Abstract
This article provides technical guidance on the content, meaning, and application of the World Association of Sexual Health (WAS) Declaration on Sexual Pleasure to various stakeholders and practitioners working in the area of sexuality, sexual health, and sexual rights. A growing body of work shows that sexual pleasure is integral to broader health, mental health, sexual health, well-being and rights and indeed can lead to improvements in health. Yet, more research is needed to identify the best ways to incorporate sexual pleasure to achieve sexual health for different outcomes and populations. In the first part of this article, we deconstruct each statement from the WAS Declaration on Sexual Pleasure and provide key evidence from the literature supporting these statements. In the latter part of the article, we provide guidance on how to include sexual pleasure as a fundamental part of sexual health and sexual rights work. We include a series of case studies and highlight key actions and principles for advocacy, implementation, and quality assurance in terms of law and policy, comprehensive sexuality education, health care services and dissemination of knowledge. This technical document seeks to inspire our partners and collaborators to embark on a journey toward a pleasure-based approach to sexual health and sexual rights. Our hope is that the literature, guidance and case studies provided here can ignite ongoing advocacy and collaboration to embrace sexual pleasure in all settings.
Keywords: Pleasure, sexual attitudes and behaviors, sexual health promotion, sexual politics, sexual rights, sexual satisfaction, sexuality education, sexuality
Introduction
A Declaration on Sexual Pleasure was issued by the World Association for Sexual Health (WAS) on September 11, 2021 at the General Assembly of the 26th World Congress of Sexual Health in Cape Town, South Africa (World Association for Sexual Health [WAS], 2021). This Declaration was the result of several years of preparation and study, including proceedings from an expert consultation held in May 2019 and input from participants at the Mexico City World Congress of Sexual Health in October 2019, where a WAS Congress Declaration on Sexual Pleasure was released (WAS, 2021). Following the 2021 World Congress, a task force worked on reviewing the evidence base and developing ideas for how this Declaration could be implemented.
The WAS Declaration on Sexual Pleasure highlights the importance of placing sexual pleasure in the forefront of sexual health promotion, comprehensive sexual health education and services and sexual health policy - reinforcing the concept of pleasure as an essential ingredient of sexuality, sexual health and sexual rights as defined by the WHO (2002, 2006, 2010 (See terms bolded for emphasis in Table 1)). This article seeks to bolster the WAS Declaration on Sexual Pleasure by situating it in the literature and linking it to action.
Table 1.
WHO Working Definitions.
| Sexual health |
| Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. |
| Sexuality |
| Sexuality as a central aspect of being human encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors. |
| Sexual rights |
There is a growing consensus that sexual health cannot be achieved and maintained without respect for, and protection of, certain human rights. The working definition of sexual rights given below is a contribution to the continuing dialogue on human rights related to sexual health.
|
| The responsible exercise of human rights requires that all persons respect the rights of others. The application of existing human rights to sexuality and sexual health constitute sexual rights. Sexual rights protect all people’s rights to fulfill and express their sexuality and enjoy sexual health, with due regard for the rights of others and within a framework of protection against discrimination. |
Today, the entitlement to experience sexual pleasure and enjoy sexuality has been supported by the formal recognition of human rights standards related to sexuality and sexual health by international, regional and national human rights, judiciary and legislative bodies (Cornwall et al., 2008; Hawkes, 2014; Miller et al., 2015). These standards call for autonomous informed decision making around sexuality, reproductive choices, the accessibility of sexual health information and education, and the ability to express sexuality without discrimination, violence or stigma either socially or within institutional or governmental settings (Kismödi et al., 2017). For instance, the WAS affirms in their Declaration of Sexual Rights that sexuality is an integral part of the personhood of every human being, regardless of whether that person chooses to reproduce (WAS, 2015). In addition, WAS has advocated for the notion that promoting sexual health and rights (including pleasure) is essential to attaining sustainable human development goals such as the eradication of poverty and achieving a peaceful world (WAS, 2008).
The structure of this article includes the full WAS Declaration on Sexual Pleasure (see Table 2) followed by an explanation of the key concepts on which the Declaration is based. This is followed by an implementation section that provides guidance on how this Declaration can be operationalized using case studies and The Pleasure Project’s© “Pleasure Principles” (2021, p. 24) to illustrate this guidance. We hope that this article will further inspire a pleasure-based approach to sexual health and make this call to action more accessible and applicable in the field.
Table 2.
WAS Declaration on Sexual Pleasure.
| In recognition that sexual pleasure is a fundamental part of sexual health and sexual rights, the World Association for Sexual Health: |
| RECOGNIZES that: |
| Sexual pleasure is the physical and/or psychological satisfaction and enjoyment derived from shared or solitary erotic experiences, including thoughts, fantasies, dreams, emotions, and feelings. 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 well-being. 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. 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 well-being*. |
DECLARES that:
|
URGES all governments, international intergovernmental and non-governmental organizations, academic institutions, health and education authorities, the media, private sector actors, and society at large, and particularly, all member organizations of the World Association for Sexual Health to:
|
Adapted from the Global Advisory Board for Sexual Health and Wellbeing (2016). Working definition of Sexual Pleasure. Retrieved from https://www.gab-shw.org/our-work/working-definition-of-sexual-pleasure/
Addressing a blind spot to make sexual health promotion more effective
The importance of the WAS Declaration on Sexual Pleasure is highlighted by the critical need to ensure that investments in sexual health are as effective as possible and not only address adverse sexual health outcomes but ensure sexual well-being, health and pleasure for all.
In both low and high-income settings, we are faced with a persistent high burden of sexual health issues including sexually transmitted infections (STIs), unintended pregnancy, unsafe abortion, sexual violence and sexual dysfunction. These problems are particularly acute in the developing world, where they present major obstacles to meaningful progress in alleviating poverty, morbidity and mortality. The COVID-19 pandemic has only ensured that this dis-equity is more acute (Sladden et al., 2021). Discriminatory norms and practices, structural inequality and gender-based violence compound these problems (Starrs et al., 2018). The profound impact of HIV/AIDS in Africa exemplifies how specific sexual norms and practices, in the absence of widespread and sustained evidenced-based sexual health promotion efforts, facilitated an epidemic that has taken millions of lives and directly contributed to extreme poverty (Gupta, 2000; McKinnon & Vandermorris, 2019; WAS, 2008). A more holistic view of sexual health and sexual rights can make programs and services more effective (Ford et al., 2019; Gruskin et al., 2019; Starrs et al., 2018; WHO, 2011).
Taken together, the range of sexual and reproductive health problems facing the global community is extensive and their impact on human lives is significant. Global data show over 350 million people are diagnosed with an STI annually and a million people have an STI at any one time (WHO, 2015, 2019). Over 200 million women currently lack access to modern contraception (Singh et al., 2010). Some 70 million women terminate pregnancies each year (Starrs et al., 2018) and an estimated 38 million people continue to live with HIV (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2020). As many as 70% of 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.
These statistics do not capture the full burden of ill health, however, or lack of sexual well-being and sexual justice. Gender-based violence and gynecological conditions such as severe menstrual problems, urinary and fecal incontinence due to obstetric fistula, uterine prolapse, pregnancy loss and sexual dysfunction—all of which have major physical, emotional, and social consequences—are greatly underestimated in global estimates (Starrs et al., 2018; WAS, 2008). WHO estimates unsafe sex to be in the top five most important global risk factors for health in several regions of the world (Murray et al., 2020). Unsafe sex is the biggest risk factor for untimely death of young women globally (WAS, 2008).
Moreover, 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. 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).
A renewed focus on sexual pleasure as part of sexual health and sexual rights can help achieve progress toward alleviating this global burden of sexual health outcomes. The more that sexual health promotion embodies the totality of human sexuality by educating, counseling and assisting people in ways that incorporate and recognize pleasure, the more likely these programs will correspond to the reality of the human experience, ultimately having the most impact on global health and international development.
Why has sexual pleasure been a blind spot?
For many decades the primary medical, academic and cultural discourses on sexuality have been dominated by concerns about disease, risk, danger, sin and shame (Fine & McClelland, 2006; Gianotten, 2021). In turn, sexual desire, passion and pleasure have been viewed as dangerous—as a threat to the social, political and religious order (Ford et al., 2019; Hart & Wellings, 2002; Hull, 2008; Kantor & Lindberg, 2020). This legacy of a negative interpretation of sexual pleasure, particularly if it is experienced in a context outside of marriage, procreation or heterosexuality, is still with us today and continues to hinder the recognition of pleasure in sexual health promotion efforts in many parts of the world.2021
From a historical vantage point, medical science has, particularly in the Western world, exercised considerable authority over sexuality since the second half of the 19th century where sexual pleasure was often seen as pathology. As Hart and Wellings (2002) suggest, “The long tradition of representing illness as a punishment for sin was continued when sexual behavior was medicalized and transformed into morbidity” (p. 896). For example, masturbation, homosexual desire and overt sexual interest, particularly if expressed by women were, until quite recently, seen as symptomatic of psychiatric illness and perversion.
Although contemporary medicine and some religious institutions have turned the corner in recognizing the positive and beneficial aspects of sexual expression, many remnants of a focus on the negative outcomes of sexual expression remain today. Discourse about sexuality is almost exclusively about risk and danger: disease, infection, abuse, addiction, violence, dysfunction, pedophilia, teen pregnancy, etc. (Ford et al., 2017; Satcher et al., 2015; Singh et al., 2021). While these problems are of great importance, they reflect the tendency of the sexual health promotion field, as well as policy makers, to focus on negative sexual and reproductive health outcomes. Far less prominent in health promotion policy and programming is a sustained recognition that sexual pleasure is an elemental aspect of human sexuality.
It is important to note that many diverse cultures have strong traditions of affirming sexual pleasure. For example, within Brazilian culture, the concept of tudo or “everything” refers to the world of erotic experiences and pleasures (Francoeur & Noonan, 2004). Sects of Buddhism have historically stressed the importance of pleasurable sexual unions for spiritual awakening (Needham et al., 1976; Ruan, 1991). Islam has a history of affirmatory statements in the Koran (El Feki & Rehman, 2016). In Turkey, grassroots efforts have emphasized sexual pleasure as a woman’s human right in recent decades (Yilmaz & Willis, 2020).
What is sexual pleasure?
As outlined in the WAS Declaration, the meaning of sexual pleasure is complex, multifaceted, and diverse (Global Advisory Board for Sexual Health and Well-being [GAB], 2016). That is, feelings around sexual pleasure are subjective, socially-constructed and may include diverse sexual activities (Ford et al., 2019; Reis et al., 2021; Rye & Meaney, 2007). Biological components of pleasure include the responses of organs in the nervous system, hormones and genital blood flow (Trejo-Pérez & Diaz-Loving, 2017). While past conceptualizations have emphasized the physiological and/or genital aspects of sexual pleasure (Abramson & Pinkerton, 2002), more recent understandings conceptualize pleasure as having emotional, cognitive, physical and mind-body connections, such as “losing oneself” (Goldey et al., 2016). Sexual pleasure has been described as the enjoyment derived from sexual interaction, including a variety of positive feelings arising from sexual stimulation (Philpott, Knerr, & Boydell, 2006; Reis et al., 2021).
Why is sexual pleasure important?
Pleasure is important to people and to their health and well-being. Cross-cultural research has found 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). For instance, the mutual sharing of sexual pleasure has been shown to increase bonding within relationships. As Tepper (2000) writes with respect to the neglected rights of people with disabilities to enjoy their sexuality, “Pleasure is an affirmation of life…It can add a sense of connectedness to the world or to each other. It can heal a sense of emotional isolation so many of us feel even though we are socially integrated” (p. 288). To the extent that a society is concerned with the well-being of individuals and stability of couples, families and communities, it is in the interests of policy makers to recognize the importance of sexual pleasure and to implement sexual health promotion programs that address sexual pleasure as fundamental to individual and partnered health and well-being.
