Sexual Health and Well-Being: A Framework to Guide Care

WHAT IS SEXUAL HEALTH?

Sex positivity and more broadly sexual well-being have become increasingly important on the global health agenda in recent years, although the focus on negative outcomes still dominates discussions of sexuality, provision of sexual health care, and management of sexually transmitted infections (STIs).¹ This shift in the narrative around sexual health calls for a pleasure-based approach, which is fundamental to reducing stigma related to sexuality and addressing elements such as consent, privacy, and communication that contribute to sexual health and well-being. Sexual health, as defined by the World Health Organization, 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.²

This concept of sexual health can help health care providers (HCPs) (as well as researchers, educators, and policymakers) recognize positive sexuality and sexual experiences as important health outcomes.

PLEASURE-INCLUSIVE VERSUS EXCLUSIVELY RISK-BASED APPROACHES TO SEXUAL HEALTH AND BEHAVIORS

Sexual health and well-being extend beyond the simple absence of adverse outcomes such as STIs and include a culture where each person is guided in having a safe and pleasurable sexual life. As sexual health is an important component of a person’s overall health, discussions about sexuality beyond the act of sex cannot be overlooked or discounted. Without a thorough assessment of sexuality, which underlies significant behaviors, experiences, and has implications outside of sexual acts, sexual health cannot be well-defined, understood, or operationalized. For sexual well-being to be attained and maintained, it is critical for the sexual rights of all persons to be respected, protected, and fulfilled in clinical settings.

However, too often, clinical (as well as public health) approaches to sexual health care and prevention and management of STIs focus exclusively on negative health outcomes and the labeling of sexual behaviors as risk factors while ignoring other aspects of sexuality.^1,3 Within an exclusively risk-based approach, discussions of sexual pleasure are always absent, and patient–provider conversations instead focus solely on risks, pathogens, and testing (see Table 1).

Table 1.

Risk-based approach versus pleasure-based approach in sexual health

Pleasure-Based Approach	Risk-Based Approach
Messages are centered on sexuality as a source of pleasure and well-being for all individuals, and the importance of attaining ideal sexual experiences is emphasized.	Solely emphasizes risks of HIV, STIs, unintended pregnancy, and other undesirable consequences of sexual activity in all messages.
Recognizes that sexual pleasure is the primary reason why people engage in sexual activity and that pleasure determines how we make sexual decisions.	Does not recognize the significance of understanding why people engage in sexual activity, including to experience pleasure or to appreciate each other’s company.
Actively promotes pleasure as a crucial ingredient for individuals to engage in safer sexual practice and use HIV/STI prevention methods (ie, regular screening, PrEP, PEP, condoms).	Reinforces fear-based messaging or shame as the primary motive for people to use sexual protection, for example, if you have sex without a condom, you will catch HIV, so wear a condom.
Encourages reflection and conversation about the connections between sexual pleasure, sexual health, and sexual rights such as self-determination, consent, privacy, safety, communication, diversity, negotiation, and confidence.	Exclusively addresses the medical and biological aspects pertaining to the unintended consequences, encompassing symptoms, diagnostic procedures, and therapeutic interventions.
Advocates for the dissemination of messages that normalize discussions surrounding sexual pleasure within the context of sexual health and sexual rights. Encourages development of trusted patient-provider relationships that encourage bidirectional communication, including accurate information regarding STIs, prevention, and treatment.	Maintain traditional views of sexuality that can be a source of fuel for the stigma that surrounds sexuality during the process of offering education, counseling, and information to patients or evaluating the condition of a patient.

Yet, there is no evidence that a sex-negative or risk-based approach to health care and safer sex promotion leads to safer sexual behaviors.

In reality, people engage in sexual activity for a variety of reasons, including bonding with others, love and affection, cultural expectations, economic necessity, easing stress, social contracts such as marriage and procreation, and importantly, sexual pleasure. Sexual pleasure is one of the main factors driving sexual behaviors. The World Association of Sexual Health (WAS) recently adopted sexual pleasure as an essential component of sexual health, defining it as “the physical and/or psychological satisfaction and enjoyment derived from shared or solitary erotic experiences, including thoughts, fantasies, dreams, emotions, and feelings.”⁴ In their statements on sexual rights, WAS stressed the importance of pleasurable, satisfying, and safe sexual experiences (Box 1).⁵ A growing body of research shows that sexual pleasure is essential to overall health, mental health, sexual health, well-being, and rights and that it can even lead to health improvements.⁴

Box 1. World Association for Sexual Health’s Declaration on Sexual Pleasure.

