorporates pleasure into a broader conceptualization of sexuality and sexual health through a training curriculum for providers focused on clinical service, counseling services, and providing care to women (and men) to promote sexual health and normalize and address sexual health problems. WISH is the first program in the Middle East region to advocate for pleasure in their research, talks and on social media. The current WISH medical school curriculum includes a module solely focused on pleasure.

  • Self-care movement. Today, an increasing amount of “service delivery” (e.g., counseling, information seeking) is often done without a provider. This new and growing “self-care movement” comprises an important dimension of healthcare service delivery, providing new opportunities to include pleasure as part of individually-tailored care. A few examples of this kind of self-care include the US based company Roman (a digital health clinic for men) that includes a focus on sexual wellness and dysfunction. The PSI “pleasure bot” funded by FCDO/UK government brings honest, validated answers to all sexual health questions 24-hours a day right to a mobile phone (Oduor & Muchiri, 2020). Likewise, “Find my Method,” a website with an international focus, includes information that addresses contraceptive options, reproductive health, other sexual health issues including pleasure.

What’s missing in service delivery best practices

While there is extensive research documenting the lack of preparedness among healthcare systems, policy and decision-makers to address sexuality and sexual pleasure (Gruskin et al., 2019) research suggests this change is possible if it is preceded with substantive familiarization with pleasure as a term and concept. Despite the presence of some of these resources, there is still not substantive guidance for to how to make it “easier” for healthcare systems to incorporate pleasure and sexuality. Increased normalization of the concept and focused trainings can help, but the question remains as to how to best build a value for pleasure into health systems, institutions, and interpersonal encounters.

Another current gap involves diverse contexts and individuals. Sexual pleasure could be better integrated within specific cultural and social contexts using culturally appropriate language to describe pleasure based on historical, political, and cultural heritage. Diverse contexts include but are not limited to low-resource settings, religious contexts, humanitarian settings where people experience many sociopolitical barriers to care and access to contraception, testing, and other sexual health services etc. Likewise, more attention to sexual pleasure among lesbian, gay, bisexual, trans, queer (LGBTQ) and non-binary people is also needed. While there is no silver bullet solution, more research that identifies ways to include pleasure in specific healthcare settings and contexts would help build the literature base (e.g., adolescent health clinics in the global north may be a starting point) (Stewart et al., 2016; Wingood et al., 2013), activities that integrate pleasure in creative, community-supported ways show promise, but complementary evaluations of these efforts are also necessary.

Research and interventions best practices

At present, there is a great need for more pleasure-inclusive scientific research and interventions in healthcare settings (Ford et al., 2019; Scott-Sheldon & Johnson, 2006). There is also a need for more work examining the effectiveness of interventions that do address pleasure. A focus on pleasure in healthcare research can help combat negative attitudes, prejudice, gender inequality, health disparities, etc. with tailored and equitable interventions. For instance, by addressing clients in terms of their motivations for sex and pleasure, interventions can be better tailored to meet people “where they are at" rather than where they ought to be (Fondell, 2009; A. Singh et al., 2020). Likewise, more formalized healthcare systems need to recognize and implement biomedical adherence strategies (e.g., the distribution of PrEP adherence interventions) with focus on addressing individual desires as well as powerful structural factors that hinder the effectiveness of healthcare intervention and research. Ideally, such studies and interventions would incorporate pleasure into their design and implementation, using socioecological approaches (to identifying risk and protective factors at multiple levels, e.g., individual, interpersonal, structural) (Ford et al., 2019; Hatzenbuehler, 2016; Philpott et al., 2017).

Below, we highlight research studies that included pleasure in their study design and analysis. One way to do this, for example, involved identifying how pleasure influences individual initiation of biomedical interventions (e.g., use of PrEP, hormonal contraceptives, TasP, microbicides, etc.). Other strategies for integrating pleasure into research involved addressing and deconstructing stigmatizing attitudes around the pursuit of pleasure in certain communities (e.g., among MSM). Existing studies suggest that attention to sexual pleasure may strengthen and complement research efforts by improving our understanding of what drives attitudes and sexual behavior (Hogben et al., 2015; Mustanski et al., 2015; Scott-Sheldon & Johnson, 2006).