Sexual pleasure has repeatedly been linked to positive overall health and sexual health outcomes. A White Paper published by the Planned Parenthood Federation of America (PPFA, 2007) in cooperation with the Society for the Scientific Study of Sexuality extensively catalogues the scientific evidence demonstrating the health benefits of sexual expression. More recent systematic literature searching and meta-analyses consistently find evidence that pleasure-inclusive interventions reduce sexual risk taking and improve sexual health (Becasen et al., 2015; Hogben et al., 2015; Philpott, Larsson, et al., 2021; Scott-Sheldon & Johnson, 2006). Sexual pleasure has also been linked to improved cardiovascular health, perinatal health, overall health and mental health (Gianotten, 2021; Laan et al., 2021; Reis et al., 2021).
Taken together, the studies cited suggest that solo and/or partnered sexual activity is associated with improved health, longevity, immunity, pain management, self-esteem and a reduction in stress. Sexual pleasure also helps to cement the kinship structure of the couple relationship, contributes to overall happiness in people’s lives (whether they are in partnerships or not) and is associated with aspects of overall health. Seen in this way, sexual pleasure is not frivolous or unnecessary: it is essential.
Therefore, to effectively contribute to health and well-being, global efforts cannot disaggregate the essence of human sexuality into components, addressing some and ignoring others (Hull, 2008; Ivankovich et al., 2013). Instead, efforts must be made to engage with sexuality as an aspect of a whole person with attention to sexual pleasure. Sexual pleasure is a missing link between informed decision-making and sexual health (Ford et al., 2019; Fava & Fortenberry, 2021; Gruskin & Kismödi, 2020; Kantor & Lindberg, 2020; Larsson, 2019).
In the face of what have increasingly been called “the global sex wars”—attacks against sexuality, reproductive freedom, gender equality, and self-determination, as well as growing political extremism and conservatism—now, more than ever, is the time to address sexual pleasure as a sexual right and a key correlate to sexual health and sexual well-being (Gruskin & Kismödi, 2020; Logie et al., 2021). The ways that people seek and experience pleasure are complex and positioned within broader structural, social, cultural, economic and political issues that extend beyond the usual responsibilities of health providers (Gruskin & Kismödi, 2020). For instance, some research finds that sexual pleasure is more strongly related to men’s motives for sex compared to women (Meston & Buss, 2007; Tang et al., 2012); yet these differences result from broader gender inequality including women’s historical lack of access to pleasure (Fahs, 2014; Reis et al., 2021) and explain why past research has given primacy to men’s sexual pleasure (Higgins & Hirsch, 2007). Such inequalities around pleasure have implications for public health practice, policy and law and, ultimately, for how individuals relate to their bodies, build relationships and live their lives. In other words, failing to address sexual pleasure perpetuates gender inequalities. To ignore pleasure in global research, programmatic and policy efforts is unrealistic and disconnected from the realities, aspirations and concerns of people.
Explication of the principles of the declaration on sexual pleasure
1. The possibility of having pleasurable and safe sexual experiences free of discrimination, coercion, and violence is a fundamental part of sexual health and well-being for all
The first principle of the Declaration positions the possibility of sexual pleasure as a fundamental element of sexual health and well-being (GAB, 2016; Starrs et al., 2018). To implement this principle of the Declaration, we encourage partners to review the aforementioned WHO (2002) working definition of sexual health, which remains the most cited definition of sexual health globally as “a state of physical, emotional, mental and social well-being related to sexuality,” including “the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” (WHO, 2006). This notion of sexual health includes sexual pleasure. It implies a positive approach to human sexuality, whereby the purpose of sexual health care should be the enhancement of life and personal relationships, not merely the provision of care related to reproduction or sexually-transmitted diseases (Coleman, 2007; Satcher, 2001).
In this vein, sexual health is inextricably linked to both physical and mental health (WAS, 2008; WHO, 2006). Just as physical and mental health problems can contribute to sexual issues and dysfunction, those issues and dysfunctions can contribute to physical and mental health problems. The possibility of sexual pleasure is a fundamental part of this cycle. That is, sexual health includes the ability to integrate sexuality into life, derive pleasure from it and to reproduce if one so chooses. It includes the ability to comprehend and weigh the risks, responsibilities, impacts, and outcomes of sexual actions and to practice abstinence when appropriate (Satcher, 2001; WHO, 2006). Since its inception, the 2002 WHO working definition of sexual health has challenged government policies and public health approaches to not only avoid problems or illness related to sexuality and reproduction, but to promote pleasure as an essential ingredient of well-being (Coleman, 2007).
In recent years, practitioner organizations have done work to build their own definitions of sexual health that include sex-positive, pleasure-based approaches. The International Planned Parenthood Foundation (IPPF) defines sex positivity “as an attitude that celebrates sexuality as a part of life that can enhance happiness, bringing energy and celebration. Sex-positive approaches strive to achieve ideal experiences, rather than solely working to prevent negative experiences. At the same time, sex-positive approaches acknowledge and tackle the various risks associated with sexuality, without reinforcing fear, shame or taboo surrounding the sexualities of young people” (IPPF, 2016). Likewise, The Pleasure Project (2021) pushes forward the IPPF sex-positive approach by defining a pleasure-based approach to sexual health as one that “celebrates sex, sexuality and the joy and well-being that can be derived from these and creates a vision of good sex built on sexual rights. It focuses on sensory, mental, physical, and sensual pleasure…and multi-faceted desires (The Pleasure Project, 2020).
Implementing the first principle of the Declaration on Sexual Pleasure means recognizing and appreciating sexual pleasure as part of sexual health and also fostering the possibility of safe sexual experiences free from discrimination, coercion, and violence. The Pleasure Project’s “Pleasure Principles” (2021, p. 24) embody this idea with “Be Positive” as a core principle, urging partners to “remember that when done right and when you feel safe, sex can be good for you.” This means that when working on sexual and reproductive health and rights, practitioners try to view pleasure as essential to sexual well-being. By focusing on sexual pleasure as a highly significant, if not primary motivating factor for sexual behavior, our efforts can better address sexual motivations, acknowledge cultures of sexuality and reduce of stigma to support better sexual health, grounded in sexual rights.
This grounding in sexual rights is key because experiences of coercion, discrimination and violence are detrimental to healthy relationships and associated with shame, negative sexual self-esteem, sexual risk behaviors, lower sexual satisfaction, decreased sexual pleasure and impaired sexual function (Cook et al., 2005; DiMauro et al., 2018; Fava & Fortenberry, 2021). Such infringements—including discrimination, coercion, and violence—are far too common. A broad literature identifies adverse impacts of specific kinds of discrimination and trauma, such as sexual assault and poverty (Fava & Fortenberry, 2021; Satcher et al., 2015; Starrs et al.; 2018). These experiences are pervasive globally and tend to co-occur (Anda et al., 1999; Dube et al., 2003). For instance, the WHO World Mental Health Survey found that 70.4% of respondents had experienced a form of lifetime trauma—including physical violence, sexual violence, war, and/or accidents—with the average number of traumas being 3.2 (Kessler et al., 2017).
Compared to men, women are much more likely to have their sexual rights violated and women experience a well-documented pleasure gap (Armstrong et al., 2012; Hull, 2008; Laan et al., 2021; Laumann et al., 2006; Reis et al., 2021). Thus, to foster the possibility of pleasure, it is imperative to put structures in place that prevent and address infringements on sexual rights. When such infringements have occurred, it is essential to promote healing (Gruskin et al., 2019). Positive adaptations are possible and can be fostered by supportive communities alongside healing clinical and public health services (Infurna & Jayawickreme, 2019). For instance, research suggests that sex-positive and pleasure-inclusive interventions may be particularly effective with vulnerable populations who have experienced trauma (Hogben et al., 2015).
A growing body of research shows that sexual pleasure is important to people—as a driver of sexual behavior, an outcome of fully developed sexuality and an element of overall health (Ford et al., 2019; Philpott et al., 2017; Philpott, Larsson, et al., 2021; Scott-Sheldon & Johnson, 2006; Singh et al., 2021). Therefore, integrating sexual pleasure into health promotion, education, policy and programs is essential to a broader public health imperative (Edwards & Coleman, 2004; Ford et al., 2019; Hull, 2008). To be effective and impactful, sexual health promotion programming must recognize and engage with the whole of a person’s sexuality. To ignore pleasure in any aspect of sexual health promotion programming is to present a conceptualization of sexuality and sexual health that is not real and will not connect with people to meaningfully addresses their needs, aspirations, desires and concerns (WAS, 2008).
2. Access to sources of sexual pleasure is part of human experience and subjective well-being
The second principle of the WAS Declaration emphasizes sexual pleasure as part of being alive and well. This assertion builds off decades of work that has gone into defining sexual health as part of well-being (Boul et al., 2008; Mitchell et al., 2021; WHO, 2002; WHO, 2006). Today, a growing literature base shows that sexual pleasure—as a whole—is fundamental to the human experience, individual health, and well-being (Knerr et al., 2008; Scott-Sheldon & Johnson, 2006).
Implementing this principle of the Declaration involves considering sexuality, including pleasure, as a normal, healthy and central part of human behavior and well-being. This approach gives value to sexual pleasure as something “at or near the essence of subjective sexual experience” including a range of feelings from the excitement of orgasm to the heightened self-awareness that can come from sexual experiences (Fava & Fortenberry, 2021). Sexual pleasure is both ingrained in daily life but also associated with deeper emotions and meaning. This perspective is included in the definition of sexual pleasure outlined above as “the physical and/or psychological satisfaction and enjoyment derived from solitary or shared erotic experiences, including thoughts, dreams and autoeroticism” (GAB, 2016). This definition aligns pleasure with subjective sexual well-being and experience. Yet, one could mistakenly assume pleasure to be an individual experience outside the purview of public health and with little clinical relevance (Fava & Fortenberry, 2021). Sexual rights, however, are key to making the link between subjective experience and public health impact. As the definition reads, “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.” In this way, emotions and bodily sensations of pleasure are linked to public health through a focus on structural determinants of health, relevant in policies, societies and contexts around the world (Gruskin & Kismödi, 2020).
The Pleasure Project (2021) translates this declarative statement into a practical step in their “Pleasure Principles” by encouraging partners to “Think Universal”—to consider the possibility of pleasure as a universal phenomenon yet different for each individual. This approach recognizes that there are layers of context and culture in our sexuality, whereby pleasure can be unequally distributed. By recognizing aspirations for safe pleasure for people not traditionally expected to experience pleasure (e.g., unmarried women, people with disabilities), pleasure-based sexual health programming can work to challenge these norms while also expanding the sexual repertoire beyond heterosexual monogamous relationships, encouraging a less traditional view of sex. Pleasure is not just for specific groups, nor is it meant to re-confirm cultural norms or stereotypes. Rather, a focus on pleasure allows us to move away from stereotypes or judgements (e.g., “promiscuity”) toward a more collective and expansive vision of change.
