Sexual Health and Wellbeing through the Life Course: Ensuring Sexual Health, Rights and Pleasure for All

Abstract

This commentary summarizes the context and positioning of sexual health, sexual rights and sexual pleasure, as three interlinked and indivisible aspects of sexual health and wellbeing (SH&W). In turn, sexual health is a major domain within broader sexual and reproductive health and rights (SRHR), both in its own right as a human right, and owing to the importance of good sexual health for ensuring good reproductive outcomes. Furthermore, SRHR is a necessary, core part of overall health, thus sexual health and wellbeing is a fundamental aspect of general health that is often overlooked or even denied for some. In this commentary, we utilize a life course approach to illustrate how the tripartite of sexual health, rights and pleasure manifest themselves with different interlocking linkages, and actively contribute to overall health throughout life. As other papers in this series attest, the linkages of pleasure with the right to and attainment of health has received inadequate attention to date, both within the scientific literature and in policy narratives.

Introduction: Defining and positioning sexual pleasure as a part of sexual health and wellbeing, broader sexual and reproductive health and rights, and physical and mental health for all

The Global Advisory Board (GAB) for Sexual Health and Wellbeing (SH&W) defines SH&W as being comprised of three essential, interlinked and indivisible elements: sexual health (including physical and psychosocial aspects), sexual rights and sexual pleasure (GAB, n.d.a). In turn, sexual health and wellbeing is integral to broader sexual and reproductive health and rights (SRHR) (Starrs et al., 2018). SH&W is thus core to overall health and wellbeing, a point worth noting as SH&W is sometimes neglected, ignored or even denied as being important for health.

In this commentary, we examine the essential contribution of sexual health, rights and pleasure to broader health, rights and wellbeing throughout the life course. Improving and maintaining SH&W is both intrinsic to the human right of everyone to enjoy the highest attainable standard of physical and mental health (Office of the UN High Commissioner for Human Rights (OHCHR), n.d.a), and is essential for achieving universal health coverage (UHC) (UNFPA, 2019; WHO, 2021). The overarching right to health has a broad conceptual basis, including many critical elements for SH&W, such as the right to: access education and information; freely make decisions about one's own health; exercise informed consent; maintain bodily integrity and autonomy; and stay free from ill-treatment and harmful practices (OHCHR, n.d.a).

The life course framework is useful for illustrating the dynamic and interactive way that sexual health, rights and pleasure contribute to SRHR and overall health from birth through to end of life. An appreciation of this sequential framework expands opportunities for clinical and life-enriching sexual health practices and interventions. Practical examples and challenges to utilizing this approach are discussed.

A developing appreciation of the intrinsic nature of sexual pleasure as part of sexual health and wellbeing

The Programme of Action of the 1994 International Conference on Population and Development (ICPD) included recognition that people should be able to enjoy “satisfying and safe sexual lives” (UNFPA, 2014). Published in 1997, and updated in 2014, the World Association for Sexual Health (WAS) endorsed a Declaration on Sexual Rights (WAS, 2014). The World Health Organization (WHO) has developed working definitions of sexuality, sexual health and sexual rights (WHO, 2002), which are summarized within the report of the Guttmacher-Lancet Commission on SRHR (Starrs et al., 2018). WHO’s definition of sexual health includes reference to “the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence”. A pleasure-based approach to SRHR was initially described by The Pleasure Project in 2004, and further defined in order to advocate for inclusion of pleasure within sexuality education, sexual health and safe sex programmes (The Pleasure Project, 2004). A pleasure-based approach is one that “celebrates sex, sexuality and the joy and wellbeing that can be derived from these, and creates a vision of good sex built on sexual rights” Singh and Philpott (2019). The GAB has also adopted a working definition of sexual pleasure as “the physical and/or psychological satisfaction and enjoyment derived from solitary or shared erotic experiences, including thoughts, dreams and autoeroticism. Self-determination, consent, safety, privacy, confidence and the ability to communicate and negotiate sexual relations are key enabling factors for pleasure to contribute to sexual health and wellbeing. Sexual pleasure should be exercised within the context of sexual rights, particularly the rights to equality and non-discrimination, autonomy and bodily integrity, the right to the highest attainable standard of health and freedom of expression. The experiences of human sexual pleasure are diverse and sexual rights ensure that pleasure is a positive experience for all concerned and not obtained by violating other people’s human rights and wellbeing” (GAB, n.d.b). Subsequently, the GAB linked sexual health, rights and pleasure, together using the “triangle” framework, to illustrate these three aspects as all being necessary for comprehensive sexual health and wellbeing (see Figure 1) (Gruskin et al., 2019).