  • Hormonal contraception and female pain. This study explored sexual function and behaviors of women on hormonal (535 women) vs. nonhormonal contraceptives (566 women) (Smith et al., 2014). Analyses show that women using hormonal contraception methods experienced significantly lower rates of arousal (including less pleasure, discomfort, fewer orgasms, and less sexual activity; all statistically significant). This study cautions providers to engage more directly with pleasure and to counsel clients on the potential link between hormonal contraception and sexual function (e.g., by valuing clients’ experiences with sexual pleasure and working with them to test or switch contraceptive methods) while also informing clients of other products such as lubricants to offset negative side effects.

  • Sexual pleasure for Black MSM. With focus on creating equitable access to biomedical interventions among Black MSM, Boone and Bowleg (2020) conducted a critical review of social and behavioral science research, analyzing 668 articles on Black men and sexuality. These studies showed a disproportionate focus on negative, adverse effects and risk around Black MSM’s sexual health. Attention to sexual pleasure was virtually non-existent, illustrating a historic legacy of systemic racism and the erasure of sexual pleasure among Black people. In particular, healthcare systems/providers were apt to implicitly or explicitly hold stereotypes about Black MSM and hypersexuality. These “toxic stereotypes” profoundly impacted clinical care, e.g., Black MSM’s sexualities were categorized as problematic rather than human; providers were more likely to focus on risk and negative outcomes, rather than positive affirming ones. TasP and PrEP are described as methods to facilitate agency and sexual expression, enabling Black MSM to pursue sexual relationships that enhance intimacy and sexual pleasure. With PrEP use (intermittently, “on demand,” or daily), MSM can gain control over their HIV risk during anal sex for enhanced intimacy and pleasure.

  • Male Sex Workers. In order to increase healthcare access and effectiveness of HIV interventions for male sex workers (MSWs) in Mexico City, Edeza et al. (2020) sought to understand motivations for risk behaviors and to explore opportunities for PrEP use as prevention. Sexual pleasure was an important reason why participants had condomless anal sex with clients. There was little knowledge of PrEP among participants, but great interest in PrEP uptake—particularly because it would support the pursuit of pleasure. Despite awareness of HIV risk, PrEP adherence rates may be strong barriers to effective HIV prevention; although attention to pleasure may be one way to support adherence.

  • Drug use, sexual pleasure, and HIV prevention. Piyaraj et al. (2018) focused on the association between using methamphetamine to enhance sexual pleasure and HIV infection among MSM in Bangkok, Thailand. HIV incidence was higher among MSM that reported using methamphetamines specifically for sexual pleasure. By accounting for sexual pleasure and drug use, the researchers were able to build a model that better identified the MSM most vulnerable to new HIV infection. Recommendations include: Decriminalizing recreational drug use, increasing prevention, treatment, and recovery interventions (e.g., PEP, PrEP, drug dependence services) among MSM who use drugs for sexual pleasure, and recognition of new, important, subcultural patterns and sexual behaviors among MSM.

  • Health Education at a Young Men’s Clinic. This study by Armstrong et al. (2009) involved a multicomponent sexual health education intervention among 157 predominately low-income, Latino and/or African American young men during their initial visit at a New York City Clinic. The first component of the intervention, involved a presentation/group discussion on sexual health topics in the waiting room, including how to increase pleasure during condom use. This was followed by individual counseling sessions and medical exams. During these sessions, providers responded to negative feelings about condoms by providing tips, such as putting lubricant on the inside of the condom, while reinforcing the protection condoms offer. Analyses of pretest and posttest knowledge showed a significant increase in knowledge (0.17 pretest vs. 0.81 posttest). Findings suggested that including pleasure in SRHR health education can mitigate negative feelings toward essential barrier methods such as condoms.

