Advancing a Measure of Sexual and Reproductive Well-Being Aligned With Core Values of Reproductive Justice and Human Rights

Abstract

Sexuality and reproduction are central to people’s life experiences and their ability to thrive. Existing frameworks and measurements related to sexuality and reproduction are predominantly focused on the presence or absence of adverse outcomes, neglecting the critical question of whether people experience positive outcomes and have the sexual and reproductive lives they wish to have. The increased attention to well-being in economic, political, and health spheres presents an opportunity to define and measure the holistic construct of sexual and reproductive well-being.

To this end, we engaged in an 18-month collaborative process to develop a definition of sexual and reproductive well-being, with the ultimate goal of informing the development of a measure that would be self-reported and assessed at the population level.

The resulting draft definition and measure development approach will serve as the foundation for subsequent measure development. This values-driven process of defining sexual and reproductive well-being will contribute to developing a reproductive justice– and human rights–aligned measure that can illuminate the extent to which structures and systems enable optimal sexual and reproductive experiences. (Am J Public Health. 2025;115(9):1463–1471. https://doi.org/10.2105/AJPH.2025.308119)

Sexuality and reproduction are core dimensions of the human experience that have wide-ranging impacts across the life course, including on physical and mental health,^1,2 and are central components of life satisfaction.^3,4 The World Health Organization has recognized the centrality of these experiences with a published working definition for sexuality as “a central aspect of being human throughout life [that] encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction.”⁵ In the United States, the reproductive justice movement was borne out of and has foregrounded a recognition that reproduction and, more recently, sexuality are central to people’s lives; this recognition includes the “human right to maintain personal bodily autonomy, have children, not have children, and parent those children we have in safe and sustainable communities.”⁶ The movement has emphasized how inequities in access to desired reproductive and sexual experiences are injustices and violations of human rights.

The increasing traction of and attention to how people’s holistic and interconnected experiences of sexuality and reproduction relate to human rights and to social justice have led to a shift among clinical and public health organizations toward calls for reproductive justice.^7–9 However, this shift has not permeated deeply into programs and policies, with ongoing siloes in sexual and reproductive health (SRH) between those, for example, engaged in pregnancy prevention, in sexually transmitted infection prevention and treatment, and in pregnancy-related care. Furthermore, SRH policies and programs in the United States continue to be entrenched in a deficit perspective focused on avoiding adverse outcomes, as opposed to emphasizing positive experiences, as evidenced by the lack of attention on a national level to positive sexuality and support and services for those unable to achieve desired pregnancies owing to infertility.^4,10–12

One barrier to breaking through these siloes and moving toward a holistic, positive frame with respect to sexuality and reproduction is the lack of availability of metrics that reflect a more aspirational vision. In the United States, the state of the population’s SRH is tracked using disparate measures, including the rates of unintended pregnancy, abortion, and contraceptive continuation.^13–15 These measures are influential tools that guide much of the conversation (and funding) related to sexuality and reproduction. However, these metrics were not developed from the framework of seeking to understand and support people’s sexual and reproductive lives from a holistic and positive perspective and have been criticized from both conceptual and methodological standpoints.¹⁶ This has included questioning the extent to which “intention” truly measures the acceptability of a pregnancy to an individual and whether decreases in abortion rates should be interpreted as representing a decreased need for this care as opposed to decreased access.^17–20 Rates of contraceptive continuation and the use of long-acting reversible contraceptive methods—other commonly used metrics—are also problematic, as they do not center people’s needs, values, and preferences with respect to contraceptive use, while they perpetuate stigmatizing and oppressive narratives of reproduction.^21–23

The prioritization of measures related to pregnancy intention and contraceptive use stems from prescriptive ideas about what reproductive behaviors and outcomes are desirable and therefore does not reflect a focus on person centeredness or reproductive autonomy.^16,24 The emphasis on these measures in public health and clinical research has the potential to incentivize programs and policies away from what people care about, including by encouraging directive contraceptive counseling.²⁵ Furthermore, the degree to which people achieve the pregnancies they wish to have and their experiences of sexuality are neglected.