A life course approach may also be useful here (Sladden et al., 2021). Our needs as sexual people change through learning, maturation and shifts in roles. With those changes come needs for new learning, new resources and new expectations about one’s sexuality. That is, at birth, during infancy and in childhood, it is necessary to protect future sexual health, rights and pleasure by ensuring bodily integrity and autonomy. This enables later, the capacity to experience sexual pleasure, realize sexual rights and enjoy sustained sexual health. Examples include preventing female genital mutilation/cutting (FGM/C) and stopping irreversible medical procedures on intersex children who are too young to participate in decision-making with fully informed consent (Office of the High Commissioner for Human Rights [OHCHR], 2021). Providing comprehensive sexuality education (CSE) at an early stage and within the context of life-skills also protects young peoples’ sexual rights, prepares them for future sexual lives and ensures the ability to decide issues relating to their sexual health, rights and pleasure (UNESCO, 2018). Through the life course into adolescence and young adult years, support and guidance are needed to help individuals learn to take responsibility for sexual health and rights—to ensure all sex is consensual, pleasurable for all partners and without force, and to avoid unintended pregnancy and STIs including HIV (McKinnon & Vandermorris, 2019). Finally, a range of sexual health issues require more attention in later life, including menopause, sexual function, cancer treatment/prevention, and enabling people to pursue a pleasurable sex life.
3. Sexual pleasure is a fundamental part of sexual rights
Sexual pleasure is a basic human need on par with other basic requirements for a healthy, happy and productive life. Sexual rights are human rights—such as the right to life, to nondiscrimination and to the highest attainable standard of health—that are codified in national constitutions, laws and policies and enshrined in regional and international human rights treaties (Kismödi et al., 2017; WAS, 2015). These formal structures are essential for providing the conditions to experience and pursue a pleasurable sexual life. For example, supporting sexual pleasure through sexual rights involves decriminalization of consensual sexual conduct, regardless of sexual orientation and independent of marital status. It includes eliminating harmful practices, such as female genital mutilation and genital- “normalizing” surgery for intersex people that can decrease the capacity for sexual pleasure, as well as dismantling stereotypes and misconceptions around pleasure (IPPF, 2008; WHO, 2010). Promoting sexual pleasure as part of sexual rights requires understanding that any sexual relationship requires consent and freedom from force of any kind (Kismödi et al., 2017). Hence, state interventions must be in place to prevent harm to the rights of others especially in relation to forms of violence, including harmful practices, rape and sexual assault (Kismödi et al., 2017; Starrs et al., 2018).
Grounded in the right to autonomy and bodily integrity is the ability to choose sexual partners and to seek and experience sexual pleasure, with due regard for the rights and freedoms of others. People should be free to exercise autonomous, consensual or solitary sexual practices with the support of social, political and economic conditions that allow all sexual rights and freedoms to be realized equally (IPPF, 2008). Laws and policies should protect children and adolescents from sexual violence and give them access to comprehensive, age-appropriate sexuality education (IPPF, 2016; WHO, 2010). No one’s sexual rights should be denied on the grounds of older age or disability (Fava & Fortenberry, 2021; Ford et al., 2019; Kismödi et al., 2017).
Sexual rights are a cornerstone of sexual pleasure (Barot et al., 2015; Fava & Fortenberry, 2021; Gruskin & Kismödi, 2020; Sladden et al., 2021; Starrs et al., 2018). The Pleasure Project (2021) affirms the importance of sexual rights in their principle of “Rights First”—where pleasure cannot exist without rights, consent, autonomy and respect for individual differences. The Pleasure Principles (2021) detail this practically by ensuring that the populations reached, including local staff, know that sexual rights are (1) human rights and (2) a pre-requisite for safe, satisfying sex lives for all. Placing rights first also means that practitioners use examples in their work of sexually diverse people (e.g., gender/sexual identities, HIV status) in fulfilling relationships without presuming that certain relationships will not have pleasurable sex.
A key distinction in developing the concept of sexual rights involves distinguishing between negative rights (freedom from violence, coercion, abuse) and positive rights (pleasure affirming approaches, enabling factors) (Corréa & Parker, 2004; Parker et al., 2004). To date, there has been a tendency for the positive approach to get pushed to the background. Yet, promotion of sexual pleasure through sexual rights means not only advocating to get rid of negative laws and policies (e.g., those banning same-sex sexual behavior) but creating and supporting laws that are affirming to sexuality and sexual pleasure (Higgins & Hirsch, 2007; Hull, 2008; Kismödi et al., 2017). Acknowledging the importance of sexual pleasure has the potential to strengthen law, policy and programmatic efforts and to minimize the stigma associated with some aspects of sexuality and related adverse outcomes. The process of destigmatization entails more than just naming stigma as a barrier to sexual health. It involves changing laws and policies that are harmful to sexual health and well-being, as well as considering how policies and central actors—including legal experts, social scientists, and media professionals—can combat blame and stereotyping and foster conditions that support health (Clair et al., 2016).
Finally, while perceptions of sexuality and the importance of sexual rights may vary based on context, basic human rights of individuals should not be jeopardized at the expense of culture (Kismödi et al., 2017; WAS, 2015). For instance, sexuality-related harmful practices—such as genital- “normalizing” surgeries forced upon intersex infants—are deeply rooted in societal norms but prevent fulfillment of human rights related to sexuality and sexual pleasure. The criminalization of same-sex sexual relationships or extramarital sex is a legal practice in several countries rooted in societal, religious and cultural norms yet this interferes with the possibility of sexual pleasure (United Nations Human Rights Council, 2010; World Health Organization, United Nations Population Fund & United Nations Children's Fund [WHO, UNICEF, & UNFPA], 1997). In other words, although the right to participate in cultural life and freedom of religion are protected in international law, this freedom should be subject to limitations necessary to protect the fundamental rights and freedoms of others (United Nations, 1966). Cultural or social claims should not be invoked to justify harmful practices, and all necessary measures (including the changing of laws) should be taken to eliminate harmful practices (United Nations Human Rights Council, 2010; WHO, UNICEF, & UNFPA, 1997).
4. Sexual pleasure includes the possibility of diverse sexual experiences
The fourth principle of the Declaration emphasizes the diversity of pleasure. This means that pleasure can be experienced in a variety of ways (Mitchell et al., 2021). While sexual pleasure can be an end to itself (e.g., masturbation), pleasure is also often connected with closeness to a partner (Tepper, 2000). International comparative research consistently shows that diverse forms of sexual pleasure improve both individual happiness and overall health, as well as relationship quality, which can contribute to the health and well-being of individuals, couples, families and communities (Buss et al., 2001; Lindau et al., 2007; Tepper, 2000).
Pleasure is linked to sexual expression. Kimmes et al. (2015) explain that a sex-positive, pleasure inclusive approach considers all consensual and wanted sexual expressions to be valid, giving value to the subjective meaning that people attribute to their experiences and well-being (Kimmes et al., 2015). In this way, someone may opt for abstinence, whereas someone else may engage in diverse and numerous sexual experiences. In both examples, a pleasure-inclusive approach recognizes the power of self-determination and personal values, without judging other experiences that are diverse from one’s own. Notably, abstinence is a sexual behavior that everyone exhibits over the course of minutes, days, weeks, years or a lifetime. The critical point is that abstinence is a choice rather than the outcome of oppression, suppression or poor sexual health (Fava & Fortenberry, 2021).
In line with this perspective, the Pleasure Project (2021) urges practitioners to “Be Flexible” in their Pleasure Principles. This involves being adaptive to each context while also recognizing that pleasure is possible for all. There is no “one-size-fits-all” method for sexual pleasure but a diversity of backgrounds, realities and contexts in terms of experiences of pleasure. This emphasis on diversity and flexibility means engaging with narratives of pleasure (e.g., who creates them? for what reasons?) and recognizing people’s experiences and history of suppression, discrimination, colonization, etc. Community-based participatory work may be useful for honoring diversity with its emphasis on people’s lived experience in their expression of sexuality. For example, exercises that include a body mapping of pleasure or erogenous zones in different contexts, for different genders or body types, can be a good way to start the pleasure conversation.
The diversity of pleasure also has relevance for masturbation, in particular, which has been a contentious topic as its primary purpose is to produce pleasure (Coleman & Bockting, 2013). Masturbation is a common sexual behavior and linked to indicators of sexual health (Herbenick et al., 2010). Research indicates that masturbation begins early and is an important marker of healthy sexual development (Coleman & Bockting, 2013; WAS, 2008). Many young people learn about their bodies and sexual responses through masturbation and it often continues throughout the life span. For example, many adults masturbate even though they are married and have access to sexual intercourse (Herbenick et al., 2010). Masturbation may help people who do not have an available partner to maintain sexual expression and functioning. It is also a safe alternative to sexual risk behaviors, including HIV transmission. The benefits of masturbation are illustrated by its wide acceptance in sex therapy as a way to improve the sexual health of the individual and/or couple (Coleman & Bockting, 2013). Yet, the experience of masturbation can be powerfully negative or positive, depending on the interaction between the prevailing societal attitudes and individual attitudes and behaviors. Addressing masturbation within sexual health programming can be controversial. However, available evidence suggests that including masturbation as a topic within comprehensive sexual health promotion is necessary and important (Ford et al., 2019; WAS, 2008).
A linkage to sexual rights is also necessary to promote and support the diversity of pleasure, including diverse aspects of sexuality, sexual orientations, gender identities and expressions (SOGIE), eroticism, pleasure and intimacy (WAS, 2015). The definition of sexual pleasure states that “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 well-being” (GAB, 2016). In distinct contexts and across the life course, sexual pleasure can be supported by facilitating and sustaining a broad spectrum of SOGIE. All people—young people in particular—require support and freedom under law, to explore, question and express sexuality, without fear of violence, coercion or rejection from family and community (Sladden et al., 2021). For instance, people with diverse SOGIE should not under any circumstance be forced into involuntary, unscientific and harmful conversion therapies (SAMHSA, 2015).
A diverse bodies perspective on sexual pleasure may also be useful here—built upon fundamental notions of embodiment and the learning of pleasure—it is important to acknowledge that pleasure may be learned and interpreted differently through different body capacities. For instance, pleasure may be different for a person with gender and genital dysphoria or an adolescent with spina bifida. With the awareness that many bodies are marginalized or considered sexually-disabled, sexual pleasure aims to be an inclusive, developmental framework that accounts for variations in pleasure and their contributions to sexual well-being (Carpentier et al., 2011; Fava & Fortenberry, 2021; Fortenberry, 2013).
5. Sexual pleasure shall be integrated into education, health promotion and service delivery, research and advocacy in all parts of the world
The fifth principle of the WAS Declaration calls for integration of pleasure into education, health services, research and advocacy, as well as broader programming and implementation. In line with past calls for progress regarding sexual health and sexual rights, this Declaration aims to reduce stigma and shame by helping researchers, educators, clinicians, and policy makers acknowledge sexual pleasure and positive sexual experiences as outcomes with great public health relevance (Mitchell et al., 2021; Satcher, 2001). In the second half of this document we showcase examples of how pleasure might be integrated into specific sectors.
Many current public health and development approaches to sexuality remain firmly rooted in a focus on adverse health outcomes and concomitant risks. This risk-focused approach has become a standard in public health, eclipsing other aspects of sexuality, even though health is rarely—if ever—the main reason for having sex (Epstein & Mamo, 2017; Philpott, Larsson, et al., 2021). The integration of sexual pleasure into current approaches will not replace but rather will strengthen and extend existing and essential programming and service delivery that increases access and adherence to, or uptake of needed sexual and reproductive health and rights (SRHR) and HIV interventions (Philpott, Larsson, et al., 2021).
To implement sexual pleasure based sexual health, The Pleasure Project (2021) encourages practitioners to “Talk Sexy” using pleasure positive messaging to communicate effectively and positively and to “Embrace Learning” building new evidence and new knowledge on the impact of pleasure-inclusive approaches. Talking sexy involves being conscious of language and rejecting cultural or sexual norms that express sexuality in sex negative terms or reinforce stereotypes. It means adjusting sexual health materials to have a “pleasure lens” (i.e., creating new materials based on communities’ experiences of pleasure and sexuality). Examples of best practices include charting words used for describing bodies and sexuality by communities and using these to embody respect, joy and non-judgmental projections of pleasure and well-being. In turn, embracing learning and being evidence-driven involves collecting and sharing knowledge with others who want to become pleasure practitioners. There is a great need for more evidence around pleasure-based sexual health. Ideally, goals and metrics can be incorporated into programs to measure sexual well-being or enhancement of safe sexual satisfaction. In interactions with clients, practitioners can begin from the basis of supporting them to achieve positive goals in their sexuality and relationships; thereby building this into program design and evaluation. Lastly, disseminating evidence will advance the broader pleasure-based sexual health community and their practice as a whole.
