How to Define Sexual Health? A Qualitative Analysis of People’s Perceptions

Abstract

Objectives

Sexual health is an essential aspect of overall health that affects an individual’s physical, psychological, and social well-being. Understanding people’s perceptions of sexual health is essential because it can impact their sexual health-related behaviors, namely, their interactions with health services, campaigns, information, and policies. Furthermore, these perceptions may have a systemic impact, as public health policies related to promoting sexual health can be influenced by social factors. Such perceptions may also influence individuals’ sexual expression and interactions with sexual partners. Thus, an understanding of people’s perceptions of sexual health can facilitate the appropriate seeking of sexual healthcare, inform professional interactions with patients and the community, and guide policymakers in the promotion of it.

Methods

A total of 151 people living in Portugal, aged 19 to 75, answered a cross-sectional online questionnaire with an open-ended question: “In your opinion, what is sexual health?”. The data was analyzed using reflexive thematic analysis.

Results

We created four themes: (1) Let’s get physical, physical, (2) I’m in charge!, (3) I am not alone in this, and (4) Sexual justice is a must!. Participants presented diverse and complex views of sexual health, considering that it includes physical and biological components, cognitive and behavioral aspects and relational factors, and it is framed by the social and political context.

Conclusions

This study emphasizes that defining and achieving sexual health goes beyond healthism and needs to be considered at multiple levels. It highlights the need for individual awareness and self knowledge, to recognize equity within relationships and the strive for social equality and sexual rights. The study also emphasizes the significance of considering and respecting sexual developmental when promoting positive attitudes toward sex in formal and informal settings, increasing education about sexual pleasure, accepting and celebrating sexual and gender diversity, recognizing consensual non-monogamous relationships, and the need for inclusivity within sexually tolerant societies. Viewing sexual health through a political lens may play a crucial role in reshaping societal norms, promoting sexual justice, and influencing policymakers to better address and support the sexual health needs of a population following their own perspectives and expressed needs.

A brief history of sexual health

Sexual health: a concept in evolution

Despite the multiple attempts of different organizations to define sexual health, little consensus has been reached throughout the years (Edwards & Coleman, 2004; Giami, 2002; Hargons et al., 2017). In 1975, the World Health Organization (WHO) formulated the initial internationally accepted definition of sexual health following a meeting in Geneva (Edwards & Coleman, 2004). A technical report described sexual health as “the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and enhance personality, communication, and love” (World Health Organization [WHO], 1975). Despite the prominence afforded to the notion of the “absence of disease” (Coleman, 2007), the definition has not received much attention. Nearly a decade later, a meeting in 1983 on sexuality, family planning and overall health reaffirmed the 1975 WHO definition of sexual health, underscoring the necessity of an understanding of sexuality to comprehend sexual health (Edwards & Coleman, 2004). Following a meeting in Copenhagen in 1987, a report was published which argued that the creation of a definition of sexual health was neither a desirable nor achievable goal. Furthermore, it was suggested that any such definition would be limited to a specific culture and a specific point in time. Despite the rejection of a universal definition of sexual health, the 1987 WHO report highlighted several aspects of it, including the need for comprehensive sexuality education and sexual development. The report emphasized that factors such as culture, sexual orientation, and disabilities can impact sexual health (Edwards & Coleman, 2004). Interest in the concept of sexual health emerged again during the peak of the HIV epidemic in the mid-1990s. HIV has affected a large part of the population, prompting answers from various sectors, including communities, the economy, the media, and politicians, to address sexual health. Curiously, this multi-sectoral response to the HIV pandemic paved the way for broader multi-sectoral responses to sexual health, not only for the study and treatment of sexually transmitted infections (Coleman, 2007). Since the original 1975 WHO definition, eight proposed definitions for sexual health were suggested until 2002 (Edwards & Coleman, 2004). Global awareness was rising about the effect that sex-related problems could have on public health (WHO, 2017). Similarly, the influence of stigma and the quality of care on sexual health were becoming increasingly evident (WHO, 2017). In response to the necessity for a more precise sexual health definition, WHO created a task force for this purpose and published an improved sexual health working definition in 2006. The WHO opted for working definitions instead of official ones to clarify what sexual health entails without requiring approval from the WHO’s general assembly, effectively avoiding political entanglements (Coleman, 2007). In 2010, the WHO task force collaborated with external experts and practitioners to outline a framework for developing sexual health programs (WHO 2017) while maintaining the working definition proposed in 2006, namely:

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. (WHO, 2006)

Rohleder and Flowers (2018) pointed out the inclusive nature of this new definition, which integrates information about disease, identity and relationships while contemplating the sociocultural context of all individuals. Miller and Green (2008) mentioned an illness-oriented approach to sexual health which has resulted in a biomedical model that medicalizes sexual issues and that this connection must be overcome. Although illness-related determinants are part of sexual health, other important factors should not be left out, or we have a limited perspective on it and, therefore, an inability to effectively improving it (Rohleder & Flowers, 2018). In fact, sexual health is not only about the absence of sexual disease or dysfunction but also a holistic state of physical, social and psychological well-being (Rohleder & Flowers, 2018). As one can see from the scarce consensus around its definitions, sexual health is bound to subjectivity (Coleman, 2011; Giami, 2002) due to its permeability to social, cultural and political contexts (Edwards & Coleman, 2004; Giami, 2002). Specific events in history stand out for having a profound influence on the ways we perceive sexuality and, consequently, sexual health, such as the 1960s revolution, the HIV-AIDS epidemic, the emancipation of LGBTQIA+ (lesbian, gay, bisexual, trans, queer/questioning, intersex, asexual, and other minoritized sexual orientations and identities) people’s rights (Edwards & Coleman, 2004), and global access to oral contraception (Watkins, 1998).

It is also important to note that some authors, such as Epstein & Mamo (2017), have criticized the evolution of the concept of sexual health, emphasizing its social construction facet and how it has been shaped by current policies, especially those advocating healthism. Healthism prioritizes well-being through a focus on health (Crawford, 1980), as stated in its definition:

Briefly, healthism is […] the preoccupation with personal health as a primary-often the primary-focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of life styles, with or without therapeutic help. The etiology of disease may be seen as complex, but healthism treats individual behavior, attitudes, and emotions as the relevant symptoms needing attention. Healthists will acknowledge, in other words, that health problems may originate outside the individual, eg. in the American diet, but since these problems are also behavioral, solutions are seen to lie within the realm of individual choice. Hence, they require above all else the assumption of individual responsibility. For the healthist, solution rests within the individual’s determination to resist culture, advertising, institutional and environmental constraints, disease agents, or, simply, lazy or poor personal habits. (Crawford, 1980)

Still, Epstein & Mamo (2017) have identified that theorists of healthism have discredited sexuality and frequently portrayed it as arguable, illegitimate, discredited, and stigmatizing. These authors stated that the intertwining of health and sexuality has elevated sexuality to the realm of health, using the “health” component to sanitize and scientize the term “sexuality,” which was previously associated with moral panic and impurity, and belittled sexual health within the frameworks of medicalization and sanitization. Healthism, thus, promotes a narrow and moralistic view of sexual health through the lenses of health, excluding a more comprehensive view that encompasses people’s lived experiences.