Existing measures used in the United States are therefore ill-suited to support the clinical and public health communities as they move toward a focus on people’s holistic lived experience of sex and reproduction owing to their fragmented approach and the notable gaps in the outcomes that are included. Of note, there have been recent innovations in measurement that are moving in the direction of centering human rights in SRH programs. This includes, both in the United States^26,27 and globally,^28,29 increasing focus on measures of person-centered reproductive health care. Furthermore, in the global context, measures have been developed to capture constructs such as contraceptive agency,³⁰ contraceptive autonomy,³¹ and preference-aligned fertility management.³² However, this type of innovation has not been prominent in the United States, and even these measures do not fully capture people’s experiences, as they are focused on specific aspects of sexual and reproductive lives and are generally focused on pregnancy prevention, as opposed to, for example, obtaining desired fertility. New measures that more holistically reflect people’s sexual and reproductive experiences—and those that align with values of justice, equity, autonomy, human rights, and person-centeredness—are sorely needed to inform policy and programmatic priorities in the United States.^33,34

SEXUAL AND REPRODUCTIVE WELL-BEING

In economic and political spaces, there has been increasing recognition of the value of prioritizing and measuring well-being as a means of determining how well people’s health and social needs are met. Well-being—defined as what is “non-instrumentally good for a person”—is a positively framed outcome that represents whether people are able to thrive in their lives.³⁵ This shift in focus—in geographies as varied as Iceland,³⁶ Scotland,³⁷ and Bhutan³⁸—stems from a recognition that the success of programs and policies does not depend only on individual- or population-level financial statistics, such as that captured with gross domestic product, but also on other components of the lived experiences of populations. Jacinda Ardern, former prime minister of New Zealand, verbalized this perspective: “We need to address the societal well-being of our nation, not just the economic well-being.”³⁹

Aspects of people’s lives that are included in measures of well-being include the work environment, leisure activities, mental and physical health, and interpersonal relationships. To date, however, well-being measures used in these political and economic contexts have neglected the experiences of sexuality and reproduction, despite their central salience to the human experience.

Applying a frame of well-being to SRH and to measurement in SRH research and practice provides an opportunity to advance work both in well-being and in SRH. From the perspective of SRH, applying the well-being framework is consistent with the reproductive justice framework because they both focus on people’s experience of sexuality and reproduction holistically and comprehensively.

Creating a valid measure of sexual and reproductive well-being (SRWB) would be a critical step toward addressing the gaps in the measurement landscape because it would move us away from a deficit approach and capture the ultimate outcome of interest: whether people are living the sexual and reproductive lives they wish to. In economics and policy contexts, attending to and measuring SRWB offer a mechanism for tracking this important component of lived experience, both in general and in response to policy interventions. This is particularly critical because the importance of sexuality and reproduction in people’s lived experience is frequently neglected or minimized in policy spheres, owing at least in part to the gendered nature of reproduction as well as the stigma of and discomfort with discussing issues related to sexual experience and pleasure.⁴⁰ Well-being as a measure of a society’s success must include consideration of people’s sexual and reproductive experiences if we are to understand how to undertake evidence-based policy interventions to improve SRWB and well-being overall.

We note that globally, and most prominently in Northern Europe, there has been increasing attention to the concept of sexual well-being, including the development of measures that capture this construct.⁴¹ This work is an important departure from stigmatizing narratives on sexuality and has already had consequences for policy and practice that incorporate positive sexuality^42–44; it has not, however, had substantial impact in the United States.⁴⁵ Our interest in a measure of SRWB for the United States is informed by this work and is distinct in incorporating experiences of reproduction to consider sexuality and reproduction holistically to align with reproductive justice. In addition, our conceptualization of well-being is as the ultimate aspirational outcome related to sexuality and reproduction. By contrast, most recent definitions of sexual well-being, including that of the United Kingdom’s National Survey of Sexual Attitudes and Lifestyles, consider sexual well-being as coexisting with, and not including, other components of sexuality, such as sexual health and sexual pleasure.^4,46 Our framing of SRWB as the ultimate end goal is aligned with how well-being is defined in economic and policy spheres and is consistent with the rights-based reproductive justice framework.

TOWARD A SEXUAL AND REPRODUCTIVE WELL-BEING MEASURE

To move forward with applying the construct of well-being to measurement in SRH, the Coalition to Expand Contraceptive Access, the Person-Centered Reproductive Health Program at the University of California, San Francisco, and the National Birth Equity Collaborative engaged in a collaborative process to develop a definition of SRWB, with the ultimate goal of informing the development of a measure of this construct that would be self-reported and assessed at the population level.