Overall, a growing body of evidence shows the effectiveness of pleasure-focused programming in terms of improved attitudes and health outcomes, such as condom use and other safer sexual behaviors (Becasen et al., 2015; Ford et al., 2019; Hanbury & Eastham, 2016; Hogben et al., 2015; Knerr et al., 2008; Schalet, 2009; Scott-Sheldon & Johnson, 2006; Wysocki, 1998). Yet ongoing work is needed to examine the full body of current efforts. Although many programs and interventions report their effectiveness, it remains difficult to assess how much of it is due to the inclusion of pleasure on its own (Philpott, Larsson, et al., 2021). Evaluation efforts are needed to extrapolate the mechanisms (i.e., time and emphasis placed on pleasure; design and implementation, etc.) that lead to success. In particular, research is needed to identify the best ways to incorporate pleasure for different outcomes and populations. Studies to date have been largely focused on eroticizing safer sex in the West with male populations and there is a need to ensure a more holistic approach with at-risk populations in low-income countries. This remains a pivotal area for future endeavors.
6. The programmatic inclusion of sexual pleasure to meet individuals’ needs, aspirations, and realities ultimately contributes to global health and sustainable development and it should require comprehensive, immediate and sustainable action
The final principle of the WAS Declaration emphasizes global health and sustainable development. This tenet is intended to be aspirational. In recent decades, commitments from governments and the global community have fueled progress made on sexual and reproductive health and rights (SRHR). Yet more entry points for pleasure-inclusive work with political, programmatic and service delivery relevance need to be explored and acted on.
To build a pleasure-inclusive world, it is necessary to collaborate with and support other pleasure champions. In line with this last declarative statement, The Pleasure Project (2021) encourages practitioners through their principle to “Love yourself.” This means having compassion and kindness individually and in collaboration with others. Importantly, pleasure stigma can affect collaborations and can have a personal impact, which may require personal exploration and self-compassion. Sexual health practitioners, sex educators and partners need to understand how their own experiences have influenced their practice and collaborations, whether that be trauma or their own sex education. Yet, advocacy for sexual justice can be joyful, creative and collaborative. This principle to “Love yourself” encourages ongoing communicative and reflective dialogue to support a growing number of pleasure-based sexual health practitioners.
As referenced above, low-income settings disproportionately suffer from a higher burden of sexual health issues, which impedes the development of these regions of the world. Sexual health problems also place a significant burden on health and well-being in high-income areas. For example, cross-national comparative research consistently shows that access to sexual and reproductive health education and clinical services is insufficient in many places and this lack of access is correlated with higher rates of unintended pregnancy and STI infection regardless of context (Darroch & Singh, 2013; Starrs et al., 2018).
At present, we have arrived at a moment in history where it is clear that advances in sexual science have measurably improved the quality and capacity of well-designed and supported sexual health programs to effectively address a range of problems that prevent individuals from living healthy and productive lives (WAS, 2008). As acknowledged in the past WHO Reproductive Health Strategy, “The number of evidence-based best practices in reproductive and sexual health care has grown substantially, and the scope of behavioral research and of internationally recognized standards, norms and guidelines has broadened” (WHO, 2004, p. 9). Likewise, the WAS Sexual Health for the Millennium Declaration and Technical Document (WAS, 2008) demonstrates how advances in the science of sexual health promotion have placed the field in an unprecedented position to contribute to human development and make an indispensable contribution to the broader objectives of the Millennium Development Goals (MDGs).
Yet, if global initiatives for sustained development are to be successful, they must incorporate rigorous evidence-based strategies for including pleasure into comprehensive, immediate and sustainable action. The field has produced some excellent examples of this but ongoing work is needed. For example, the Guttmacher-Lancet Commission Report (Starrs et al., 2018) represents a huge achievement by providing a framework for addressing well-being as part of an essential package of sexual and reproductive health services. This perspective provides the groundwork to eventually include sexual pleasure in global health and sustainable development efforts.
Likewise, from 2014–2015, the Guttmacher Institute linked sexual health and sexual rights with SDG indicators: health (Goal 3), education (Goal 4), and gender equality (Goal 5) (Barot et al., 2015). In turn, nine topic areas were linked to these indicators: contraception, sexual and reproductive health service availability, knowledge about SRHR adolescent fertility, quality of care, prevention of STIs, abortion, comprehensive sex education, and gender equality in SRHR (Barot et al., 2015). This same type of rigorous engagement with the SDGs could be done for sexual pleasure. One way to do this would be to emphasize the public health perspective: the reason to address sexual pleasure is because it helps protect people better than current approaches. If global health and sustainable development efforts incorporate sexual pleasure, it is more likely that they will meet people’s needs and realities, ultimately reaching objectives and, therefore, contributing the most impact to the SDGs.
Another model for the programmatic inclusion of sexual pleasure in global health and sustainable development involves employing the “triangle” framework of sexual health, sexual rights and sexual pleasure, whereby partners and programs can work to ensure that all three aspects are in place (Gruskin et al., 2019; Sladden et al., 2021). The application of this triangle will look different across settings but it could be used as an aspirational guide. For example, building from this triangle framework, a range of organizations have called for sexual pleasure to be more fully incorporated within sexual health and sexual rights. Since 2004, The Pleasure Project (2021) has advocated for the inclusion of pleasure in sexuality education and safe sex programs (Knerr et al., 2008; Philpott, Knerr, & Maher, 2006; Philpott, Larsson, et al., 2021; Philpott et al., 2017). Love Matters (RNW Media) has engaged young people with innovative content that “cuts through shame and stigma and proudly talks about pleasure” rather than focusing solely on sexual dysfunction and disease (Sladden et al., 2021). Pleasure has increasingly been recognized during major HIV/AIDS and SRHR conferences worldwide, including the International Conference of Family Planning (ICFP) 2018, Women Deliver 2019 and AIDS 2020 (Philpott, Larsson, et al., 2021; Singh et al., 2021; Sladden et al., 2021). In 2021, ICFP 2021 included a complete track on sexual pleasure and health (Sladden et al., 2021).
Implementation of the declaration
The WAS Declaration on Sexual Pleasure urges all governments, international intergovernmental and non-governmental organizations, academic institutions, health and education authorities, the media, private sector actors, and society at large, and particularly, all member organizations of the World Association for Sexual Health to promote sexual pleasure in law and policy, education, health services, research and knowledge creation, and advocacy.
In this section, we aim to give guidance on how to include sexual pleasure as a fundamental part of sexual health and sexual rights work. In line with the WAS Declaration on Sexual Pleasure, we review key areas where attention to sexual pleasure could strengthen and expand existing efforts. We include a series of case studies and highlight key actions for advocacy and implementation. The case studies were selected to illustrate best practices in pleasure-inclusive work in line with the range of research, interventions and evidence required to enact the WAS Declaration on Sexual Pleasure. These are not exhaustive or representative of the wide range of work happening in this field. More examples are housed on The Pleasure Map (https://thepleasureproject.org/pleasuremap/). We encourage practitioners to also review The Pleasure Project’s© aforementioned “Pleasure Principles”—a series of straight-forward principles based on the Declaration intended to guide and inspire a sex-positive, pleasure-based approach to sexual health (2021, p. 24).
A. Promote sexual pleasure in law and policy as a fundamental part of sexual health and well-being, grounded in the principles of sexual rights as human rights, including self-determination, nondiscrimination, privacy, bodily integrity, and equality
Laws and policies are necessary to support the promotion of sexual pleasure, grounded in sexual rights. Below we outline three case studies that show the importance of law and policy for sexual pleasure. For more guidance on implementing sexual pleasure as part of sexual rights into policies and programs, partners should review the technical document supporting the 2015 WAS Declaration of Sexual Rights (Kismödi et al., 2017).
Sexual rights are human rights—such as the right to life and to the highest attainable standard of health. These rights are protected in national, regional and international human rights laws, policies and treaties (Kismödi et al., 2017; WAS, 2015). Sexual rights must be in place to provide the possibility of a pleasurable sexual life. That is, all persons are entitled to the conditions that enable the pursuit of a pleasurable sexuality throughout their lives, in the context of nonviolent, consensual actions and interactions (Barot et al., 2015; Fava & Fortenberry, 2021; Gruskin & Kismödi, 2020; Sladden et al., 2021; Starrs et al., 2018; WHO, 2006).
Fulfillment of sexual rights is best realized when there is access to systems to ameliorate infringements on rights. For instance, sexuality and gender-related identities are often used to exclude some people from equal access to marriage, military service, and adoptive family formation (Fava & Fortenberry, 2021; Gruskin & Kismödi, 2020; Sladden et al., 2021). In many countries, marriage equality would not have happened without a court system to enforce rights that were already present in principle (Sladden et al., 2021).
Below we outline three case studies that encompass the importance of rights-based law and policy for the promotion of sexual pleasure.
Legal Case Study: Recognition of Adolescent Sexuality
Laws, policies and practices can contain contradictory provisions in terms of adolescents’ right to privacy in relation to sexuality, sexual health and sexual pleasure (Kismödi et al., 2017). These, on the one hand, may support adolescents’ privacy, confidentiality, interests and evolving decision-making capacity. Yet, on the other hand, they may require parental consent for all medical and health intervention below the age of 18.
Case law in the United Kingdom determined that it is lawful for doctors to provide advice and treatment related to contraception and sexuality to minors without parental consent, provided certain criteria were met. This policy was laid out in Gillick v. West Norfolk and Wisbech Area Health Authority in 1985 (Kismödi et al., 2017). The criteria have come to be known as the Fraser Guidelines and are used as guiding standards for service provision for adolescents in the United Kingdom. According to these guidelines, it is lawful for doctors to provide contraceptives, treatment and other related advice, including that relevant to sexual pleasure without parental consent if, inter alia, the health professional is satisfied that the adolescent will understand the professional’s advice, cannot be persuaded to inform their parents, and that it is in the adolescent’s best interest to be given contraceptive advice or treatment without parental consent. A useful fact sheet explains this (https://www.icmec.org/wp-content/uploads/2019/04/gillick-competency-factsheet.pdf).
These have been used in other national, global, or regional guidelines. For example, in Mexico there is a regulation that was established in 2015 known as NORMA Oficial Mexicana NOM-047-SSA2-2015, Para la atención a la salud del Grupo Etario de 10 a 19 años de edad (Kuri-Morales et al., 2020). This established the same criteria in terms of the legal recognition of adolescent sexuality. Its implementation has translated into the establishment of friendly services on sexual and reproductive health, including discussions of sexual pleasure, specially designed for adolescents.
Case Study: Model for Providers Addressing Sexual Consent in Law
The following case study comes from Fulfil! (IPPF, 2016). Fulfil! presents a series of case studies to support service providers in the implementation of young people’s sexual rights while balancing ethical, legal and practical factors. It is a generic case study (not connected to a specific place) designed to provide a model for dealing with sexual rights in a situation with implications for sexual pleasure.