People’s perceptions of sexual health often mirror societal norms, cultural values, and personal experiences (Epstein & Mamo, 2017). By understanding these perceptions within the general population, the research community and policy-makers can address social issues and take practical steps to ensure and promote sexual health. This involves identifying and addressing misconceptions and stigma surrounding sexual health topics, which is crucial for removing barriers to accessing sexual healthcare, but it also allows to overcome healthism and get a more nuanced vision of people’s internalization and lived experience of sexual health. Consideration of lived experiences goes in line with Epstein’s (2023) argument that acknoweldges that lay expertise has the potential to contribute to knowledge production and inform practices of citizenship and political struggles.

Understanding this expertise on sexual health may be particularly important, as, despite the promotion of it in several European Union countries, studies have shown that the right to sexual and reproductive health is still not guaranteed (e.g., Keygnaert et al., 2014; Pizzarossa & Perehudoff, 2017; Ravindran & Govender, 2020). This lack of guarantee compromises sexual health rights and highlights the need for continued advocacy and policy improvements.

Sexual health in Portugal

It is essential to examine the definitions of sexual health within specific groups, such as those residing in the same country and accessing the same healthcare system. This is crucial because attitudes toward sexual health often mirror public health policies in each country (Giami, 2002). For example, Portugal has a broad number of initiatives dedicated to sexual health promotion, such as attempts to implement sexuality education in schools (Rocha et al., 2015), free planned parenthood (Remoaldo, 2001), same-sex marriage, decriminalization of abortion, prohibition of discrimination based on sexual orientation (Alarcão et al., 2016), and, more recently, child adoption by same-sex couples (Gato et al., 2021). Although these initiatives might cultivate awareness about sexual health and sexual justice in Portugal, it is our concern that the population’s perception and meanings are not in line with the legal and political framework for action in sexual health healthcare. This misalignment could result in laypeople’s definitions evolving faster than those recognized by international and national organizations, potentially leading to outdated and ineffective approaches to promoting sexual health. Similarly, while organizations evolve in defining sexual health, laypeople’s definitions might remain the same. It is imperative to continually assess the definitions of sexual health held by the general population, rather than assuming that they are informed by current knowledge and policies. Failure to do so may result in the inability to effectively promote sexual health in accordance with the population's needs. The understanding of sexual health held by the general population may inform the policies of policy makers, namely the Portuguese government and, subsequently, those of other European countries.

Theoretical framing

According to the Common-Sense Model of Illness Representation (CSM) (Diefenbach & Leventhal, 1996), an individual’s cognitive and emotional perceptions of a health threat influence the actions they take to cope with the threat and affect critical illness-related outcomes such as well-being and social functioning (Diefenbach & Leventhal, 1996). Additionally, the Theory of Planned Behavior (TPB) (Ajzen, 1991) suggests that our beliefs shape our attitudes, influencing our behavior. Both models highlight the significance of cognition and beliefs about illness and health in health-related behaviors and reckon the role of sociocognitive factors in shaping people’s health-related behaviors. Therefore, knowing people’s representations and understandings of sexual health might help better explain their health-related behaviors and how their perceptions are in line with policy maker’s definitions. To date, and to the best of our knowledge, there has been no research on people’s views of sexual health, which is relevant considering the TPB to understand whether people have attitudes that lead them to take actions to promote and monitor their health.

This is in line with the concept of healthism, which emphasizes the importance of personal responsibility for adopting healthy habits (Riley et al., 2018). While it is important to consider the role of individual responsibility in health promotion, critics of healthism argue that it is also essential to acknowledge that health problems are not merely personal problems (Daly, 2023). Instead, they must be viewed within a broader political context (Crawford, 1980). Understanding the beliefs and conceptions of laypeople regarding sexual health can help us understand the factors that influence their behavior when dealing with health-related issues. This can include behaviors such as seeking help or taking risks to improve and maintain their health. It can also help identify neglectful attitudes that may prevent them from taking adequate actions to protect their sexual health. Furthermore, since the CSM and the TPB focus on cognitive and sociocognitive factors that shape health behaviors, it can contribute to understanding health-related behaviors beyond a purely healthiest model and take a more nuanced and comprehensive look at sexual health, encompassing other experiences that are not illness/health-focused, and recognizing the influence of external factors (e.g., national healthcare system).

Identifying patterns in participants’ definitions can broaden the approach to sexual health beyond a strictly health-related approach which may, in turn, have healthcare implications. It can help to start a conversation in healthcare settings to promote psychoeducation and awareness about sexual health, to include specific training in healthcare curricula to overcome gaps in common knowledge about it (Burnes et al., 2017a, 2017b), or to invest in the improvement of sexuality education in schools (Rocha et al., 2015). Furthermore, knowing if participants’ definitions of sexual health are positively oriented (Donaghue, 2015), for instance, can be an important contribution to research and to the creation of guidelines for clinicians such as counseling psychologists. This is because sex-positive approaches have been shown to promote sexual health and the empowerment of patients, which in turn contributes to their overall wellbeing (Cruz et al., 2017; Hargons et al., 2017). Positive sex approaches are characterized by openness, nonjudgment and freedom of sexual expression and sexuality (Donaghue, 2015) and acknowledge biological, psychological, and social factors that influence individual functioning (Burnes et al., 2017b). This would include considering a broader and comprehensive perspective of sexual health.

Relevance to professionals

Multiple types of professionals, such as psychologists (Reissing & Giulio, 2010), nurses (Evans, 2013), occupational therapists (Lynch & Fortune, 2019), physiotherapists (Areskoug-Josefsson & Gard, 2015), doctors, school and college teachers, among others, play an essential role in sexual health promotion (WHO, 1975) in different life stages. Knowing people’s perceptions of sexual health is crucial for creating favorable conditions for using services and fostering professionals’ collaborative and informed attitudes while also overcoming the exclusive focus on the biomedical model. Thus, this analysis can increase professional awareness about inadequate clinical, educational, and political practice, as well as sexual health promotion strategies that unduly concentrate on outdated problems and lack focus on urgent, more updated issues.

The current study

Our aim with this study is to move beyond a healthistic approach to sexual health. To this end, we will analyze participants’ definitions of sexual health to gain insight into people’s perceptions and understanding of it. This will enable the adoption of a more comprehensive approach to sexual health and to ascertain whether people have an updated, broad vision of it, which could facilitate an appropriate search for sexual healthcare and inform professionals’ communication with patients and the community. By developing this analysis through reflexive thematic analysis, we expect to contribute to a better conceptual understanding of sexual health and, hopefully, expand reflection and knowledge to inform researchers, health professionals and policymakers about its understanding.