What’s missing in research and interventions best practices

Existing research and interventions have made great strides to better measure and incorporate pleasure in recent decades. Yet, as referenced above, there is still a lack of explicit recognition of the tension between pleasure and condoms (as well as other forms of contraception) and how to best address this tension in research and practice efforts. For example, researchers, as well as participants, often implicitly assume that condoms affect or destroy pleasure without fully exploring why (Philpott et al., 2006). As noted above, the impact of structural factors—such as drug laws or gender norms that devalue women’s pleasure, resulting in limited ability to negotiate sexual health, choice and gender-based violence—are often overlooked. Interventions with sex workers highlight questions around public regulation of sex and its intersections with pleasure advocacy (e.g., when promotion of condoms, free services, etc. clashes with sex work laws). In such instances, sexual rights—and the social and legal structures that enable pleasure—become relevant for policy and law as well as health service provision.

Finally, Smith et al. (2014) call for more research on how to best train and educate service delivery providers and how to evaluate whether such training is effective. For instance, how do we help providers address pain/discomfort during sex while also supporting effective contraception and STI prevention? Importantly, healthcare providers play a unique role not just in the provision of medical advice and treatment, but also the linkage between information and treatments that impact pleasure (e.g., lubricant, engaging in adequate stimulation, incorporating sex toys, etc. to address negative side effects of condoms or hormonal contraceptives). Additionally, healthcare providers play a crucial role in correcting the spread of misinformation around topics such as HIV transmission based on sero-status while promoting access to sexual pleasure and sexual empowerment(Calabrese et al., 2021).

Health promotion best practices

Health promotion and communication strategies such as social marketing also have the potential to support or hinder the ability for a targeted population to access and use health services and products (Wingood, 1997) . Below, we identify a series of health promotion strategies and campaign marketing examples that promote sexual pleasure within sexual and reproductive health.

  • Pleasure inclusive advertisements. Video advertisements can be marketed in many ways. One fantastic example of a pleasure-inclusive video is a recent DKT Ghana video that openly portrays intimacy and pleasure between a series of heterosexual couples (e.g., a pair that is dating, a married couple with children). In this campaign, the ad for Lydia intrauterine device (IUD) contraceptives is titled “You Decide” promoting sexual agency for women as a form of protection and family planning.

  • Boldly marketed devices. A bold, humorous Durex vibrator commercial from the UK portrays a scenario of a man whose parents are visiting. When he tells his female partner that he has made sandwiches using the cucumber from the refrigerator, her eyes widen. This is followed by the line “Isn’t it time you got a Vibrator” and a link to Durex Play. IKEA does something similar in their iconic commercial of a child playing with a vibrator followed by the line “Tidy up.” Both these examples from Durex and IKEA normalize vibrator use and pleasure more broadly. Likewise, in their unmatched, provocative, and exciting website, Lelo’s homepage positions pleasure as being “in your hands.” The site uses images of pleasure (e.g., models in underwear) to market sexual health products including condoms, lubricants, vibrators, masturbatory devices, etc. The advertisements use colloquial, everyday language. For example, they sell products that help discover g-spots, enhance oral sensations, and are “clitorally mind-blowing.” Importantly, Lelo advertisements also integrate messages around prevention consisting of “#Staysafe Deals” to promote sexual health and behavior while staying safe during the COVID-19 Pandemic.

  • Prudence products. Owned by DKT Brazil, Prudence Products uses a pleasure-inclusive approach to advertise products—primarily condoms—on social media platforms. These products are marketed in versatile, current ways, such as a Brazil-themed condom at World Cup soccer competitions. On Instagram, Prudence markets items using erotic and exciting images (e.g., a bra being unhooked). During Carnival celebrations in Brazil, a campaign encouraged people to “engage in all of the sexual activity they please, if they do so safely” across multiple social media outlets. As part of this effort, DKT distributed over 100,000 Prudence condoms in taxis, restrooms, steam-rooms, on beaches, and at Carnival parties and advertised on street cars in all major cities.