A young gay man lives in a country in which the heterosexual age of consent is 16 but the age of consent for same-sex activity is 18. Adolescents below the age of consent who have same sex activity with adults are considered to be victims of abuse under the law. He is 16 and has had 4 male partners (all between 16 and 20 years old) with whom he has had consensual sex; with 2 of them he had unprotected anal sex. One of the partners has disclosed that he is HIV positive. The young man goes to a local clinic for rapid HIV testing. He is worried about telling the provider about his sex life, as he is not sure if he will face censure for having sex with other men. Finally, the provider asks and the young man reveals that he had unprotected sex with other men.
Legal factors: The young man is having sex under the age of consent with other young men, some of them above 18; thus, he is considered to be the victim of abuse under the law.
Practical factors: The young man is distressed about his health and he is looking to access a sexual health service (HIV testing) that will benefit him and support sexuality and sexual pleasure in the future. He would also benefit from sexual health education including attention to sexual pleasure, given that he has had unprotected anal sex with two partners. On the other hand, there are no signs of abuse; his sexual partners are all around his age (16–20 years old).
Ethical factors: The provider has the ethical duty to guarantee this young man’s sexual rights, in terms of providing him sexual health education, as well as a specific service. The provider also needs to support him in a safe, friendly, pleasure-inclusive and confidential space.
Balance of factors: Although same sex relationships below the age of 18 are illegal, the young man does not exhibit or report signs of abuse; also, his sexual partners have been other males around his age. If the case were to be reported, the young man could face a wide variety of negative consequences, such as family rejection or homophobic abuse by authorities. The provider should support him in a safe, private and confidential space; he should also provide him with sexual health education and an HIV test without stigma and using a sex-positive, pleasure-inclusive approach.
Overall this case study encourages the service provider to consider the range of factors and impacts of actions to support the young man who has sought consensual sex for pleasure, and guides them to take decisions in the young man’s best interests within different contexts.
Case Study: Policy support for sexual pleasure in the time of COVID
The COVID-19 pandemic brought huge challenges for sexual health care services and comprehensive education. However, the COVID-19 pandemic also elevated sexual pleasure into the public discourse in many countries, as health authorities issued frank guidance on COVID-safe sexual activity. Governments had to adopt restrictive measures to reduce the spread of infection with in-person sexual activity being inadvisable in COVID-19-affected households or communities and a need for detailed, pandemic-related guidance. These measures undoubtedly affected sexual lives as people were also asked to socially distance and “stay at home.” Yet, the pandemic also presented opportunities for new ways to advocate for and to highlight pleasure as a fundamental part of sexual rights, health and well-being. Below, we present a series of examples for how policies and research could support sexual pleasure.
As reported elsewhere in this special issue (Philpott, Larsson, et al., 2021), some health authorities made headlines with recommendations on: multiple types of partners; use of sex toys (e.g., Government of the District of Columbia, 2020; Government of Colombia Ministry of Health and Social Protection, 2020); masturbation (e.g., Sexual Health and Crisis Pregnancy Programme, 2021); consensual cybersex activity (e.g., Government of Colombia Ministry of Health and Social Protection, 2020). Family Planning Victoria (https://www.fpv.org.au/blog/sexual-pleasure-in-the-time-of-covid-19-world-sexual-health-day) made publicly their resources focused on how we can all “Prioritise Pleasure” in sexuality education, sexual health care, advocacy and in our everyday lives. This sharing of resources followed the launch of the organization’s 2018 Pleasure Agenda campaign, which advocated for the inclusion of pleasure in school-based sexuality and relationships education.
As acknowledged by Philpott et al., “Tacitly acknowledged by these pandemic-era recommendations is the fact that, in addition to being a central driver of sexual behavior, sexual pleasure is also an element of overall well-being… Devoid of the emphasis on reproductive health (and even disease transmission, in the case of solo or distanced sexual activities), these recommendations instead, directly or indirectly, addressed the ongoing need for intimate connection, sexual desire, and sexual pleasure.”
The pandemic also provided an opportunity to study the effects of policies on sexual well-being around the world (e.g., Bangladesh, India, Italy, Japan, Nepal, Turkey) (Ballester-Arnal et al., 2020). In general, there are diverse results depending on the country of the participants and the variables analyzed. For example, the “INSIDE” project in Spain (Ballester-Arnal et al., 2020) surveyed over 1,000 Spanish citizens in April 2020 using this research to inform policy recommendations such as noting the potential for COVID-19 to negatively impact physical and mental well-being, which in turn decreased sexual functioning and sexual satisfaction, worsening quality individual and dyadic sexual life. The INSIDE project also found that sexual repertoire expanded with new activities such as sexting or viewing pornography, masturbation, the use of recreational drugs, and alcohol consumption. Changing times document the need for policy support for sexual pleasure in the time of COVID.
B. Ensure that comprehensive sexuality education addresses sexual pleasure in an inclusive, evidence-informed and rights-based manner tailored to people’s diverse capacities and needs across the life span, in order to allow experiences of informed, self-determined, respectful, and safe sexual pleasure
A growing body of literature supports the inclusion of pleasure in comprehensive sexuality education and other training and education efforts. The Pleasure Project, as referenced previously, includes a pleasure map highlighting a range of smaller organizations globally that encompass best practices related to sexual pleasure, including many that focus on education (Philpott, Singh, et al., 2021).
People seek sexual activity that feels close, natural, and uninterrupted—where sexual pleasure is often prioritized over risk reduction and contraception (Higgins et al., 2008). In addition, biological, neurological, and cognitive studies show that pleasure is an effective communication method because pleasure-inclusive messages attract more attention, are easily remembered and less likely to induce counterarguments than non-sexual messages (Ford et al., 2013; Reichert, 2002). Thus, a goal for education would involve the presence of more holistic, pleasure-inclusive approaches and understandings of safer sex and sexuality education such as those presented in the case studies below. These efforts incorporate the notion of physical and psychological pleasure grounded in sexual rights including self-determination, consent, safety, privacy, confidence and communication/negotiation (GAB, 2016). Beyond these case studies, we also encourage practitioners to review the IPPF “Happy, Healthy and Hot” guide, which provides young people living with HIV with practical, pleasure-inclusive information and explores how human rights and sexual well-being are related to healthy decision-making and relationships (IPPF, 2020). Likewise, the Jamaican Guidelines for Comprehensive Sexuality Education (CSE), which refer to pleasure throughout, are another great resource (SIECUS, 2021).
Case Study: Possibilities of sex positive sex education in Kenya and Ghana: “They tell us that sex is sweet at the right time” (Singh et al., 2021)
The Pleasure Project and Rutgers, with GH SRHR Alliance (Ghana) and SRHR Alliance (Kenya), conducted a qualitative pilot study of sexuality education under the Get Up Speak Out programme, analyzing the extent to which they included sex-positive content, with recommendations to enhance sex-positivity. Peer Educators in the programme were trained to collect data, and data were subsequently collected through interviews with facilitators, focus group discussions with learners, observation of sessions, and curricula content analysis with a range of educators and their learners in Ghana and Kenya.
This research found that there were many possibilities for sex-positivity in contexts perceived as restrictive contexts, illustrating ways for sexuality education to become more sex-positive and pleasure inclusive. The research also found many educators who were comfortable discussing pleasure or sexuality, and what experiences or support they had received to ensure they felt comfortable, and how this aligned to their values, faith or beliefs. This study also enabled the development of a new tool for a pleasure audit, with markers of high-quality, sex-positive and pleasure-inclusive sexuality education or sexual health programs.
Quotes—
A male CSE teacher from Kenya said:
You need to tell young people the truth about sex. If you tell them if you have sex you will get infected –this is wrong. Instead you have to tell them that if you have sex without a condom with an infected person then you will get infected. If you tell a child that sugar is bad for you, the day that child will dip his finger in the sugar and taste it, he will know it tastes good. You will be the liar. Don’t cheat them. Just give them the right information and guide them through. Give them freedom to make decisions after you have prepared them psychologically. Do not scare them.
Another female CSE educator from Kenya said:
They like to discuss healthy relationships and sex. I tell them that sex is sweet at the right time. There’s no right time but I tell them to have sex when they are ready and can handle the responsibilities that come with it. Parents not being open is a challenge as they don’t talk to their children. I stand in the gap between parents and children and talk to them about sex.
Case Study: Advancing formal CSE with sex-positive and pleasure approaches. The case of Argentina.
Despite not including sexual pleasure as a thematic area, civil society organizations in Argentina have tried to include sex-positive and pleasure approaches in the updated versions of CSE resources that were originally produced within the Ministries of Education (MOE) and Health (MOH) (Ministry of Education in Argentina [MOE], 2021; Ministry of Health in Argentina [MOH], 2021). In the context of COVID-19, the MOE released a new document entitled: “Challenges of the quarantine: Let’s talk about sexuality within the family context” [Desafío en Cuarentena. Hablemos de sexualidad en familia]
This document addresses pleasure in its definition of sexuality, as a dimension of human life that includes biological aspects, but also emotions, identity, and interpersonal relations. Also, it says that sexuality has to do with experiencing pleasure and exercising SRHR, and with acknowledging the possibility of enjoying pleasure in our bodies and those of others.
In this same context in 2021, the Ministry of Education and Health in Argentina developed another document entitled: “Changes that are seen and felt. Comprehensive Sexuality Education to learn more about puberty” [Cambios que se ven y se sienten. Educación Sexual Integral para saber más sobre la pubertad]. This document also represents a step forward toward guaranteeing the inclusion of sex-positive and pleasure approaches in CSE. When addressing body parts, it not only refers to their biological aspects, but also to the pleasure sensations humans can experience when touching certain parts of their bodies such as the clitoris or genitals, among others.
Finally, it is worth referring to Argentina’s annual campaigns to prevent adolescent unintended pregnancies. The 2020 campaign, “Week for the Prevention of unintended pregnancies among adolescents: for a safe and pleasurable reunion” had a strong focus on raising awareness about the importance of exercising your right to a healthy sexual life, but most importantly, on addressing sexual relations from a pleasure approach rather than a prevention approach.
These examples represent a few cases that include sex-positive and pleasure approaches in documents that are designed and validated by the Ministries of Education and Health in a Latin American country, Argentina, and that are intended to be used in both formal and non-formal educational settings. Undoubtedly, this represents a step forward toward guaranteeing quality comprehensive sexuality education for all.
Case Study: Sex Positive Families
Sex Positive Families (https://sexpositivefamilies.com/) was launched in June 2017 by Melisa Pinto Carnagey, who has the strong conviction that “all children deserve holistic, comprehensive, and shame-free sexuality education so they can live informed, empowered, and safer lives.” With a strong team of experts, Sex Positive Families offers in-person, virtual and on-demand workshops for adolescents, young people, and parents to develop skills, analyze strategies, and share resources aiming to understand and walk-through sexual health at every age and stage. One of their best known workshops is the one on puberty education entitled: “Growing into You!”, which is a live workshop with a gender-inclusive approach for adolescents and their trusted adults.
Growing into You! is a virtual workshop with the objective of guiding families on how to talk openly about puberty, as well as to learn about all the changes that happen during puberty and beyond. The workshop is targeted at adolescents ages 8-to-12, of all gender identities, and although virtual, it promotes a collective dialogue where adolescents can meet other peers, share information with their parents, caregivers or trusted adults to overcome the stigmas and taboos around puberty, and strengthen the linkages between adolescents and their families. This workshop sets the foundation for broader discussions of sexual health and pleasure.
Some of the topics that are addressed during the workshop are: body basics related to puberty (for all bodies and gender identities), correct anatomical terms and functions (for all genitals and reproductive/internal anatomy), the physical and emotional changes that can occur, how to take care of bodies during puberty, fun ways to keep the puberty talks open at home, and answers to their many amazing curiosities. Topics with relevance to sexual pleasure such as gender, sexual relations, consent, and masturbation are also covered, with the idea to discuss these and many other topics with greater ease and openness.