Methods

Participants

A total of 151 people participated in the study (M_age = 40.10 years; SD = 14.75; ranging between 19 and 75 years old). All participants lived in Portugal, and most were Lisbon residents (52.7%), 5.4% lived in Oporto, and 2.1% lived in the Portuguese islands (Azores and Madeira), while the rest lived in other parts of the country. Of all, 47.9% of the participants were either parents or guardians or had been at the time of the study.

Dataset generation

The study received approval from the Ethical and Deontological Committee for Scientific Research of the School of Psychology and Life Sciences (CEDIC) of Lusófona University in Lisbon. This study was conducted through a collaboration between MUSEX - the Pedagogical Museum for Sex, the Master’s Degree in Sexology at Universidade Lusófona, and the Portuguese Society of Clinical Sexology (SPSC). It was developed in the context of the first time the National Sexual Health Day in Portugal in September 2021, and previous research has been published using the data from the same project (Beato et al., 2024). This existing published material addresses a different research question and is based on different theoretical models and while most participants overlap (i.e, they answered both sets of research questions), some participants who answered the questions related to the current study did not answer the questions from the previous study, and vice versa, because answering was not compulsory to progress in the survey. The data reported in this study was generated before the data for the other study, so we do not believe that the current answers were influenced by any priming effect.

The questionnaire was designed by the project’s principal researcher and other members of the SPSC, who reached a consensus on the content of each question, including open- and closed-ended questions. It was decided to recruit participants via an online format to promote anonymity and encourage self-disclosure on sexual topics across different geographical locations.

Four psychology researchers revised the questionnaire before it was implemented online by the third author. To generate data with a non-probabilistic snowball-like sampling method, we uploaded a questionnaire to an online survey platform named Qualtrics. With six colleagues/collaborators, the research team tested the online survey to ensure its usability and functionality in different web browsers. We made it available on social media between August 19 and September 29, 2021. The study’s information, such as the study objectives, the right to anonymity and the study duration (10–15 min) were stated in the informed consent. The research team’s email was also included in the informed consent form so that participants could contact the research team to clarify any doubts. Before deleting any IP addresses, the research team checked whether there were answers with the same IPs to prevent duplication. Subsequently, IPs and geolocations were removed. The encrypted dataset can only be accessed by the research team.

To complete the questionnaire, participants had to be (1) more than 18 years old (the age of consent in Portugal) and (2) fluent in Portuguese. For this study’s purposes, we only analyzed the answers of people who lived and were living in Portugal. This is because answers may be influenced by national campaigns and knowledge derived from personal experience with the national healthcare system. In qualitative research, no specific number of participants is required. Instead, we follow guidelines based on the concept of information power. This implies that the more pertinent information the participants have, the fewer participants will be needed (Braun & Clarke, 2021; Sim et al., 2018). Although 151 people participated in the current study, 476 accessed the survey online platform Qualtrics and agreed to participate (68.3% drop-out). Participants who did not respond to this study’s open-ended research question were excluded from the current study.

The current study focused on one open question: “In your opinion, what is sexual health?”. Before presenting the open-ended question, the authors provided neutral examples (i.e., not related to the research topic) on how to answer in a not-so-informative way to an open-ended question (e.g., “I find it awesome”; “I dislike”; “I think it is nice”) and also provided examples of how to answer in an extensive and informative way such that the participants could then frame their answers with maximum accuracy and richness.

Data analysis

The Statistical Package for the Social Sciences (SPSS) software program was used only to analyze participants’ sociodemographic characteristics (e.g., average age and standard deviation).

We used Braun and Clarke (2021) reflexive thematic analysis (TA) approach to analyze our open-ended question. We followed a data-driven and contextual approach to critically understand the meaning of the answers related to a specific context (Braun & Clarke, 2022). Reflexive TA is centered on themes and patterns of meaning of the participants rather than on individual significance (Braun & Clarke, 2021), which makes it ideal for our study’s goal. In TA, a thematic structure is created after analyzing and coding the data (Braun & Clarke, 2021) and then grouping information by core meanings or central organizing concepts, ideally with no more than six themes and subthemes (Braun & Clarke, 2021). We used an inductive approach that involved turning specific data content into broader generalizations (Alhojailan, 2012), and during data analysis, we searched for both semantic and latent meanings (Braun & Clarke, 2021). Another outstanding feature of this approach involves the development of codes and themes as analytic outputs, meaning that they are created after a thorough analysis of the data and not previously planned and searched for (Braun & Clarke, 2021). Reflexive TA, contrary to other TA approaches, acknowledges the researcher’s assumptions and biases as inevitable elements of analysis (Braun & Clarke, 2021). The reflexive approach requires deep immersion in the coding process alternated with periods of distance to cultivate insight and reflection about the data (Braun & Clarke, 2021). In this study, despite using multiple coders as in other TA approaches, we realize this was an opportunity to enrich our reflections and insight, not an attempt to reach consensus (Braun & Clarke, 2021). Reflexive TA also calls for an honest self-assessment of the researcher’s theoretical and philosophical assumptions and contemplation on how this might affect the coding process (Braun & Clarke, 2021). For this reason, and since we have a background in psychology and sexology studies and clinical practice in diverse contexts, we may assume that our background inevitably shapes our understanding of sexual health and related constructs. Throughout the process, we then reflected on our contextualized beliefs about sexual health, its management in clinical practice and, as people who live in Portugal, we reflected on our personal experiences such as having had, or not, sexuality education during middle school. We recognize that our view may be biased toward healthism because our training and activities revolve around providing healthcare, namely, mental health care. As strong advocates and activists in different contexts related to sexual rights and justice (e.g., neurodiversity rights advocates), we reckon that the analysis of some members of the research team may have been informed by these experiences. We refined themes, subthemes and our thematic map multiple times and in different stages of our analysis. The authors’ conclusions were reached collaboratively through regular meetings and careful data inspection to ensure alignment with the proposed map.

According to Braun and Clarke (2024) recommendations, it is discouraged to separate the “Results” and the Discussion” sections. Still, the authors acknowledge that specific journals may mandate this structure (Braun & Clarke, 2021)—as is the case of this paper’s journal. Consequently, we will incorporate distinct sections for “Results” and “Discussion”.

In the following sections, the themes are presented in bold, subthemes are underlined, and the participants’ answers are illustrated in italics. Whenever possible, some of the participants’ sentences were adjusted because maintaining the literal translation would have caused the sentences to lose clarity. However, this was done without altering the meaning of the sentences. Additionally, each participant is assigned a random number for identification purposes, and a minimal anonymous sociodemographic description is provided along with each quote. This includes the participant’s gender, age, sexual orientation, and professional background.