Figure 1.

The sexual health, rights and pleasure triangle for sexual health and wellbeing. Source. The Global Advisory Board for Sexual Health and Wellbeing

More recently, the WAS endorsed their Declaration on Sexual Pleasure (WAS, 2019) – the focus of this series, further highlighting the importance of sexual pleasure as an integral element of SH&W. The Guttmacher-Lancet Commission has also acknowledged the inclusion of sexual wellbeing and pleasure considerations within SH&W, as part of the comprehensive SRHR package (Starrs et al., 2018). The latest international guidance on comprehensive sexuality education (CSE) (UNESCO et al., 2018), and associated out-of-school CSE guidance (UNFPA et al., 2020), note the importance of teaching about safe and satisfying sexual relationships, including about sexual pleasure, feelings and wellbeing.

Despite these advances, sexual pleasure has often been overlooked as a fundamental aspect of personal health, fulfillment, and expression of wellbeing. Promoting sexual pleasure is sometimes viewed as frivolous, rather than being core to human experience, and a natural part of life that most people relate to and wish to experience. Literature remains sparse on interventions to maintain sexual wellbeing and pleasure (Starrs et al., 2018). However, viewing sexual health purely from a disease perspective is counterproductive. A sex-affirmative approach that gets “serious about pleasure” opens up opportunities to attract greater numbers of individuals to seek out sexual and reproductive health (SRH) care. Young people are interested in receiving guidance on self-pleasure as a safe-sex behavior, and on building responsible, healthy attitudes toward sex, that will guide them throughout their lives. Older women, including those in their post-reproductive years, and persons with disabilities have been overlooked within sexual health practice to the point of being considered asexual, with greater attention needed to ensure access to satisfying and safe sexual lives for all including into older age. Many men will not attend reproductive care services, and the double stigma of HIV for gay men and other men who have sex with men, discourages their uptake of HIV services. However, many men are interested in maintaining their sexual health and function, and can be encouraged to access SRH care through sex-positive messaging provided in a non-judgmental manner.

Thus, shifting from a disease-oriented to a sex-affirmative, pleasure-inclusive approach to SH&W brings news ways to increase uptake of SRH care and promotion of sexual rights. These entry points can still provide an avenue for educating and treating people about some harmful sexual behaviors and consequences. We now need a comprehensive, evidence-based approach to integrating sexual health, rights and pleasure within all aspects of our public health and SRHR policies and programming, to maximize SH&W as part of good overall health through all stages of life. Below, we further illustrate how, throughout the life course continuum, this triangle of sexual health, rights and pleasure is essential for protecting and maintaining sexual health and wellbeing for all.

Pleasure inclusive practices

Building on the triangle framework for SH&W, a range of organizations have called for sexual pleasure to be more fully incorporated and accepted within a holistic definition of health. For over a decade, Love Matters (RNW Media) has been engaging young people both offline and online, using innovative content to talk about sexual pleasure, rather than focus on sexual dysfunction and disease. The Pleasure Project has increased visibility of sexual health, rights and pleasure concepts and interventions worldwide during major AIDS and SRHR conferences, including recently the International Conference on Family Planning (ICFP) 2018, Women Deliver 2019 and AIDS 2020 (Philpott et al., 2021). Similarly, UNFPA and The Condom Project have promoted positive benefits of safe sex through CONDOMIZE! global events and in-country campaigns (The Condom Project, 2009; The CONDOMIZE Campaign, n.d.). These efforts have drawn further attention to sexual pleasure, destigmatization of sexual behavior, and the importance of good SRHR. This year, ICFP 2021 will include a complete track on sexual health and pleasure.

Academics, health professionals, development partners and communities engaged in working to improve comprehensive SRHR, increasingly recognize the importance of enjoyable, satisfying and pleasurable sex for our wellbeing and physical and mental health. Clinical approaches and interventions are increasingly focusing on sex-positive and affirmative programming, including sexual pleasure, to build acceptance and uptake of sexual health services, and to improve sexual as well as reproductive health outcomes (Ford et al., 2019; Philpott et al., 2021).

Examples include the GAB and Share-net checklists for integrating sexual pleasure within SRH information/education, service delivery, advocacy and research programmes (GAB, 2020a, 2020b). The GAB has also developed a life course-based, online training course, which supports health professionals in discussing sexual rights and sexual pleasure in various situations, with clients from early adolescence through to post-menopause (GAB, 2020c). The Pleasure Project and Rutgers International have conducted research in how pleasure inclusive approaches have been adapted or instigated in sex education programmes in Ghana and Kenya (Singh et al., 2021). Plan International is also promoting sexual pleasure within clinical guidance (Plan International, 2020).