  • Marketing strategies for condom manufacturers. Condom sales increased significantly during the height of the HIV pandemic and have declined since the advent of treatment of HIV with protease inhibitors. Further developments of PrEP and PEP, Long-acting reproductive technologies, and greater access to emergency contraception have also been associated with declining condom use (Holt et al., 2018; Kortsmit et al., 2019). In an effort to overcome these developments and to maintain market share, manufacturers have incorporated messages about pleasure as components of condom education and disease prevention marketing efforts. This has included technological improvements in condom design (size and shape), construction (materials) and addition of improved quality lubrication and sensations all designed to improve users’ perception of pleasure. In addition, these manufacturers have moved into the sales of vibrators, lubricants and other sexual pleasure enhancement products. They have also been creative in overcoming barriers of access in retail markets and media advertisements. For example, when network TV has not allowed condom advertisements, condom manufacturers have placed engaging content on YouTube and other social media. In addition, their advertisements have focused on situating condoms as a broader part of sexual enjoyment.

  • Love matters. As one of the RNW Media’s Flagship SRHR Programs, Love Matters in India and China, develops and supports health promotion that “breaks the silence around sex, cuts through shame and stigma, and proudly talks about pleasure.” Love Matters uses the internet to bring young people pleasure-inclusive information on sex, relationships, love, bodies, contraception, STI/HIV prevention and “everything in between.” The program has been expanded to a Love Matters Global Network with a tailored focus to different places. For example, with the goal of empowerment of young people in China, Love Matters China uses evidence-based, culturally competent SRHR information to inform campaign ads across mainstream media. Overall, RNW media is a pleasure positive resource that considers pleasure is an essential element of SRHR.

  • Health promotion of HIV microbicides. In an extensive review of health promotion strategies related to microbicides, Sidibe et al. (2014) find a greater effectiveness of health messaging that communicates the benefits of microbicides such as increased pleasure, intimacy and sexual empowerment, in addition to HIV prevention (Sidibe et al., 2014). Efforts were more successful when they conceptualized sexual pleasure within broader structural, social, and cultural contexts. For instance, marketing microbicides as a form of lubricant to increase pleasure helped increase product utilization. Yet, health promotion was also successful when it recognized that women do not want to seem too eager for sex (e.g., fear of association with sex workers). Overall, pleasure-inclusive health promotion was most successful with a complementary focus on both pleasure and HIV-prevention when promoting microbicides.

What’s missing health promotion best practices

While this list of health promotion best practices is not exhaustive, it offers a glimpse of the potential for pleasure to be leveraged to increase the utilization of sexual health products and services. While some health promotion efforts display sexual pleasure in diverse ways, there is a heavy focus on heteronormative and cisgender people and on couples and intimate relationships. There is little focus on sex occurring outside of committed relationships. Thus, existing efforts could be improved with a better recognition of the diversity of pleasure (across partnerships, age-groups, body types, disability, HIV sero-status, etc.). Some existing pleasure-inclusive efforts have been put forward by the private sector actors and non-governmental organizations, however there remains a deficit of how and why pleasure is advertised with little to no initiation from the public sector (Gurevich et al., 2017; Higgins & Hirsch, 2007).

Moving forward, greater attention to pleasure from governments, international bodies, and academics would help extend understandings of the best way improve sexual health. Keeping in mind the difficultly of tailoring sexual health advertisements across target populations, existing health promotion efforts could be strengthened with more guidance on how to best integrate pleasure into social media advertisements without creating backlash (e.g., associating the product with sex work). Health promotion efforts appeared most successful with a dual focus on the benefits of the product (e.g., increased sexual pleasure) as well as its effectiveness (e.g., HIV prevention). It will also be important to distinguish between using pleasure-enhancing erotic images to promote health and the significant social and individual issues of commercial pornography (e.g., objectification, exploitation of pornography actors, pornography addiction). As with many commercial products, the benefits and harms are complexly interweaved in social structures (gender and poverty in particular) and with individual vulnerabilities.

Discussion

Throughout this paper, we sought to identify best practices for sexual pleasure in four thematic areas: Sexual Health Education, Service Delivery, Research and Interventions, and Health Promotion. The best practices we included present opportunities and challenges for healthcare systems and settings to include a value for pleasure. The opportunities are clear—there are existing interventions and strategies that are pleasure-inclusive and can be implemented across a wide range of settings. Challenges remain such as the recognition of how to deliver these interventions within diverse contexts where people experience sociopolitical barriers to care including limited access to contraception, testing, and other sexual health services. Despite the presence of pleasure-inclusive services, barriers will remain for many people and ongoing efforts will be needed to expand care in all types of settings.