Results

Participants’ answers varied in length. Some were brief, such as Not having sexual diseases (P130, gender – prefer not to say, 72 years old, sexual orientation – prefer not to say, professional working in the law area). Other participants provided medium-length answers, typically two or three sentences, such as Medically, to treat the sexual organs… then to monitor well-being, so that everyone can live their sexuality to the full, in the way they choose. It is to treat dysfunctions (P26, women, 65 years old, heterosexual, retired specialist in public complaints management). There were also longer answers, such as I understand that sexual health is the state our sex life is in. It can be good or bad. As it is health, we must take care of it and go to the doctor whenever there are any symptoms of an abnormality. Sexual health can even reflect the state of our general health. Basically, it’s part of our both physical and mental (P54, man, 57 years old, heterosexual, teacher).

In terms of gender differences, men focused on the physical aspects of sexual activity, regarding it as functional and genital. On the other hand, women emphasized the importance of reproductive health for their definition of sexual health.

Regarding relationship configurations, it was evident that monogamous relationships were more commonly referred to than consensual non-monogamous relationships (CNM).

We noticed that although our research question was intended to generate information about people’s views on sexual health, some participants seized the opportunity to speak anonymously about their private sex lives, focusing their answers on their own sexual activity and suffering.

Overall, the patterns in the answers lead us to develop four themes: (1) Let’s get physical, physical; (2) I’m in charge!; (3) I am not alone in this; and (4) Sexual justice is a must!.

The final thematic map is presented in Figure 1.

Figure 1.

Final thematic map.

Theme: Let’s get physical, physical

This theme emphasizes the satisfaction of biological needs as a crucial part of sexual health. Some answers evoked a tone of fulfilling a basic physical need when discussing sexual activity, while others focused more on physical issues that can interfere with reproductive health, such as sexual dysfunction, STIs and diseases that affect reproductive organs. The shared meaning of these answers is that sexual health has a very palpable, organic dimension and is expressed and achieved only with good physical health.

Subtheme: sex as a natural act

This subtheme is about sexual activity as an inevitable part of human nature or a ‘basic organic need’ that must be fulfilled. For some participants, sexual health is about being able to satisfy these physical needs to attain a state of well-being:

[…] I realized sex itself has an invigorating effect on any person. It is something of extreme importance, and without this activity, we can enter a spiral of anxiety and need. How can such a basic need like sex have such a harmful impact on our health, especially mental health? […] (P129, gender – other, 30 years old, heterosexual, call center worker)

Other participants referred to sexual activity as something simple, restraining their view of sexual health to the materialization of a physical act, i.e., sexual activity:

To look at sexuality like other fields, with no limits, in order to avoid [people being] uninformed about sexuality like me […] when I was little, everything about intimacy was rude and shameful; nowadays, I see sexual life as just sex, nothing more… (P115, woman, 58 years old, heterosexual, nurse)

Also, the idea of sexual activity as a physiological need that does not require complex or elaborate thoughts was highlighted:

[It is] Being aware of it and understanding it [sexual activity] as a physiological necessity and not as a big deal… (P51, man, unknown age, heterosexual, writer)

Sexual health was also defined – especially by participants who identified as women - as part of reproductive health, with participants interpreting these concepts as synonyms:

Sexual health is everything that surrounds human reproduction, from sexual behavior, contraceptive methods and STIs to family planning. (P4, woman, 19 years old, heterosexual, student)

Subtheme: physical well-being

This subtheme focused on physical well-being, with particular importance given to being free from disease to pursue one’s sexual health. Some participants even define it as limited to being free of an STI:

Never really thought about it. I would say it’s a matter of educating oneself on good sexual practices in order to avoid unwanted outcomes like STIs. (P7, man, 24 years old, heterosexual)

Some participants mentioned diseases that affect reproductive organs as barriers to engaging in sexual activity and, therefore, to sexual health:

To me, sexuality doesn’t exist anymore since my husband got prostate cancer years ago. (P61, woman, unknown age, heterosexual)

Other participants - especially participants who identified as men - stated that sexual health is the ability to feel sexually aroused when needed, reflecting the idea that one’s body must be physically responsive to the wish or need to be sexually active:

[Having sexual health] it is to be horny when necessary. (P102, man, 60 years old, heterosexual, welder)

Theme: I’m in charge!

This theme reflects a sense of entitlement about one’s own sexual health. Our data analysis showed that for some participants one must take on a personal active role to pursue their sexual health. This illustrates people’s autonomy in searching for adequate care and improving their sexual health. From this perspective, people do not seem to be limited to their biological nature but are influential agents of their own sexual health through their behavior and attitudes and perceive this autonomy as a necessary part of sexual health.

Subtheme: agency

This subtheme gathers definitions that we interpret as being more focused on taking control of and acting on one’s own sexual health. It is about people pursuing knowledge, searching for healthcare services, and recognizing when such action is needed through self-awareness. This places sexual health in an interconnected light as an ideal state that combines biological, cognitive, and behavioral efforts. People are not seen as passive in the process of attaining sexual health but rather as initiators of it. This can manifest by seeking information when needed:

Sexual health is related to the ability to speak openly about one’s sex life in the contexts one finds important, to look for information when it is needed, to feel comfortable exploring one’s own body and the other’s body, and to prioritize sexual health like any other health field. (P110, woman, unknown age, heterosexual, administrative staff)

Other answers highlighted that sexual health is related to protecting oneself from IST and diseases:

Sexual health involves healthily living sexuality, doing whatever one feels like without any taboo or prejudice, but always being careful and paying attention to matters of safety and health (STIs and other diseases), being alert and looking for specialized counselling as soon as one notices any irregularities. (P99, woman, 21 years old, undefined sexual orientation, tutor)

Although still focusing on physical issues, the term ‘self-defense’, which is stated below, evokes an active role and a prioritization of the self, as if contagious diseases are enemies of sexual health and the individual is a warrior that actively protects themself. Although physical health is considered, the disease is seen as a consequence of one’s behavior. Individual responsibility seems to have a part in the achievement of sexual health, given that preventive and defensive measures are highly dependent on each person:

It is precaution, self-defense against contagion. (P34, man, 58 years old, heterosexual, sales technician)

Taking an active role in one’s sexual health can also mean being aware of one’s sexuality and how it is expressed. Agency about one’s sexual health is not only about avoiding negative consequences related to sexuality but also about observing and exploring one’s preferences and emotional states. The following extract describes the active role one can have in knowing oneself and communicating one’s characteristics and needs to others, which can contribute to consensual intimate interactions. When people ‘demand respect,’ they assume agency over what happens to them and ensure that is aligned with their will:

[It is] To know what we like and how to speak about it with no difficulty. It is to demand respect and to know how to respect our partner. It is to feel happy and accomplished with our intimate experiences. (P141, woman, 30 years old, heterosexual, nurse)

In addition to knowing oneself, one can promote one’s sexual health by being aware of any changes and contacting health services if they occur:

Because it is a form of health, we must take care of it and visit the doctor whenever a new symptom arises. (P95, woman, 57 years old, heterosexual, teacher)