Recognizing that measure development work, particularly in SRH, is often limited by a lack of intentional framing and defining of the construct of interest—which can result in imprecise measures without broad acceptability— this work was intentionally collaborative and longitudinal, with the goal of ensuring careful and inclusive consideration of the definition of SRWB before moving to the measure development process. By engaging in an intensive, 18-month foundational process, the team showed their commitment to avoiding the errors of many previous efforts at developing measures of sexuality and reproduction, which have been siloed by discipline and have not engaged consistently or rigorously with the lived realities of the populations whose experiences are being measured. We acknowledged the reality of stratified reproduction, in which people from minoritized groups—including individuals with disabilities, gender-expansive individuals, and people of color—have their reproduction devalued in formal and informal ways.⁴⁷ In doing this, we worked to ensure that our definition and measure development approach incorporated this reality to consider the full range of influences on SRWB.

To initiate this process, we convened a working group of experts in reproductive epidemiology, maternal and child health, reproductive health care, economics, and reproductive justice in a series of virtual meetings; our goal was to produce and disseminate a definition of SRWB and create a strategy to develop and validate a SRWB measure. This group was intentionally diverse with respect to discipline, gender, race/ethnicity, and region of the country.

Aligning Measures With Values

In the expert working group’s early engagements, concern and skepticism about previous measurement efforts in SRH was evident, as we recognized the potential harm of these measures and how public health and clinical priorities, as opposed to reproductive rights and justice, have been foregrounded. There was a demonstrated need for a common foundation and understanding for conducting this work to provide a touchpoint and an accountability mechanism throughout the process. To this end, the working group developed a collaborative set of principles to ground the work. Recognizing how process and output are intricately interrelated, these principles were intended to capture the underlying goal of this work—to develop a subjectively defined, holistic, and positively framed measure—and process considerations such as centering values and engaging with communities.

The principles we developed are as follows:

• 1.Center values of reproductive justice throughout this process. Root this measure and the process in concrete values and goals from conceptualization through implementation.
• 2.Define SRWB “in the eye of the beholder.” Everyone has different lived experiences and desires, impacted differently by policy and structural contexts. Prioritize how individuals understand and define their subjective well-being across the life course.
• 3.Rely on diverse community engagement. Measure developers alone should not define well-being for all individuals. The development process must engage in an inclusive process that is informed by community feedback and qualitative information gathering conducted throughout measure development and validation.
• 4.Move away from negative definitions and toward a positive framing. Many existing health-related measures are defined in the negative, including by the absence of illness or problem. Focus the SRWB measure on positive elements, emphasizing the outcome of well-being and key components along the pathway to achieving well-being.
• 5.Reiterate the importance and unique contribution of holistic measures, such as that of SRWB. Frame why a SRWB measure is needed and its intended use as part of this process to emphasize the potential positive impacts and promote culture shift.
• 6.Build on, but do not be constrained by, previous measurement approaches. Measures have their limitations and can be used inappropriately. It is important to consider both traditional and innovative approaches to measure development to learn from and reimagine their value and utility and not re-create previous harms.

An additional consideration that arose from conversations among the working group was the need for explicit grounding of SRWB in the structures and systems that influence people’s ability to achieve this aspirational outcome. We identified this step as an essential component of developing any robust measure to ensure that this process was contextualized and not performed in isolation without considering oppressive factors.

We developed a conceptual model that proposed the socioecological factors and context that constitute SRWB and influence people’s ability to achieve SRWB (Figure 1). The graphic is an adaptation of a model developed by Braveman et al. for the Robert Wood Johnson Foundation⁴⁸ and illustrates how structural, social, and individual determinants directly and indirectly shape the outcome of SRWB. The social determinants of health equity are intentionally illustrated as a “sea” in which this model “swims” to demonstrate how systems of power and history pervade all societal structures, policies, practices, values, choices, and, ultimately, SRWB.^49–50 Being explicit about the relationship between SRWB and these social determinants of health equity and the socioecological determinants included in the model helps ensure that the continued development of the SRWB measure, including the definition of SRWB, will be informed by contextual factors.