Finally, after these workshops were gaining track, many Spanish speaking communities asked for them, but in their own language, and in response to this demand, Sex Positive Families launched as an organization for this Spanish speaking community with the mission of breaking the stigma around sexuality education that exists within Latin communities. Through workshops delivered by certified sexual health educators, Sex Positive Families will continue working to discuss sexuality related topics with children and adolescents in age-appropriate ways so that they can grow proud of themselves, empowered, and emerge as adults with pleasurable sex lives.
Case Study: Vulgar
Vulgar (https://www.vulgar.mx/) is a sexuality education project with pleasure-based and social justice approaches. It was founded by Sucia Urrea and Melina Gaze, who provide in-person (3-D) and virtual (2-D) workshops, and who love “very much” to talk about sexual pleasure. The rationale behind their work relies on the following premises:
It is through pleasure that we can question social structures that have hidden, satanized and criminalized our bodies and pleasures.
It is through comprehensive sexuality education that we can promote new social behaviors and attitudes to overcome sexism, racism, and other forms of violence that many of us have experienced and practiced.
It is by talking about pleasure that we can have other important conversations about consent, power balance, and social conditions that need to be reanalyzed and established to guarantee well-being.
Vulgar offers CSE workshops with the idea of providing a new opportunity to better understand the meaning and relevance of self-determination, consent, and gender equality in our lives. Through CSE sessions, they guide participants to question themselves about violent structures and to believe that fairer and more pleasurable societies are possible.
Despite being based in Mexico City, Vulgar offers 2-D (virtual) workshops that have allowed them to reach a lot of people interested in sexual pleasure in Latin America. Their workshop entitled: “Sexualities, pleasure and power” (https://www.vulgar.mx/capacitacion) is targeted at educators and activists, and addresses methodologies to teach, share and discuss different sexuality related topics free of shame and stigmas. The objectives of the workshop are: (a) to analyze sexuality from a pleasure and power perspective; (b) to question cisgender, binary and biological norms, and offer different alternatives; (c) to incorporate different proposals from trans-feminists, and anti-racists movements into CSE; and (d) provide tools on how to facilitate a session creatively, as well as strategies on group management and teamwork.
Finally, Vulgar also offers resources that are accessible through their website, social media channels and blog. They have held collaborations with experts in Latin America to address sexual pleasure from different perspectives and they expect to continue growing as an innovative source of information on how to effectively incorporate sexual pleasure in CSE.
Case Study: Love Matters—Pleasure Positive Sex Education around the world
Love Matters [https://www.rnw.org/what-we-do/love-matters/] is RNW Media’s flagship sexual and reproductive health and rights programme (RNW Media, 2021). Since launching the first platform in India in 2011, Love Matters has flourished to become a collaborative global network with 7 member countries across the world. Love Matters talks about pleasure, rather than sticking to the conventional focus on dysfunction and avoiding disease. With this pleasure-positive approach and non-judgmental discussions on mobile-friendly platforms, Love Matters delivers accessible evidence- and right-based information and advice to young people to help them make informed decisions. They also create an online space for them to share their thoughts with their peers and to pose questions to (s)experts.
Love Matters currently consists of seven member countries; Egypt, Kenya, Nigeria, DRC, China, India and Mexico through a social franchise model. Love Matters had 123.1 million video views and 5.7 million followers in 2019. The first platform was launched in November 2010 in Netherlands, and then subsequently launched in India in 2011. This was following the banning of sexual education in a number of regions in India in the years prior to this. RNW Media launched in response to limited sex education in many parts of the world.
Love Matters’ second launch was in South America in 2011, with Let’s talk about Sex and Love [Hablemos de Sexo y Amor, as in Spanish; https://hablemosdesexo.com/] which is currently implemented in partnership with Mexico Vivo Foundation. Next in line was Kenya, where Love Matters went live in 2012. As part of the launch, Kenyan newspaper The Star, launched a weekly feature and an advice column, talking about common relationship issues.
In 2013, Love Matters took the decision to expand to China, where it is commonly taboo for people to openly talk about sex and sexual problems.
After the success of the platform in various regions, it was expanded to the Middle East. The platform aims to tackle many taboos within Middle Eastern culture, which in general doesn’t offer sex education within schools. While Love Matters’ approach goes against many traditional views in many countries, it has been accepted by many, especially young people as an important tool for sex education.
Love Matters’ Global Network operates at the intersection between media and public health, specializing in media for social change. Harnessing the power of technology, popular culture, design thinking, storytelling and using websites, social media platforms, Discussion Boards, campaigns, podcasts, radio programs, videos including animation and virtual reality, augmented reality; the aim is to give complete, unbiased and pleasure positive sex education to young people.
Love Matters has become a reference in many countries around the world, to talk about sexual pleasure and many other sexuality related topics in an open and stigma-free way, and this way of understanding and interpreting sexuality represents a step forward in some of the most conservative and challenging environments.
Love Matters is an excellent example leveraging the power of social media and digital content for new ways of communicating what people want and need to know but are ashamed of asking. They often count on a YouTube channel to share fun and shame-free sexuality education videos, and hold regular sessions on Instagram TV where they address questions of their followers with the help of experts.
Case Study: Agents of Ishq giving sex a good name in India
Agents of Ishq [Love/Passion in Arabic; http://agentsofishq.com/about-us/] is a multi-media project about sex, love and desire. They create free content in the form of videos, images and audio about sex, love and desire in India. Agents of Ishq create positive conversations about, love, sex and desire that move away from usual conversations about moral policing, sexuality and violence. Paromita Vohra, Writer, filmmaker and curator, started Agents of Ishq to create a safe place to talk about sex and love honestly, avoiding feelings of shame or “being un-cool” or ashamed about confusions. She talks about why Agents of Ishq is important and why certain subjects are easier to speak with teachers, trainers, funder about in public such as violence rather than pleasure and desire (https://www.youtube.com/watch?v=DNRTsUXO-OE).
Agents of Ishq is now one of India’s most well-known platforms that discusses everything from consent to masturbation to mental and sexual health. Paromita says “we saturate the space with pleasure.” It’s a wide-ranging platform that includes everything from personal narratives of intimate life to explainer videos and articles, aiming to fill a gap for Indians who have been long deprived of a safe space like this. Agents of Ishq also debunks narratives that eroticism is something more prevalent in the north of the globe, and highlight histories, art forms and people who have discussed sex and pleasure through time in India. This section of their website “Our erotic histories ‘includes histories of women loving women in 19th India’”, or their “Love Sex and Data” conference in October 2021 included presentations from classical singers to social media stars. They expand sex education into an art form.
On their website they promise to include content that is “honest, frank and clear as crystal. We like two roses kissing each other as much as the next person but sometimes you have to come out of the flower bushes and talk about nuts and bolts and things that make us nutty. Like safe sex, menstruation, how babies are made, chromosomes, fantasies, consent, violence, respect, agency, ishq. We believe in agency, pleasure, safety and mutual consent. But we don’t think ALL conversations about sex should be about abuse, rape, heart-break, caution and fear. We feel other kinds of conversations – kind, loving, open, sex-is-normal ones – might even help some of the conversations about the tough stuff.”
Paromita says “To be human is to seek pleasure. And to control others is often to control pleasure—or define for them what is supposed to be pleasurable, something that gatekeepers of all kinds, including the market, do for people. In many ways, pleasure is the antidote to violence because it is inclusive—it is not about polarities but about relationships built through mutual kindness, enjoyment and respect,” [Indian Express October 13th 2021]
Find Agents of Ishq on Facebook, Twitter and Instagram.
C. Guarantee that sexual pleasure is integral to sexual health care services provision, and that sexual health services are accessible, affordable, acceptable, and free from stigma, discrimination, and prosecution
Historically, the health care service sector has approached sexual health from the perspective of preventing or addressing negative consequences of sexual activity. However, health care providers are situated in an optimal position to address the complexity of sexual pleasure. Research shows that people of all backgrounds and interests—including adolescents, refugees, and those undergoing palliative care—are interested in discussing sexuality and sexual pleasure within health service settings (Fuzzell et al., 2016; Perz et al., 2013). However, many health care 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). The health care profession still largely views sexuality through the lens of its problems rather than its possibilities (Gianotten, 2021). Providing more education and training opportunities allows providers to become comfortable with placing sexual pleasure and sexual rights at the center of client engagement (Coleman et al., 2013). A value for sexual pleasure can 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 (Ford et al., 2021).
Beyond provider-client interactions, other systemic and structural elements, such as accessibility, affordability and confidentiality also impact the availability of pleasure-inclusive sexual health services. Broader challenges relevant to sexual pleasure remain globally—including a lack of 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 can overshadow the need for attention to sexual pleasure. Creative ways of educating and training health care practitioners, clients and systems about the importance of pleasure need to be formulated (Tumwine et al., 2020).
Approaches and programs that focus on pleasure and those that approach health care from a positive, affirming and abundance perspective rather than from a fear, disease burden, ill-health and scarcity perspective show promising results in terms of safe sex practices and behaviors (Calabrese et al., 2021; Ford et al., 2021; Gianotten, 2021; Goldey et al., 2016; Hogben et al., 2015; Oriel, 2005).
Case Study: MyDEx
MyDEx: Online sex education to get the sex you want (Bauermeister et al., 2019)
The MyDEx or “My Desires & Expectations” intervention offered sexual health services and education opportunities within the USA context of increasing use of online fora for sexual meet ups, or social support to reduce alienation and help overcome feelings of internalized stigma and homophobia, in situations where young gay and bisexual men or men who have sex with men do not receive social support elsewhere or offline.
MyDEx was designed to address the fact that more than 70% of all new HIV infections in the United States occur as a result of transmission through sexual contact among men who have sex with men (MSM) with inequities also accentuated by race/ethnicity, with young men who have sex with men who identify as Latino and/or Black carrying a disproportionate burden of new infections compared to non-Hispanic White counterparts. The myDEx intervention designed an innovative HIV prevention intervention aiming to decrease sexual risk-taking and promote HIV prevention behaviors.
MyDEx included sexual health and HIV testing, PrEP and condom use information in an appealing app and website designed with potential users of the resource. The intervention team worked with paid representatives in a Youth Advisory Board [YAB], made up of young men who have sex with men, diverse across ethnicities and age to design an intervention to promote active learning, human centered and youth engagement and the YAB’s expertise on same-sex dating behaviors and use of popular MSM dating and hook up specific apps was correspondingly used and privileged in trainings they ran for the myDEx app developers. The resulting MyDEx intervention was split across 6 sections or sessions with accessible content, including videos, role plays and quizzes that focused on; sexuality, pleasure and desire, different types of relationships from longer term romances to quick hook ups, a session that specifically focused on “What makes good sex?” from a sex positive and sexual well-being perspective and a session that specifically asked users to think about “Getting the Sex you want.” Throughout content was interactive, positive and affirming and included a sexual diary “MnTap.” Messages about safer sex, negotiating the pleasurable sex you want and doing so safely were throughout the intervention.
A block randomized trial was undertaken of myDEx against a control arm of HIV Risk Reduction Tool information-only site that mirrored the USA Center of Disease Control HIV Risk Reduction Tool, with content also divided into 6-sessions to match myDEx’s design. Block randomization allowed for age and ethnicity to be matched. Results showed high acceptability for this type of sexual health information that is more acceptable to users, more used to using online sources of information for health and sexual relationships and satisfaction. Young MSM in the myDEx arm found the intervention more relevant and useful than the traditional HIV and disease control information in the control arm. There was no difference in number of sexual partners in either arm, but a striking two-fold decrease in the myDEx arm of the number of partners with whom they engaged in condomless, receptive anal intercourse during the follow-up period at 90 days.