[It is] To be acquainted with one’s sexuality and with other people’s and to look for help when one is not well. Being healthy also means acknowledging when something is not right. Therefore, it is also about knowing where and how to seek help. (P86, woman, 49 years old, bisexual, researcher)

Subtheme: delight

This subtheme also illustrated an autonomous individual approach to sexual health, but with a greater focus on the recreational and enjoyable states related to sexuality. This means that participants defined sexual health as experiencing one’s sexuality to its fullest, making pleasure and playfulness a part of sexual health, with participants thinking beyond the reproductive purposes of sexual activity and acknowledging it as a source of pleasant experiences and not only the relief of biological needs or a purely physical dimension of well-being. The idea of innovation and not sticking to the same sexual experiences is part of this subtheme:

[It is] Everything that involves healthy sex implies respecting the other with well-established boundaries and imagination to get away from routine. (P144, man, unknown age, heterosexual, retired bank officer)

Similarly, participants seemed to think about self-discovery and exploration of sexuality, highlighting the importance of not only having an active role in one’s sexual health but also having a curious attitude towards it. Delight comes from a person’s will to discover themselves and might stem from motivational, inner drives, which can lead to actively seeking different experiences. Once again, I’m in charge! is an appropriate theme name because sexual health is seen as an adventure to be taken within each one’s rules, and sexuality takes place at a very personal and self-managed level. There seems to be an aim on being immune to external influences, which shows that participants are not fully aware of or wish to be free of the contextual nature of sexual health:

Sexual health is liberation from society’s dogmas but also self-discovery that occurs in consensual and safe environments, without political influence or sexual lobbies, so that the person discovers themselves without any external manipulation. (P116, man, 36 years old, queer, manager)

Self-acceptance and self-knowledge are seen as allies to delighting states such as pleasure. To experience pleasure and have others experience it as well, there is a know-how prerequisite of knowing oneself and being accepting of one’s sexual identity. This idea draws attention to pleasure as being a result of a positive view of sexuality:

Personal satisfaction with one’s own sexual identity, with one’s own body, knowing it and knowing how to use it for one’s own pleasure and to satisfy one’s partner. (P54, woman, 39 years old, heterosexual, medical doctor)

Theme: I am not alone in this

This theme illustrates the role of positive close relationships in sexual health, meaning that participants considered several relationship-derived components essential to sexual health: romanticism and feelings of connection to others, such as reciprocity and affection. People find it crucial to feel well about their sexuality within close interpersonal relationships and stress that connection and the emotional part of sexuality is crucial. This reflects a notion of physical and psychological nature being intersected, with emotions and attachment to other people having a central role in sexual health:

[It] is to have a healthy relationship of any kind, may it be heterosexual, gay, etc. … Sexual health has to do with feelings and the way the relationship or sexual practice makes us feel. (P40, woman, 32 years old, heterosexual, call center supervisor)

Some defined sexual health as the inseparable bond between sex and love, making traditional monogamous relationships a central part of it. This view places sexual health as an attribute destined for a particular relationship structure, which does not translate into an accepting and validating attitude toward other people’s experiences and others relationship structures.

It is a state of well-being during the sexual act […] it discourages having multiple partners or any practice that dissociates sex from love. (P63, man, 22 years old, heterosexual, student)

Feelings of trust toward the other/s person/s during sexual experiences were considered important and coherent with the previous extract. For some participants, sexual health is about viewing sexual activity as something precious to the self that must be thought out before becoming involved with someone.

[…] after having shared my sexuality with someone, it is to feel good sexually affectionately with one another. (P120, woman, 24 years old, heterosexual, nurse)

Positive communication skills are also part of being sexually healthy, as they allow negotiation between partners, such as the establishment of boundaries and the clear articulation of desires and intentions:

It is essential to be aware of one’s sexual preferences and to be able to discuss them in an open and straightforward manner, and demonstrate respect for one’s partner and to be able to respect their needs. It is a state of emotional and intimate fulfilment derived from these shared experiences. (P113, woman, 30 years, heterosexual, nurse)

Mutuality was also considered a fundamental part of sexually healthy relationships. This means that interaction not only plays a role, but is an essential component of emotional and relational well-being:

It involves more than the good functioning of each one’s reproductive systems; it is the pleasure we get from our partner and that we reciprocate. A sexual act where only one of the parties gets pleasure does not offer emotional or mental health to the other party. (P138, woman, 60 years old, heterosexual, administrative staff)

Theme: Sexual justice is a must!

This theme captures a shared responsibility between people and their social and political environments. Our interpretation of the data is that people believe that to have sexual health, one must be situated in a socio-political context where sexual rights are advocated, access to healthcare is provided, knowledge is openly discussed, and freedom and acceptance are practized in daily life.

Subtheme: politically speaking

This subtheme encompasses the government’s political responsibility to implement laws and public policies that support and actively promote sexual health by defending sexual rights and ensuring access to services that meet the population’s needs.

This is expressed by having access to healthcare resources:

It is to have access to contraceptive methods—to all of them and not just heteronormative people. I believe that feminine hygiene products should be accessible in the same way condoms are, as well as access to family planning, complete information about menopause and the period before/during/after pregnancy, not selling the idea that pregnancy is all roses. (P29, gender – other, unknown age, bisexual, student)

The extract above also evokes a sense of commitment to realistic information sources and not embellishing sexual health challenges such as pregnancy.

The following extract includes an answer focused on the important role of healthcare professionals, especially those with expertise in sexuality. This can be connected to the desired realistic information, which can result from professionals’ proficiency in what they do:

[…] Physical [health] depends on doctors, gynaecologists and other healthcare professionals, and emotional [health] can go through the same technicians […]. This is where traumas that can completely impair good sexual health appear. Sexologists have a major role in this, helping release ties that are sometimes almost impossible to untie (rape, for instance, an issue I have battled with for nearly 60 years). (P18, nonbinary, 60 years old, lesbian, trainer)

For this study’s participants, in addition to offering realistic information, sexuality education approaches should adopt a broad concept of sexual health. Some participants expressed the view that the sexuality education they received at school was misleading, particularly insofar as it failed to meet their expectations of learning more than the negative consequences of sexual activity:

Contrary to what is taught in school, it is not only to prevent STIs or unwanted pregnancies. Sexual health is a global approach to physical relationships in all emotional and psychological contexts. (P49, woman, 21 years old, bisexual, unknown professional background)

Subtheme: intimate citizenship

This subtheme is about people abiding by sexually fair global values such as equality, acceptance of diversity, consent, and openness in communication in all types of relationship structures. This reflects a predisposition from people on an individual and community level to respect and apply certain ideals that contribute to collective standards of ethical sexual health. Living in a society where acceptance of sexual diversity is a reality was considered a requirement for sexual health attainment, with participants acknowledging prejudice (e.g., discrimination against LGBTQIA+ people) as a barrier to sexual health:

Homophobia is a serious problem of sexual health (P23, man, 47 years old, bisexual, truck driver)

Diversity in gender identity was also highlighted:

Is to know who we are, how we identify ourselves regarding gender, and to be able to experience our sexuality without fear (P142, woman, 37 years old, bisexual, administrative staff)

Participants reinforced that sexual health is being informed and acknowledging the existence of different sexual realities, such as diverse relationship configurations:

It is not something strictly sexual but also […] to educate about polyamory or ethical nonmonogamy (P111, nonbinary, 27 years old, sexual orientation - other, operations assistant)

This was closely related to the idea of freedom of choice in matters of respecting others’ sexuality and accepting people’s differences and uniqueness without prejudice:

To me, sexual health is intimately connected to an absence of prejudice surrounding sexual expression and consent, being informed and awareness of the self and others. (P68, woman, 28 years old, sexual orientation - other, nurse)

A culture of responsibility toward the other/s person/people was noted whereby intimate citizenship includes a series of default principles that need to be present in sexual encounters, independently of the existence of an emotional bond, to prevent any harm to others:

It is complete personal sexual fulfilment without any deviant or addictive practices or practices that put the person or others in danger. (P73, man, 32 years old, heterosexual, lawyer)

Participants also include having consent in interpersonal relationships:

[Sexual health] is closely linked to sexual expression […] that should be consensual, informed and conscious of oneself and the other. (P9, women, 28 years old, heterosexual, nurse)

This theme—Sexual justice is a must!—seemed more relevant and extensively reported and explained in the answers given by LGBTQIA+ participants.

In sum, the theme Let’s get physical, physical emphasized the satisfaction of biological needs as an important part of sexual health and highlighted the crucial role of physical health in sexual health. The theme I’m in charge! reinforces the importance of bodily autonomy and responsibility over sexual health and for achieving sexual pleasure. The role of positive close relationships in sexual health and the importance of trust and mutuality is highlighted by the theme I am not alone in this. Sexual justice is a must! reinforces the importance of socio-political environments for achieving sexual justice, in which participants also highlighted the need for healthcare access, openly discussing sexual knowledge and information in different contexts, and practicing freedom and acceptance toward different sexual expressions in their diverse daily life contexts in a way that does not impose one’s sexuality to any other vulnerable person.

Discussion

Multiple institutions have defined sexual health as a multidimensional construct (Edwards & Coleman, 2004). Our analysis supports this multidimensional nature, acknowledging that the themes are interrelated through specific subthemes. We created 4 themes: (1) Let’s get physical, physical, (2) I’m in charge!, (3) I am not alone in this, and (4) Sexual justice is a must!. The first theme had two subthemes: (1) sex as a natural act and (2) physical well-being. The second theme also had two subthemes: (1) agency and (2) delight. The third theme had no subthemes, and the fourth theme had two subthemes: (1) intimate citizenship and (2) politically speaking. Overall, the themes are interconnected even though the latent meaning of each theme differs. Our analysis reflects participants’ diverse and complex views of sexual health, with a final thematic map including physical/biological, cognitive, behavioral, relational, social and political factors as integral parts of sexual health. This aligns with and supports Epstein’s vision (Zhang, 2024), highlighting this concept’s economic, cultural and political ramifications.

Participants went beyond defining sexual health and discussed and opened up about their unmet needs in a safe platform, even though this was not requested. It can be that people do not receive the adequate or culturally competent help they need when they use health services (Dai et al., 2020; Moleiro & Pinto, 2009) because some health professionals feel they have limited skill sets in dealing with sexual health subjects (Mollen et al., 2020; Mollen & Abbott, 2022; Nixon & Quinlan, 2022) or people do not feel at ease talking about sexuality face to face. Online contexts and interventions for sexual problems can potentially address some of these barriers as they provide a safe space or even support regardless of location and encourage more open discussion of sensitive topics to marginalized or underpriviledged populations (Costa et al., 2023).

The theme Let’s get physical, physical and specifically its subtheme physical well-being focuses on physical health, which is an essential part of sexual health. Some participants interpret physical well-being as part of a multidimensional concept, while others—especially men—seemed to view sexual health as predominantly “functional” and “genital.” It was not surprising that participants’ answers reflected a biomedical perspective, given that historically, sexual health was considered subordinate to it (Gruskin et al., 2019). However, looking through the lens of CSM (Diefenbach & Leventhal, 1996), if people do not perceive an emotional and psychological dimension of sexual health, this could lead to them not perceiving psychological problems related to sexuality as health threats and, therefore, not taking actions to neutralize them. Sexual health was also viewed as a synonym for reproductive health – especially for women. Although sexual health and reproductive health are intimately connected, defining them as the same can hinder a broad and comprehensive view of sexual health (WHO, 2017) and potentially neglect the experience of positive sexual outcomes, such as sexual pleasure. This gender difference – i.e., men tended to focus more on the “functional” and “genital” views of sex, while women tended to emphasize the importance of reproductive health in their view of sexual health - may be partly explained by sociocultural factors, such as the perception of women’s sexuality as primarily for procreation and for providing pleasure to men (Laan et al., 2021)—a patriarchal view of sexuality.

Although participants of this study appeared motivated to prevent STIs, STI prevalence in Portugal has grown recently (Santos et al., 2020). This may be because sexuality education in Portugal mainly focuses on transmitting information and does not use more effective teaching methodologies, such as covering motivational processes and behavioral skills that effectively encourage people to engage in safety behaviors (Reis et al., 2012). It is also important to note that people also receive sexuality education informally (e.g., peers). While this informal education is associated with a more positive attitude toward sex, it is also linked to a higher likelihood of being diagnosed with an STI due to, for example, the focus on pleasure and less frequent condom use (Rodrigues et al., 2024). It may be necessary to combine both formal (e.g., schools) and informal sexual education to benefit from the positive aspects of each (Rodrigues et al., 2024). Also, it is worth noting that the sexuality education provided in schools is perceived as disappointing by this study’s participants, which highlights the need to have another approach to it that fulfills people’s needs. It would be beneficial to consider the factors that facilitate the implementation of sexuality education in Portuguese schools. These may include, for example, the presence of a team responsible for implementing sexuality education, which could include a psychologist (Rocha & Duarte, 2016).

The TPB considers perceived behavioral control a significant predictor of behavior (Ajzen, 1991), and the theme I’m in charge! is in line with this theoretical approach as it points to a strong sense of behavioral control that participants may use, for example, to overcome shortcomings derived from a lack of proper sexuality education and look for more experience, knowledge and resources. This possibility seems to be reflected in the subtheme delight- which stresses the participants’ openness toward exploring sexuality-, but also in the subtheme agency- which stresses their pursuit of sexual well-being and adequate healthcare services and information.