A diverse range of community and civil society organizations have embraced a pleasure-inclusive approach, primarily within HIV prevention programmes for gay, bisexual and other men who have sex with men, transgender people and sex worker communities, and on occasion within comprehensive sexuality education for adolescents and young people. For example, recently the University of Windsor (UWindsor) in Canada illustrates a growing trend for reducing young women’s risk of gender-based violence (GBV), and increasing their agency and autonomy, by open and frank discussion with young women regarding their sexual rights (UWindsor, 2020; Bielski, 2020). This includes acknowledgement of their desires, hopes and dreams in terms of future relationships – including fostering a healthy acceptance of the importance of pleasure throughout their sexual lives. Pleasure-inclusive sexual health practice now encompasses a wide range of interventions and services such as SRH self-care, education, sexual psychotherapy, counseling, virtual health, social media messaging and broader social and behavior change communication (The Pleasure Project, n.d.). This must be accompanied by broader social, cultural and legal changes to remove stigma, discrimination and harmful laws, and create environments that enable the realization of sexual health, rights and pleasure. Further research is needed on understanding these enabling and supportive environmental factors, and for identifying effective means for addressing cultural, legal and sometimes religious barriers to achieving these.

Exploring the protection, promotion and maintenance of sexual health, rights and pleasure throughout the life course

Different aspects of sexual health, rights and pleasure come to the fore and interlink throughout the life course. At birth, and during infancy and childhood, it is necessary to protect each individual’s future sexual health, rights and pleasure by ensuring and maintaining bodily integrity and autonomy. This enables the later, full capacity for each individual to realize their sexual rights, experience sexual pleasure, and enjoy sustained sexual and reproductive health. Examples include preventing female genital mutilation/cutting (FGM/C), as well as halting irreversible medical procedures on intersex infants and children, too young to participate with fully informed consent in the decision-making process (OHCHR et al., 2014).

Throughout childhood, protection of future sexual and reproductive health and rights is sustained by preventing child sexual exploitation and abuse (CSEA), and harmful practices. Ending child marriage and keeping children in school, may contribute to realizing the sexual rights, predominantly of girls, to choose their own relationship(s) and sexual partner(s), as well as the timing of marriage, sexual debut, and ultimately pregnancy if so chosen – as a subsequent but equally important reproductive right. Introducing comprehensive sexuality education (CSE) at an early stage, and within the context of building important life-skills helps to: protect young peoples’ sexual and reproductive rights; prepare them for their future sexual lives; and ensure their ability to understand and decide about issues relating to their sexual health, rights and pleasure. This includes building positive self/body image, challenging harmful gender norms, a positive approach to sexuality and pleasure, and enabling young people so they may pursue mutually respectful, consensual, safe, satisfying and pleasurable sexual relations, free from stigma and discrimination. Young people can learn about pleasure – what they themselves enjoy and how they can impart pleasure to others, while respecting the rights of others. Perceptions of sexuality and sexual behavior can be shifted away from widespread notions that sexual pleasure is primarily a male domain, to a more gender equitable and transformative framework of accepting pleasurable sexual relations for all sexually active persons.

Emerging perceptions of self, regarding gender identity and expression, and subsequent sexual orientation (collectively termed SOGIE), may appear early in childhood and adolescence, or sometimes not until later in life. It is essential for the health and wellbeing of all people that there is a safe and accepting, non-discriminatory cultural and social environment in which diverse SOGIE can be explored and enabled. All young people need support, and freedom under law, to explore, question and express their own innate sexuality, without fear of violence or rejection from family and society, or coercion and force of young people with diverse SOGIE into involuntary, unscientific and unfounded conversion therapies.

Progressing through the life course into adolescence and young adult years, many young people start to explore their sexual lives. They need support and guidance to learn to take responsibility for their sexual health and rights – to learn about their own bodies’ sense of pleasure, and to ensure all future partnered sex is consensual, pleasurable and without force, and to avoid unintended pregnancy, and acquisition or transmission of STIs including HIV. Young people need to know how to access, and feel comfortable in seeking SRH-related information, commodities, testing and treatment services, as their need arises. STIs, unintended pregnancy and GBV, including inter-partner violence and sexual violence, can all be reduced if sexually active persons are pre-equipped with knowledge, sexual and reproductive rights, positive attitudes to SH&W, and with access to commodities and services without the need for parental consent (McKinnon & Van-dermorris, 2019).