FIGURE 1—

Socioecological Determinants of Sexual and Reproductive Well-Being

Source. Adapted from Braveman et al.⁴⁸ for the Robert Wood Johnson Foundation; Commission to Build a Healthier America, www.commissiononhealth.org for the Sexual and Reproductive Wellbeing Measure Planning Project, January 2023.

Note. See additional examples at each socioecological level in Figure A (available as a supplement to the online version of this article at http://www.ajph.org).

Defining Sexual and Reproductive Well-Being

With a foundation for measure development shaped by reproductive justice and a contextual understanding of the construct of interest, we collaboratively defined the concept of SRWB (Box 1) based on the conceptual model; evidence about people’s experiences, and insights into their SRWB; existing SRH definitions and measures; expert working group discussions; and reproductive justice. Our definition articulates the key concepts and overarching domains of the construct, identifying the ultimate health and social outcomes as well as essential factors along the pathway to achieving those outcomes. Throughout the process of developing the definition, we ensured attention to inclusivity and worked to develop a broad definition that is applicable to people across the life course regardless of context, preference, or specific sexual and reproductive experiences.

BOX 1—

Draft Definition of Sexual and Reproductive Well-Being

Sexual and reproductive well-being is a state of complete physical, mental, and social fulfillment in all matters related to sex and reproduction free of injustice, oppression, coercion, violence, and stigma and their consequences. This includes having the following:
•Freedom and ability to control, act on, and not act on one’s sexual and reproductive decisions, desires, goals, and identities, including having comprehensive information, services, and supports and not being hindered or harmed
•Access to and experience of holistic and high-quality care for one’s sexuality and reproduction, free of judgement, bias, and coercion, that prioritizes personal needs and desires
•Optimal sexual and reproductive outcomes in accordance with one’s needs and desires:  ○Attaining one’s ideal state of sexual and reproductive health  ○Choosing if, when, and how to become a parent, and the ability and resources to do so  ○Having a pleasurable and safe sex life

In framing this definition, we intentionally moved beyond health outcomes being considered equivalent to well-being and recognized how experiences in the process of achieving these health outcomes also contribute to achieving well-being. As an evocative example, we considered how someone who has the number of children they wish but experiences a lack of agency in their sexual relationships or abusive or disrespectful health care could not be considered to have achieved SRWB. Rather, SRWB occurs when someone has good SRH outcomes, the family size they desire, positive sexuality, and experiences agency and quality care in the process of achieving those outcomes.

Developing a Measurement Strategy

To move toward a measurement for this definition, the project team, in consultation with the working group, developed an initial measurement framework of SRWB drawing from the draft definition. The initial measurement framework distills the conceptual definition into initial proposed measurement domains to guide measure development, including item generation. These domains were as follows:

• 1.Agency, autonomy, and freedom from oppression in matters related to sexuality and reproduction;
• 2.Experience of SRH care;
• 3.One’s ideal state of SRH;
• 4.The choice of if, when, and how to become a parent and the ability and resources to do so; and
• 5.A pleasurable and safe sex life.

We next considered with the working group how to use this draft definition and measurement framework as a foundation for the process of measure development, including ensuring continued adherence to the core identified values and to scientific rigor. Specifically, we considered the importance of centering the perspectives and expertise of the population for whom the measure is designed and developed a plan for prioritizing community voices through the measure development process, building on principles of cocreation.⁵¹ This includes extensive qualitative work and community consultation in each stage of the measure development process, including in refining the definition of SRWB. By contrast to the common strategy of item generation occurring through consultation between researchers, we intentionally planned for exploration of item wording through the first stage of our qualitative work.⁵² The proposed steps for measure development, with attention to how community voices will be included in this process, were as follows:

• •
  Step 1. Refine the definition and measurement framework through interviews and other stakeholder discussions

  • •
    Ensure intentionality in the inclusion of diverse communities and perspectives
  • •
    Iteratively explore the wording and interpretation of the domains and questions
• •
  Step 2. Draft a preliminary instrument and conduct cognitive interviews with a representative sample of different populations