The theme I am not alone in this suggests that people define sexual health within a relational scope, viewing human interaction within close relationships as a fundamental part of sexual health. In line with a systemic approach to sexuality (Hertlein et al., 2009) and with interdependence theory (Van Lange & Balliet, 2015), it is known that, within close relationships, processes and outcomes are well-established correlates of sexual outcomes such as dysfunction, satisfaction, pleasure, well-being and distress (e.g., Brotto et al., 2016; Byers et al., 2021; Pascoal et al., 2013; 2020; Rausch & Rettenberger, 2021; Rosen et al., 2020). It has been argued that sexual health research needs to include partners (Mustanski et al., 2014) to comprehensively address the interaction between individual, partner and dyadic factors to understand sexuality outcomes. This aligns with our participant’s acknowledgement of the relevance of positive close relationships in shaping their sexual health.

This study participants made an important, nuanced contribution by stressing trust and mutuality as core aspects of sexual health. This necessarily raises the issue of trust as a relationship-derived factor contributing to sexual health (Fortenberry, 2019) that needs to be accounted for together with other more established ones, such as relationship satisfaction and its components such as intimacy, communication, and self-disclosure (Bühler et al., 2021). Useful relational skills to attain healthy relationships can be trained in multiple contexts, such as psychotherapeutic settings (Leavitt et al., 2021) and couples’ therapy (Pentel et al., 2021), for people to fulfill a relational dimension of sexual health.

It is important to note that most of the answers related to relationships were focused predominantly on monogamous relationships, and some answers did not show acceptance or validation of CNM people’s experiences (e.g., polyamory, swingers, open relationships, relationship anarchy). In Western countries, monogamous people are seen as trustworthy and sexually satisfied, and CNM are usually viewed as promiscuous (Cardoso et al., 2021) and as having more sexual health problems (e.g., more sexually transmitted infections; Rodrigues et al., 2022). Stigma regarding non-monogamous relationships appears to be rooted in societal norms and the limited scope of sexuality education, which often fails to address the diversity of relationship configurations.

Participants highlighted that emotional involvement in partnerships and reciprocity is essential to achieving sexual health. However, regarding relationships, they also referred to the preexistence of a set of ethical principles that should frame these relationships, such as rules of respect, acceptance, and freedom. These principles exist beyond a close relationship and can be applied to any type of relationship (e.g., one-night stand, open relationships, committed relationships). This particular aspect that goes beyond the spectrum of an existing emotional bond is stressed under the subtheme intimate citizenship integrated into the theme Sexual justice is a must!, which will be discussed next.

The theme Sexual justice is a must! points to the need for advocacy for a political responsibility to deliver adequate and updated services to the population. Considering the TPB (Ajzen, 1991) and its recognition of intention as a main predictor of behavioral achievement, it is crucial to study motivational factors such as sexual pleasure (Meston & Buss, 2007) and their role in people’s health behaviors to improve models and practices that account for sexual health-related behaviors. This result highlights the importance of sexual pleasure and align with the World Association for Sexual Health Declaration on Sexual Pleasure (WAS, 2021), which prioritizes sexual pleasure in the context of sexual health promotion.

For the subtheme, politically speaking, it appears that participants attribute external responsibility for the achievement of sexual health to governmental entities and policy makers. This is on the basis that these should ensure quality and inclusive services to the population. People seem to view the accomplishment of sexual health not only as multidimensional but also as collaborative, recognizing that people must take the initiative to promote their health but that this is only possible within an updated and available political context. Political engagement in sexual health translates into initiatives to improve public health outcomes (Epstein, 2023; Zhang, 2024). The politically speaking subtheme aligns with Epstein’s (2023) position, supporting that framing and understanding sexual health within a political context becomes a mechanism through which societal perceptions and norms about sexual health can be redefined. That means that individual experiences related to sexual health are not just personal but also shaped by political contexts and societal structures. Examining sexual health through a political lens makes it possible to challenge and enrich current norms and perceptions. So, a political approach to sexual health can be instrumental in redefining societal norms, as well as promoting sexual health and sexual justice, which can serve both regulatory and transformative purposes, such as influencing policymakers to better address and support the sexual health needs of a population according to their own views and voiced necessities.

In line with the need for political engagement in sexual health improvement, in the theme Sexual justice is a must!, our self-identified LGBTQIA+ participants highlighted that sexual health can only be achieved if acceptance of gender and sexual diversity is valued and recognized as a human and sexual right. According to Epstein and Mamo (2017), the act of viewing sexual health as a means of addressing social issues is a form of self-empowerment and sexual liberation, which can in turn faciliate social change to ensure sexual rights. Thus, viewing sexual health as a tool for addressing social issues may assist people in recognizing that taking the initiative to improve their own sexual rights is a viable course of action, which is connected to the subtheme agency, I’m in charge!. This is especially important since even though society may be becoming more accepting of LGBTQIA+ people, this does not guarantee that stigma is reduced both in daily life and within the healthcare system. For example, in the United States, despite initiatives for LGBTQIA+ rights, over 35% of American adults believe same-sex relationships are wrong to some degree (Ford et al., 2023). Specifically in Portugal, studies have shown that psychology students may have negative biases toward LGBTQIA+ people (Gato & Fontaine, 2016), which can create barriers for those seeking psychotherapy (e.g., Moleiro & Pinto, 2009). This impacts the possibility of seeking healthcare, as LGBTQIA+ people usually avoid asking for professional help for health problems (Ayhan et al., 2020). In a Portuguese study regarding the perceived challenges and training requirements for professionals who deal with same-sex couple adoption (Gato et al., 2020), the authors highlighted that adoption application forms are absent for same-sex couples and that there is a lack of training syllabi and guidelines for professionals such as psychologists, social workers, kindergarten teachers, and lawyers. Acceptance of sexual diversity can also be cultivated through education by including LGBTQIA+-related curricula within and outside of sexuality education classes (Goldfarb & Lieberman, 2021). Preparing teachers to discuss this content in schools is one of the initial steps to promoting bias-free and inclusive classrooms (Wright & Delgado, 2023) that may reduce the stigma about LGBTQIA+ content.

The importance of sexuality education to promote sexual justice is sustained by the literature. For example, Reichert et al. (2001) state that pleasure-inclusive messages are more captivating and easily remembered than non-pleasure-related messages and are less likely to find resistance in the message receiver. Sexual health promotion through school has better results when implemented early in elementary school and through long-duration programs (Goldfarb & Lieberman, 2021). Our results are in line with this literature and show that people acknowledge that comprehensive sexuality education is a means to achieve sexual justice and, subsequently, sexual health.