MyDEx was designed in a highly client centered way, with intensive inputs and insights from the client group. The result was a non judgmental sex and pleasure-positive intervention addressing emotional and sexual factors that influence sexual behavior and risk taking. It was found to be highly acceptable and led to positive changes in emotional and cognitive decision making. MyDEx led to reductions in sexual risk and condomless sex. MyDEx shows that use of digital spaces for sexual health information can be sex positive and use the benefits of existing technology and apps for both information and sexual interactions in a more accessible, appealing and pleasure-positive way.
Case Study: SRH Provider Training Toolkit and Pleasuremeter
SRH Provider Training Toolkit & Pleasuremeter. (Castellanos-Usigli & Braeken-van Schaik, 2019)
In 2018, the Global Advisory Board for Sexual Health and Well-being (GAB) developed a training toolkit that incorporates sexual pleasure into SRH services, counseling, and education with clients. The toolkit introduces the Pleasuremeter, a tool designed 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.
This important toolkit was piloted in a two-day workshop at the 2017 World Congress for Sexual Health with a group of 18 medical students. It was then reviewed by a panel of international SRHR experts (including IPPF and WHO experts, sexologists and medical students involved in SRHR advocacy), edited, finalized and is now available online at www.gab-shw.org/ resources/training-toolkit/.
As of September 2019, members of the GAB have facilitated six workshops using the toolkit—four in India, one in South Africa and a workshop in Prague—with 96 medical students and 22 SRHR professionals and these numbers are growing. The toolkit has been presented in diverse audiences of practitioners in China, Ethiopia, Holland, the United Kingdom and the United States.
How it works: Taken from (Castellanos-Usigli & Braeken-van Schaik, 2019)
The Pleasuremeter explores how an individual experiences sexual pleasure and the six enabling factors contained in the GAB’s definition. These factors are used as entry points to discuss ideal sexual experiences. The client begins by scoring the level of sexual pleasure experienced….The health professional can decide on the range of the scale they use in the questions (e.g., 1–5 or 1–10) and the given time frame to elicit reflection on past sexual experiences (e.g., last 3, 6 or 12 months) depending on what would be most useful for the client….After discussing each factor, the final step of the process in using the Pleasuremeter involves prompting the client with a further set of open-ended questions to reflect in more depth on ideal sexual experiences on the basis of their answers:
Out of all the factors that we have discussed, let us look at the ones that had the highest scores and the ones with the lowest. What is needed for the factors with the lowest scores to move toward the highest in future sexual relationships?
Of all the factors in the Pleasuremeter, which ones are most important for you to have good sex? What were some of the easiest and hardest factors for you to rate? Are there other factors that we did not discuss that would enable you to have better sex?
The Pleasuremeter is a novel conceptual tool to support health professionals in exploring the links between sexual health, sexual rights and sexual pleasure. This broadens the conversation beyond risk factors. As a conceptual tool, it is meant to supplement, not replace, clinical or educational assessments in service delivery. This toolkit, including the Pleasuremeter, is currently in the process of being transformed into a digital training course with in an effort to scale up its implementation globally.
Case Study: Sister Love
Sister Love (https://www.sisterlove.org/): Creating Healthy Love Parties (Diallo et al., 2010)
Atlanta Georgia, USA and Johannesburg, South Africa
Sister Love Inc. is a community-based organization based in Atlanta, Georgia USA that since 1989 has been providing Healthy Love Parties to African American Women and women of African descent in Atlanta, Georgia. It’s a community focused workshop “run by those we serve” and “that speaks to the realities of African-American women’s lives while providing practical and innovative strategies to help Black women face and overcome challenges posed by the AIDS pandemic” [SisterLove.org].
Sister Love seeks to address the inequities in the USA where Black Women are 15x more likely to become HIV positive than white women and where HIV is one of the three leading causes of death for black women. Sister Love has been delivering the “Healthy Love Party” intervention for over two decades adapting its content to address the changing HIV/AIDS epidemic for black in the US.
A series of informal meetings where discussions focused on self-help, and empowerment through sharing personal stories led to the development of this initiative called “Healthy Love Parties” in 1989. These workshops include eroticization of safer sex and safe spaces where black women can connect with their sexuality in ways that are positive and self-loving rather than shameful or degrading. Sister Love is delivered to preexisting groups in locations chosen by women themselves, for example college campuses, churches, participants’ homes, and community centers and describes itself as the “intervention that makes house calls” (Diallo et al. 2010)
In itself this is unusual, empowering and de-medicalizing and based on affirming Black Women’s realities, lived experiences and the possibility of positive sexual, romantic and intimate experiences—rather that starting from a position of prevention of disease or risk.
The Healthy Love Workshop [HLW] is a single-session intervention lasting 3–4 hours that is typically delivered to groups of 4–15 women, by Sister Love trained facilitators, women who share the lived experiences and life experiences, the workshop aims to increase consistent use of condoms and other safer sex methods, as well as HIV testing and sexual abstinence. The HLW is grounded in beliefs that women can empower themselves, respects black women's lived experiences and the importance of their collective wisdom.
The HLW consists of three modules (Setting the Tone, The Facts, and Safer Sex) providing basic information on HIV/AIDS and STIs (HIV/AIDS Facts, STI Facts, and The Look of HIV). Importantly the HLW includes but moves beyond correct use of condoms and their negotiation to the shared cultural aspects of Black women’s experiences that can shape their social vulnerability and HIV risks including a keen sensitivity to women’s unequal treatment and status as females and Blacks in the South, how language can emphasize the potential for women’s internalized sexual oppression or their empowerment and their rights relative to male partners. The intervention takes an affirming, black woman-centered, sex-positive focus on ways of avoiding or eliminating risks. The intervention is based on the beliefs that are sex positive, pleasure inclusive and affirming.
A group-randomized trial design in 2006/7 was used to assess intervention efficacy. Groups of women—including university dormitory residents, church groups, friendship groups, social support groups, neighbors, and other affinity groups—were pair-matched according to group type. One group from each pair was randomly assigned to receive the HLW or a comparison workshop of more traditional disease and risk focused HIV messages.
The randomized trial study paper concludes
“Compared to women who received prevention information in the didactic HIV101 workshop, participants in the highly interactive, skill-enhancing HLW reported greater improvements in self-efficacy for condom use and HIV knowledge immediately after the intervention, greater intentions to use condoms with their primary male partners at 3 months post intervention, and greater improvements in attitudes toward using condoms and HIV knowledge at 6 months post intervention. These intervention effects were accompanied by reports from women in the HLW condition of significantly greater use of condoms during vaginal sex with all male partners, particularly with primary male partners, at the 3-month follow-up, and greater use of condoms at last vaginal, anal or oral sex with any male partner at both 3- and 6-month follow-ups. Further, at the 6-month follow-up, HLW participants were more than twice as likely as comparison participants to report HIV testing and receipt of test results during the previous 3 months.”
Sister Love has been running innovative sexual health workshops, that affirm Black women’s life experiences and possibilities of pleasure, for over three decades and this rigorous evaluation with the USA Centers of Disease Control shows that a sex positive pleasure inclusive approach has a larger effect on reported condom use, at 3 and 6 months follow up and increased HIV testing rates. Sister Love exemplifies a community based and owned pleasure inclusive intervention with demonstrated impact in communities that are at higher risk and where more traditional sex-negative or less life affirming bio-medical interventions have less impact.
Below we highlight more key case studies that may be useful for thinking about ways to build, adapt and promote pleasure in health services.
D. Enhance the development of rights-based, evidence-informed knowledge of the benefits of sexual pleasure as part of well-being, including rights-based funding resources, research methodologies, and dissemination of knowledge to address the role of sexual pleasure in individual and public health
Research and knowledge creation represent central areas where ongoing work is needed to document the importance of sexual pleasure for health and well-being and to build a base of evidence-driven approaches. Existing research shows that intervention efforts that incorporate sexual pleasure consistently produce improved sexual health knowledge, attitudes, and behaviors including partner communication, condom use, and safer sex behaviors (Becasen et al., 2015; Hogben et al., 2015; Mustanski et al., 2015; Philpott, Knerr, & Maher, 2006; Schalet, 2009; Scott-Sheldon & Johnson, 2006).
Incorporating pleasure into health promotion programs has been shown to successfully increase safer sex through a variety of approaches such as eroticizing condoms, use of erotic images and films, promoting lubricants, and introduction of a “pleasure dialogue” as part of each person’s sexual repertoire (Arrington-Sanders et al., 2015; Hoppe, 2011; Philpott, Knerr, & Maher, 2006; Robinson et al., 2002; Wysocki, 1998). A 2021 review article on women’s health identified a series of ways to enhance pleasure including lubricants, vibrators, and educational interventions—which were found to increase sexual pleasure using approaches grounded in sexual health and sexual rights in diverse contexts (Guitelman et al., 2021; Reis et al., 2021; Tambling et al., 2012; Warshowsky et al., 2020). Beyond this growing body of work on sexual pleasure, more research is still needed (Jones, 2019; Reis et al., 2021). Below we highlight a few case studies of pleasure-based knowledge generation leading the way:
It bears noting that studies may not be able to definitively establish causal pathways between sexual pleasure and health and well-being due to methodological and ethical issues (Gianotten, 2021) and the linkage between sexual pleasure and sexual health is likely bidirectional: positive sexual expression may benefit good health and good health may support positive sexual expression (Gianotten, 2021). Boul et al. (2008) suggest viewing sexual pleasure in terms of beneficial cycles: sexual pleasure and its associated positive emotions reinforce sexual behavior and enhance self-esteem which in turn support sexual pleasure and health. In other words, identifying “the chicken and the egg” in this process may matter less, once the importance of pleasure and related beneficial cycles are more established (Gianotten, 2021). This dilemma is comparable to that faced a few decades ago when proponents claimed that “exercise benefits health” and opponents claimed that “good health creates the opportunity for exercise.” Today, the medical community is convinced of the health benefits of exercise (Fergus et al., 2019; Gianotten, 2021). We may hope for a similar trajectory for sexual pleasure.
Case Study: Pleasure Positive Sexual Health: Does it improve sexual and reproductive health?
It is important to evidence and test sex-positive and pleasure inclusive sexual health for its impact on a range of outcomes, in different contexts and with a wider range of groups of people, with diverse sexual identities and behaviors. We need more evidence on the integration of sexual pleasure into SRHR related education, promotion, policies, programs, and services. Unfortunately to date the slim evidence has been focused largely in North America on HIV risks, and with “higher risk” groups. More research is needed that takes a pleasure positive approach to really understand what works, where and with whom—and how to deliver pleasure inclusive sexual health well.
One previous systematic review and meta-analysis, conducted in 2006 and the most comprehensive review of the evidence to date, demonstrated the value-add of incorporating sexual pleasure into HIV-prevention interventions (Scott-Sheldon & Johnson, 2006). This meta-analysis examined the effectiveness of sexual risk reduction interventions in 21 studies that integrated a safer sex eroticization component. Eroticization was defined as any sexually arousing, exciting, or pleasurable material that was used to promote safe sexual behavior. Compared to controls, intervention participants exhibited lower sexual risk on six dimensions: HIV-related knowledge, attitudes toward condoms, condom use, overall behavioral risk, communication with sexual partners, and sexual frequency. Additional analyses showed significant improvement in condom use in the intervention compared to the control groups. Overall, findings suggested that eroticizing safer sex leads to more risk-preventive attitudes, which in turn facilitates less risky sexual behavior.
Today’s unprecedented attention and openness to sexual pleasure in sexual health domains is occurring simultaneously with sustained political and ideological resistance to comprehensive SRHR information and services (let alone sex-positive information and services). As such, in 2020 The Pleasure Project initiated an update and expansion of the Scott-Sheldon review and meta-analysis, also building on The Pleasure Project’s literature review (Knerr et al., 2008), in the hope of equipping the SRHR and HIV fields to better meet the needs of communities by considering key reasons people have sex.