As people ready themselves to make reproductive choices, continued protection and maintenance of sexual health remains critical, both for enabling or preventing conception, and for ensuring positive, intended reproductive outcomes. The choice of if, when and how many children to have are also sexual and reproductive rights (WHO, 2006). For those wishing to have children, the acquisition of an STI without access to treatment can have significant adverse impact on all stages of reproduction from fertility through to neonatal morbidity and mortality, with vertical transmission of HIV requiring life-long treatment.

During later years, maintaining sexual wellbeing for older people remains important. A range of sexual health issues may need increased attention, including the arrival of menopause, sustaining sexual function, enabling people to pursue a satisfying, safe and pleasurable sex life, and preventing and managing cancers of the reproductive organs. Older people retain interest and derive pleasure from sexual activity, including during periods of declining health, rehabilitation or palliative care. Furthermore, the discovery of giving and receiving sexual pleasure may be learned and relearned throughout the life course, with an appreciation and understanding of this giving further opportunities to incorporate guidance on sexual pleasure into clinical practice and other approaches for maximizing wellbeing. The WAS Sexual Rights Declaration acknowledges the importance of sexual rights throughout life, including aspects of sexuality, SOGIE, eroticism, pleasure and intimacy. Sustained access to sexual health services and information, relevant to each stage of life, is thus necessary for all people throughout life (Barrett & Hinchliff, 2017).

Ensuring equity and justice as an enabling environment for sexual health and wellbeing

Importantly, SRHR include dimensions of equity and justice for all. Attainment of sexual health, rights and pleasure requires supportive and socially, culturally and legally enabling environments, free from harmful gender norms and discrimination. Many obstacles stand between individuals and their enjoyment of good SRHR, and specifically SH&W. These obstacles are interrelated and entrenched, operating at different levels – sometimes experienced during clinical care, impacted by health systems (Ford et al., 2021), and more broadly affected by societal and cultural values, attitudes and practices (OHCHR, n.d.b). Many structural and environmental factors directly relate to, and influence the ability of, individuals to realize their sexual rights and enjoy sexual pleasure. For example, cultural attitudes, expressed through social and gender norms and legal frameworks, impact on: the capacity for SOGI expression; individuals ability to engage safely in sex work; the access of people with disabilities to information and services they require to pursue a fulfilling sex life; the ability for individuals to partake in consensual sex outside of marriage; for adolescents to access confidential sexual health services; and for populations who are targeted by criminal laws, e.g. regarding sexual orientation, sex work, drug use or HIV criminalization, to safely access SRH services. The result is significant adverse health and social outcomes. For example, countries with laws criminalizing same-sex sexual activity have higher rates of HIV among gay men (Lyons, 2020), and stigma, discrimination and violence are widespread against marginalized populations. Within this context, sexual pleasure is a fundamental part of sexual rights. The possibility of having pleasurable and safe sexual experiences free of discrimination, coercion and violence is as equally important as ensuring good SRH throughout life (WAS, 2019).

Conclusion – Seizing the moment

The sexual health initiatives mentioned above illustrate how sexual and public health practitioners are harnessing multi-faceted interactions and interventions for promoting and protecting sexual health and wellbeing as an integral element of SRHR. Whilst the current COVID-19 pandemic has brought immense loss of life, suffering and hardship, it has also illustrated how innovation can occur with the introduction of novel ways of working and delivering health and social services. We have an opportunity to embrace change, and novel concepts and ideas, to “build forward better” – to establish new social norms and ways of being to deliver sex-positive interventions. Utilizing the triangle of sexual health, rights and pleasure for improving SH&W throughout the life course, creates a more holistic view of what SH&W means for each of us as sexual beings, sharing equal rights to satisfying, consensual, safe and respectful relationships, if we so choose, throughout life.

Finally, it is imperative that sexual, public health and development practitioners increase understanding about sexuality, sexual health and wellbeing, and the meaning of sexual rights and pleasure for different individuals and populations, and in different contexts. Of note, Wood et al. caution us to avoid becoming prescriptive about a “pleasure imperative” (2019), that is, not make sexual pleasure a normative requirement of sexual activity – accepting and understanding the diverse reality and individuality of people’s lives. At the same time, we do need enforceable human rights standards for ensuring universal awareness, acceptance and access to sexual health and wellbeing, including choice and enjoyment of consensual sexual relations, and accountability for realization of this. The global health community can increase dialogue and advocacy to better illustrate the diverse experience and realization of sexual rights and sexual pleasure. Collectively we can work to change widely-held negative community attitudes toward promotion of sexual health and wellbeing. This will help build more supportive and enabling environments, to facilitate and ensure satisfying and safe sexual lives for all.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Conflict of interest statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.