In the theme Sexual justice is a must!, specifically in the subtheme intimate citizenship, some of the participants emphasized that achieving complete personal sexual fulfillment involves engaging in safe and consensual sexual activities framed by good communication, while avoiding harmful or addictive practices. This subtheme is related to the internalization of the idea that human relationships, despite their status, must be a safe zone (e.g., Servino et al., 2011). By approaching relationships following these principles, people may achieve a state of sexual health that enhances their overall well-being and quality of life. This result aligns with literature that shows that good communication is an interpersonal behavior positively associated with sexual satisfaction—an indicator of sexual health (Blondeel et al., 2024)—in both men and women (Pascoal et al., 2019) and across different types of relationship structures (e.g., hookups; Ben-Ze’ev, 2023). For example, a study (Campbell, 2008) examined how men and women felt after one-night stands. The results indicated that both genders experienced positive outcomes such as increased confidence, feeling alive, and sexual satisfaction. Interestingly, there was only a slight difference in the disappointment of not developing a further relationship between men and women, suggesting similar expectations, probably due to effective communication, implying the existence of effective implicit norms beyond the boundaries of close relationships. Moreover, poor communication, including inadequate communication about sexual needs, seems to be strongly associated with sexual distress (e.g., Hendrickx et al., 2016). This highlights the importance of ethical values of equity and respect guiding and framing any intimate relationship, and suggests that effective communication may be a key process in achieving this.

Implications

Our results reaffirm sexual health as a multidimensional construct, and accentuate its nuances at different levels. Different professionals, such as psychologists, social workers, doctors, and teachers, should address its promotion (WHO, 1975). For this to be adequately tailored to people’s needs (Pentel et al., 2021), it is urgently necessary to adapt training curricula in these areas to prepare professionals to promote sexual health. In addition to having access to intimate and sensitive information from their clients, healthcare professionals can provide customized tools and strategies tailored to the specific needs of people in different contexts, unlike what occurs in educational settings with large groups. Our results highlight that people might feel that they are learning a very restrained, limited set of skills related to sexual health, thus stressing the importance of investing in different paradigms of sexuality education, such as a comprehensive approach (Mark et al., 2021) that goes beyond information transmission and promoting behavioral and emotional skills (Reis et al., 2012).

The core of sexuality education in Portugal is centered on preventing unwanted outcomes of sexual activity, such as STIs and unplanned pregnancies (Rocha et al., 2015). Considering the challenges faced by the implementation of sexuality education in Portugal, such as the lack of practical application of theoretical knowledge and the difficulties experienced by teachers (Rocha et al., 2015), healthcare professionals could play a crucial role in school-based sexuality education. They could enhance it by identifying individuals at risk more sensitively and by teaching communication skills to both teachers and students. It is also essential to talk about measuring and monitoring sexual health in different contexts (e.g., media) as a way to raise awareness and promote familiarity with the concept (Ford et al., 2023). By openly addressing this topic, we can empower people to take charge of their sexual health, seek appropriate care, and contribute to a culture of informed decision-making and well-being. Also, this may reduce perceived gender differences, which may serve as sexual justice (Laan et al., 2021).

Our findings also suggest that some people might have narrow perspectives on sexual health, possibly not acknowledging other critical dimensions beyond the physical dimension and, therefore, ignoring aspects that are detrimental to their sexual health. Healthcare professionals need to be aware of this and use psychoeducation (Donker et al., 2009) and a biopsychosocial approach in counseling that considers biological, psychological and social factors (Nimbi et al., 2021), mirroring a multidimensional conceptualization of sexual health. For example, professionals must consider that a failure to engage in discourse on the topic of sexual pleasure with their patients, or an indifferent approach to such discourse, may result in adverse effects for people (Rudolph et al., 2024). The role of sexual pleasure as a motivation and outcome of sexual activity must be considered to improve people’s sexual health (Coleman et al., 2021). Nonetheless, it should be noticed that having a narrow, strict view of sexual health can cause people and professionals to neglect available services or refrain from searching for or referring to them (Diefenbach & Leventhal, 1996).

Lastly, while participants did mention fundamental concepts in their answers, such as consent and sexual freedom, child sexual abuse prevention was not referred to. Child sexual abuse is highly prevalent (Lee & Kim, 2023) and can have a strong negative impact on its victims (Downing et al., 2021), affecting their sexual health, rights and pleasure (Fava & Fortenberry, 2021). Although our results do not represent all people living in Portugal, the absence of this and other issues that may impact sexual health could inform future studies that search for gaps in people’s knowledge to support policymaking and health promotion changes.

Limitations and future directions

We used a snowball-like sampling method to generate data online, which may have led to an overrepresentation of educated people participating in our study. This suggests that our research might have overlooked the perspectives of certain groups (i.e., older people and people without internet access). Therefore, further qualitative and quantitative studies with a broader variety of sociodemographic characteristics could bring us a more comprehensive understanding of the subject.

Although online surveys are widely used in sexual health research (Ross et al., 2005), we cannot guarantee that the participants did not search for scientifically established answers or use other people’s opinions. Additionally, the lack of interaction between the researchers and participants made it impossible to clarify ambiguous answers. However, this data generation method was used because it allows participants to be more geographically diverse (Braun et al., 2017) and facilitates disclosure on sensitive topics such as sexual health (Davey et al., 2019). The richness of our participants’ answers helped us reflect on current problems surrounding sexual health in Portugal. While this study does not claim to be statistically generalisable, it has nevertheless offered us a starting point for further reflection and analysis.

Our data was generated in the summer of 2021, indicating that the participant’s answers were given within the context of a pandemic. For this reason, we underline the importance of studying people’s conceptions of sexual health in a post-pandemic context and continuously in time, not because our participants do not signal an essential perspective on sexual health but because it is imperative to keep up with social and political changes and how they can change such views. Also, it is possible that our study results may not apply to all people in Portugal because the people who decided to participate may be already motivated and possess more knowledge about sexual health and the prevention of STIs, which could have influenced the outcomes.

Furthermore, considering that almost half of the participants were parents or guardians at the time of the study or had been in the past, we find it surprising that they did not mention child abuse in their answers. Parent’s and children’s knowledge of this topic should be studied.

Final considerations

This study represents an early step in the production of literature about sexual health. It emphasized that achieving sexual health goes beyond healthism and requires the recognition of equity in relationships as well as perceiving to have social equality and sexual rights, emphasizing this is dependent on the political context. Important implications may begin with sensitizing and training professionals in healthcare, social work, and education to reinforce the importance of sexual health using a comprehensive lens, increase the acceptance and celebration of sexual and gender diversity, and promote inclusiveness within sexually tolerant societies. It also emphasizes the need to embrace and promote sex-positive messaging to promote sexual justice in Portugal. Still, it is fundamental to target individual, interpersonal and societal barriers to sexual health, and collect evidence for better ways to promote it in Portugal.

Funding Statement

This work was partially funded by Fundação para a Ciência e Tecnologia (FCT) under HEI-Lab R&D Unit (UIDB/05380/2020) and partially funded by FCT – Fundação para a Ciência e a Tecnologia, I.P, through the Research Center for Psychological Science of the Faculty of Psychology, University of Lisbon (UIDB/04527/2020) and was partially financed by national funds through FCT under project https://doi.org/10.54499/2022.09087.PTDC.

Disclosure statement

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

Data sharing statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.