Perhaps the biggest challenge at present is the state of the evidence-base for pleasure interventions in healthcare. While we have some data that individual programs or interventions are effective, the body of these interventions as a whole has not been systematically evaluated to establish effectiveness (Castellanos-Usigli & Braeken-van Schaik, 2019; Kantor & Lindberg, 2019; Philpott et al., 2021; Scott-Sheldon & Johnson, 2006; Weitkamp et al., 2020). At present, the Scott-Sheldon and Johnson (2006) research synthesis is probably the most systematic effort to date (though it is limited in scope with its focus on eroticization). Notably, Scott-Sheldon and Johnson (2006) do find a lot of positive effects, ranging from small to moderate. They conclude that safer sex eroticization is indeed beneficial for reducing sexual risk. Yet, the current state of the evidence-base for pleasure in healthcare settings remains a real limitation. It is not so much that individual programs or interventions are not effective, but rather that the body of these interventions as a whole have not previously been examined systematically. While a lot of individual interventions will report their effectiveness, it remains difficult to assess how much of this effectiveness is due to the inclusion of pleasure on its own (Philpott et al., 2021). In theory, a systematic review or meta-analysis could provide an overall estimate of effectiveness for the entire intervention but extrapolating how much of that is due to pleasure would probably depend on the mechanism (i.e., time and emphasis placed on pleasure; design and implementation, etc.). In particular, research is needed to identify the best ways to incorporate pleasure for different outcomes and populations. This remains a pivotal area for future research in healthcare settings.

In a 2014 commentary titled “Celebration Meets Caution,” Higgins (2014) discusses recent hype related to long-acting reversible contraception (LARC) and the benefits and problems with these technologies. While some argue that LARC use could singlehandedly end unintended pregnancies and their associations with poverty, these recent efforts tend to over-emphasize LARC methods, failing to acknowledge how poor women of color may experience LARC promotion through a lens of racism and eugenics (Higgins, 2014). Higgins concludes by arguing for a reproductive justice approach that makes LARC affordable and accessible while also respecting women’s decisions not to use them, to have LARC removed when they desire, and to determine for themselves how contraception and pregnancy fit into their lives. Efforts to include sexual pleasure in healthcare services might do well to follow a similar justice approach. This would involve supporting people to integrate pleasure and healthcare seeking on their own terms and recognizing cultural and structural factors that contribute to SRHR disparities, despite increasing access to these types of services.

As outlined above, global SRHR disparities have been notoriously difficult to overcome and making headway will require ongoing, collaboration that complements successful traditional efforts with bolder, sex-positive efforts that value sexual rights, sexual health and sexual pleasure. Pleasure is a diverse, personal experience. Individuals likely know how pleasure fits into their lives better than broader healthcare systems and providers (Ford et al., 2019; Higgins et al., 2008; Hull, 2008; Stewart et al., 2016). Thus, education and training will be most effective when they support healthcare providers to deliver pleasure-inclusive care with the knowledge and skills to do so in a competent, compassionate, client-centered manner (Coleman et al., 2013; Higgins, 2014; WHO, 2015a). Integrating a focus on sexual pleasure in healthcare will remain a difficult, sensitive, and incremental process. Future research and programmatic work should focus on how to formulate multi-faceted methods for involving pleasure across individual, interpersonal, and structural levels in health systems (Ford et al., 2019; Philpott et al., 2017). Overall, the best practices we have reviewed here support our argument that that a value for sexual pleasure could expand opportunities for clients and providers to talk about how they can engage in sexual behaviors that they find pleasurable amidst health conditions, treatments for those conditions and broader contexts.

Note

1

In advertising, premiums are free promotional items such as toys, gifts, rewards etc. that consumers receive from purchasing a product. In the case of the orgasm premium, the pleasure/orgasm become the added bonus of the condom or health service product (Purdy, 2019).

Disclosure statement

No potential conflict of interest was reported by the author(s).

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