Together with support from The Case for Her and in partnership with The World Health Organization, Philpott, Larsson, et al. (2021) undertook a systematic review. The review focuses on the literature since Scott-Sheldon (i.e., from 2006) and is intended to answer the question: Do sexual and reproductive health interventions which incorporate sexual pleasure improve relevant health outcomes? Their hypothesis is that incorporating considerations or concerns around sexual pleasure, this key driver of sexual activity and sexual satisfaction, into SRHR interventions will result in better SRH-related outcomes through 2020 and 2021 focused on the literature since Scott-Sheldon (i.e., from 2006) intended to answer the question: Do sexual and reproductive health interventions which incorporate sexual pleasure improve relevant health outcomes?
Eligible studies are intervention studies with a control group, either randomized controlled trials or quasi-experimental studies, with both pre- and post- intervention measurements. One intervention arm needs to contain at least one component that incorporates pleasure. The authors require that the intervention manual or corresponding published manuscript makes a direct mention of incorporating pleasure that is in line with the definitions for pleasure proposed by the GAB (2016) and adopted by the World Association for Sexual Health (WAS, 2021). In order to isolate the role of pleasure, Philpott, Larsson, et al. (2021) require that another arm provides a comparison measure. The results are finalized and are being reviewed currently.
Philpott, Larsson, et al. (2021) describes in more detail the methodology and challenges of this systematic review, the need for this evidence and its importance for the fields of international development and health, the SDGs attainment and public health.
Case Study: Review of the Health Benefits of Sexual Expression
(Gianotten, 2021)
An essential part of building the evidence base for pleasure involves documenting its link to health. In their 2021 review study, Gianotten et al. conceptualizes the positive impacts of sexual activity, with an emphasis on sexual pleasure. This review employs an expansive approach to “sexual expression,” “sexual health,” and “normal sexuality,” in an attempt to move away from the longstanding focus of biomedical research on penile-vaginal intercourse among heterosexual couples. This past focus does not represent the true diversity of sexual expression. In contrast to past work, this review paper examines pleasure in the context of solo and partnered activity and explores the health benefits of non-penetrative sexual acts such as manual stimulation and oral sex which are quite common, particularly among gender-diverse and sexually-diverse populations (Fortenberry, 2013; Herbenick et al., 2010).
The authors of this review suggest examining the benefits of sexual expression, including sexual pleasure, in terms of time scales: short-term, intermediate-term, and long-term. For example, a short-term benefit is increased pain threshold for a period of time following female genital stimulation (Komisaruk & Rodriguez del Cerro, 2021; Whipple & Komisaruk, 1985). Other short-term benefits include, but are not limited to, improved functioning of the immune system, muscle relaxation, anti-inflammatory effects, decreased cortisol, sleep improvement, endorphin-release, and pain reduction (for migraines, menstruation, endometriosis, etc.) (Gianotten, 2021).
An example of an intermediate-term benefit of sexual pleasure and expression is the postponement of menopause in women who report having sex more often (Arnot & Mace, 2020). Other documented effects include improved mental focus and mood (less depression, stress, etc.), improved fertility, positive pregnancy and birth outcomes, relationship stability, and less sexual dysfunction.
A long-term benefit is the decreased risk of prostate cancer in men who have ejaculated more frequently over their lifetime (Rider et al., 2016). Likewise, longer-term benefits of sexual pleasure also include improved overall functioning and longevity, greater individual happiness and happiness in couples, positive self-esteem and body image, improved circulation, cardiovascular health, decreased diabetes and obesity, and decreased risk of cognitive decline and dementia (Gianotten, 2021). For instance, a study of 16,000 US adults found those who reported more sexual activity reported more overall happiness (Blanchflower & Oswald, 2004).
This review concludes that sexual expression “appears to favor physical and mental health. We guess that many more health benefits will be found when sexuality and intimacy are less taken for granted when studying people.” The article ends with a series of recommendations for how to better address sexual expression and sexual pleasure thereby promoting health in education, training, clinical settings and public health and policy more broadly.
Case Study: A Systematic Review of Sexual Health Interventions
(Hogben et al., 2015)
In their 2015, systematic review Hogben et al. examine the extent to which interventions based on a positively-framed and holistic definition of sexual health have effects in domains relevant to sexual health and public health. These domains were drawn from a 2010 consultation on sexual health and public health at the US CDC and are: (1) knowledge, (2) attitudes, norms, intentions and self-efficacy, (3) negotiation and communication, (4) healthcare use, (5) sexual behavior; and (6) adverse health outcomes (e.g., STD, unintended pregnancy).
What is unique and pleasure-forward about this study is their focus on sexual health framed in positive terms. Outcomes pertinent to sexual health are often framed in negative terms (e.g., the presence of infection), with sexual behaviors construed in terms of their odds of resulting in infection, etc. This review instead employs a positive approach to sexual health. The authors reviewed existing definitions of sexual health and derived common positively-framed elements across them, using these to select studies for a systematic review of interventions designed around sexual health framed in positive terms. A companion paper (Becasen et al., 2015) presents a meta-analysis of effect sizes in a subset of these domains.
Hogben et al. (2015), reviewed 2784 intervention studies among 9064 studies initially identified. The authors narrowed the search to include 58 studies where (1) the intervention treated sexuality or relationships with a sexual or romantic component as something of intrinsic value; and (2) the intervention acknowledged that healthy sexual relationships require positive experiences for all parties involved. For the first criteria, interventions were included if they focused on (a) the possibility of having safe and fulfilling (any of emotionally, socially, mentally, physically, spiritually) sexual experiences, (b) acceptance that sexuality is a natural, healthy part of life, or (c) access to medically accurate and developmentally appropriate education and services. For the second criteria, studies were included if they focused on (a) respectful relationships with honest communication (no coercion), (b) taking responsibility for sexual choices and their impact on oneself, partners, families, and the community, or (c) respect for diversity of values and beliefs around sexuality and societal factors that promote sexual health.
Results showed that interventions were predominantly individual and small-group designs that addressed sexual behaviors (72%) and attitudes/norms (55%). Of the interventions, 98% reported a positive finding in at least one domain: 50% also reported null effects. The most consistently positive effects on behaviors and adverse events were found for sexual minorities, vulnerable populations, and parental communication. Overall, findings suggested that whether via direct action or through partnerships, incorporating sexual health definitions into public health efforts improved sexual health outcomes. The framework developed in this study allowed the authors to systematically review positively framed sexual health interventions and presumably a similar approach could be used for interventions that include sexual pleasure.
Way forward
E. Reaffirm the global, national, community, interpersonal, and individual commitments to recognition of the diversity in sexual pleasure experiences respecting human rights of all people and supported by consistent, evidence-informed policy and practices, interpersonal behavior, and collective action
This article provides evidence and examples for why and how to address sexual pleasure. We hope this article will serve as an explication of the WAS Declaration on Sexual Pleasure and will foster the growing body of pleasure-focused work for generations to come. As we set out to promote sexual pleasure, we encourage partners to keep the following things in mind:
Expand across populations. There is a need to move beyond discussions of pleasure focused only on certain populations. This includes a focus on women, young people, on sexual orientation and/or gender and on marginalized populations to support the relevance of sexual pleasure as a universal demand for all people (Gruskin et al., 2019). Relatable content should be developed and leveraged through the use of social media and other relevant vectors. If we want communities to learn about pleasure, we need to invest time in creating content for the platforms they are currently consuming. Attention must be given to the diverse ways individuals experience sexual pleasure as well as more ecological approaches to create enabling environments necessary to enjoy sexual rights and pleasure. The most vulnerable or disadvantaged populations clearly will vary between countries and within countries. Additionally, pleasure should not be seen as a preserve of a few with privilege or indeed an approach only to “test” with “higher risk groups” (Philpott, Larsson, et al., 2021). Vigilance is needed to ensure better laws, policies and programs to support sexual health, sexual rights and sexual pleasure for all people without distinction. Moreover, diversity should be addressed with alliance building efforts that respect differing perceptions of sexuality, sexual pleasure, and sexual rights. This means using an intersectional, interdisciplinary and multi-sectorial approach to make sure programs are endorsed, implemented, funded and maintained, locally and globally (Gruskin et al., 2019).
A commitment to community-based practices. To be successful, sexual pleasure efforts must be designed and implemented with the input, cooperation and acceptance of the communities involved. In 2010, the WHO published Developing Sexual Health Programmes: A Conceptual Framework and Basis for Action (WHO, 2010). This document provides a framework for promoting sexual health with key attention to profound impacts of legal, political, religious, economic and socio-cultural determinants. Today, more than a decade has passed since that conceptual framework was published and the need address these structural determinants is ever present for sexual health and sexual rights promotion (Logie et al., 2021). The same is true of sexual pleasure. Multi-level (individual, interpersonal, structural) barriers to recognizing the role of sexual pleasure in health and well-being must be addressed through community-based approaches such as the “Pleasure Principles” below.
Monitoring and Evaluation. Where sexual pleasure has been brought into operational terms, there is a clear need to document efforts and most importantly the difference this has made to people's lives. Ongoing work is needed to examine the full body of work that has integrated sexual pleasure into education, health promotion and service delivery, research and advocacy. Evaluation efforts are needed to extrapolate the mechanisms (i.e., time/emphasis placed on pleasure; design/implementation, etc.) that lead to success. Rigorous evaluation of what has been put in place in terms of pleasure-inclusive approaches can effectively be used to frame arguments that are more likely to be accepted locally and globally and in ways that can facilitate access to resources which can then further support direct impacts on people’s lives.
Linked policy, programs, and advocacy. Achieving a world where intersections between sexual pleasure, sexual health and sexual rights are reinforced will not only require strong programs and policy, but linked and comprehensive global, national and local grassroots advocacy (Gruskin et al., 2019). This means, for example, sexual pleasure, sexuality and sexual health-related considerations should be translated into poverty reduction strategies and programs, with a clear understanding of how discrimination and violence around sexuality can intensify poverty and how sexual fulfillment and autonomy can contribute to health and well-being.
While the importance of sexual rights and sexual health is sometimes acknowledged in discussions of international health and development, none have been explicit in focusing on sexual pleasure in the context of sexual health or within the broader agenda of human rights and development (Gruskin & Kismödi, 2020). Most program managers, service providers, lawmakers, and policymakers are not equipped to address the complexity of sexual pleasure or the diverse ways that sexual pleasure is experienced across the life course and in different populations (Fava & Fortenberry, 2021; Ford et al., 2021; Sladden et al., 2021). We can do better than this. The relationship between sexual pleasure, sexual health, human rights and development needs to be translated into actionable human rights-based measures. Advocacy is needed to support policy/legal change, demand equal rights and conditions for all, encourage investment in local and national rights-based sexual health services that address pleasure, demand quality of care and comprehensive sexuality education and hold stakeholders accountable (Gruskin et al., 2019). Such advocacy efforts must include civil society organizations, researchers, service providers, and public and private sectors.
Conclusion
We encourage all partners and practitioners to use the WAS Declaration on Sexual Pleasure, as well as other past Declarations on Sexual Rights and Sexual Health for the Millennium to guide and inspire their work. This article providing technical guidance seeks to inspire our partners and collaborators to embark on a journey toward a pleasure-based approach to sexual health and sexual rights. The way forward may not yet be clear, but it is our hope that literature, guidance and case studies provided here can ignite ongoing advocacy and collaboration to embrace sexual pleasure in all settings.
Correction Statement
This article has been republished with minor changes. These changes do not impact the academic content of the article.
Funding Statement
Funding was received from the Institute for Sexual and Gender Health, University of Minnesota Medical School.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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