  • •
    Based on the results of step 1 and reviews of qualitative and quantitative research on sexual and reproductive experiences in the United States and globally, develop a preliminary set of survey items
  • •
    Learn from participants’ impressions and experiences about the items to refine and revise them to best represent the perspectives of diverse communities
• •
  Step 3. Rigorously test and refine the instrument and develop recommendations for use

  • •
    Evaluate validity and reliability to determine whether the measure accurately represents the construct of SRWB
  • •
    Ensure that testing represents and is relevant for diverse communities
  • •
    Conduct a stakeholder-engaged consensus-building process to develop appropriate implementation and interpretation guidance that optimizes impact

Having laid the groundwork for a values-driven and rights-based measure development process of SRWB, we now look forward to the next steps: operationalizing this strategy and achieving the goal of a valid and reliable measure of the degree to which people are living the sexual and reproductive lives they wish to. In doing so, we will benefit from the work that has already been done in developing measures of several domains included in this definition, such as experience of care and agency.^27,30 However, recognizing that our ultimate goal is a concise measure appropriate for use in demographic monitoring, it will be necessary to modify existing items or develop new items to more concisely capture these constructs with wording that is universally relevant and understood across contexts, preferences, and experiences. Although this will be challenging, this difficulty cannot and should not stand in the way of working to measure what we actually care about, rather than continuing to measure things that are more easily quantifiable but do not adequately capture the realities of people’s lives.

Having a population-level measure of SRWB would mark a fundamental shift in how SRH is measured. Through tracking SRWB over time and in response to policies and programs, we can see how factors such as contraceptive and abortion access, paid family leave policies, and economic supports can influence people’s holistic experience of their sexuality and reproduction. Furthermore, by stratifying the measure by age, sexual orientation, race, and gender, inequities in this outcome can be identified and mitigated.

In addition to these practical implications, the availability of metrics drives what is prioritized, as laid out in the frequently used adage “What gets measured gets done.” The currently available SRH metrics—including unintended pregnancy rates, abortion rates, and metrics of sexually transmitted infections (with a notable lack of focus on people’s ability to achieve desired fertility)—drive a fragmented policy and programmatic agenda that seeks to address individual negative outcomes, without attending to the bigger picture of people’s lives. Furthermore, these metrics are disconnected from a human rights–based framework that centers people’s right to optimal SRH and experiences. As a result, the SRH narrative tends to focus on risks and challenges rather than on supporting people in achieving their optimal sexual and reproductive lives. A SRWB measure can help to shift the narrative for SRH with respect to clinical care, public health, and policy interventions so that the guiding light is not focused on specific deficit-framed metrics but on a vision of the world as we want it to be and, ultimately, on reproductive justice.

Importantly, a SRWB measure alone will not address the inability of our current measurement approach to help us understand how to improve people’s sexual and reproductive lives. Nevertheless, as the ultimate aspirational measure, the SRWB measure would provide a critical shift in focus and ability to track this population-level outcome over time. Results of this measure would by necessity have to be interpreted in the context of both more detailed measures (e.g., existing measures and those to be developed that capture experiences with abortion, obstetrics, or gender-affirming care; sexual pleasure; and reproductive services access) and contextual measures (e.g., those related to policy environments). The development and dissemination of a SRWB measure would provide a critical foundation for an evolving measurement approach that centers people, their experiences, and how systems and structures can best support them.

More broadly, we recognize that the opportunity to engage in an extended, iterative process with a diverse working group to define the construct of interest before beginning measure development is uncommon in measurement work. This process was instrumental in our effort to ensure that our definition and the measure that will ultimately be created reflect people’s lived experiences. In SRH and beyond there is an unrealized need for metrics that reflect values related to person centeredness and autonomy. Efforts to develop these metrics will benefit from an intentional approach to community engagement and explicit grounding in principles and values from the outset. Doing this will ensure that the too often siloed and unrepresentative measure development processes of the past, which have resulted in measures that do not capture what people themselves care about, are not reproduced.

CONCLUSIONS

A move toward values-aligned, holistic, and person-centered metrics such as SRWB can help center our focus on achieving positive outcomes for people’s SRH and beyond. Our process of defining SRWB in an intentional and collaborative manner will contribute to our ultimate work to develop a reproductive justice–aligned measure that can inform an understanding of how much structures, systems, and policies enable optimal sexual and reproductive experiences and promote sexual and reproductive equity.