In recognition that sexual pleasure is a fundamental part of sexual health and sexual rights, the World Association for Sexual Health:

RECOGNIZES that:

Sexual pleasure is the physical and/or psychological satisfaction and enjoyment derived from shared or solitary erotic experiences, including thoughts, fantasies, dreams, emotions, and feelings. Self-determination, consent, safety, privacy, confidence, and the ability to communicate and negotiate sexual relations are key enabling factors for pleasure to contribute to sexual health and well-being. Sexual pleasure should be exercised within the context of sexual rights, particularly the rights to equality and nondiscrimination, autonomy and bodily integrity, the right to the highest attainable standard of health and freedom of expression. The experiences of human sexual pleasure are diverse and sexual rights ensure that pleasure is a positive experience for all concerned and not obtained by violating other people’s human rights and well-being.

DECLARES that:

1. The possibility of having pleasurable and safe sexual experiences free of discrimination, coercion, and violence is a fundamental part of sexual health and well-being for all

2. Access to sources of sexual pleasure is part of human experience and subjective well-being;

3. Sexual pleasure is a fundamental part of sexual rights as a matter of human rights;

4. Sexual pleasure includes the possibility of diverse sexual experiences;

5. Sexual pleasure shall be integrated into education, health promotion and service delivery, research and advocacy in all parts of the world;

6. The programmatic inclusion of sexual pleasure to meet individuals’ needs, aspirations, and realities ultimately contributes to global health and sustainable development and it should require comprehensive, immediate, and sustainable action.

URGES all governments, international intergovernmental and non-governmental organizations, academic institutions, health and education authorities, the media, private sector actors, and society at large, and particularly, all member organizations of the World Association for Sexual Health to:

1. Promote sexual pleasure in law and policy as a fundamental part of sexual health and well-being, grounded in the principles of sexual rights as human rights, including self-determination, nondiscrimination, privacy, bodily integrity, and equality;

2. Ensure that comprehensive sexuality education addresses sexual pleasure in an inclusive, evidence-informed, and rights-based manner tailored to people’s diverse capacities and needs across the life span, in order to allow experiences of informed, self-determined, respectful, and safe sexual pleasure;

3. Guarantee that sexual pleasure is integral to sexual health care services provision, and that sexual health services are accessible, affordable, acceptable, and free from stigma, discrimination, and prosecution;

4. Enhance the development of rights-based, evidence-informed knowledge of the benefits of sexual pleasure as part of well-being, including rights-based funding resources, research methodologies, and dissemination of knowledge to address the role of sexual pleasure in individual and public health;

5. Reaffirm the global, national, community, interpersonal, and individual commitments to recognition of the diversity in sexual pleasure experiences respecting human rights of all people and supported by consistent, evidence-informed policy and practices, interpersonal behavior, and collective action.

Adapted from the Global Advisory Board for Sexual Health and Wellbeing (2016). Working definition of Sexual Pleasure. Retrieved from https://www.gab-shw.org/our-work/working-definition-of-sexual-pleasure

The strategy of combining pleasure, sexual health promotion, and STI/HIV prevention is gaining momentum as it has been shown to generate and sustain interest in sexual health promotion among vulnerable populations while encouraging safe sexual health practices. A recent meta-analysis of 33 unique interventions targeting STIs and safer sex practices from 2005 to 2020 found that prioritizing pleasure, rather than the fear of danger or disease, increases the likelihood of safer sex practices.⁶ Sexual health programs that include sexual desire and sexual pleasure were found to improve knowledge and attitudes around sex and increase condom use, as compared with those that did not.⁶ Although more research is needed to determine the best ways to incorporate sexual pleasure to achieve sexual health for various outcomes and populations, a pleasure-inclusive sexual health approach holds promise for increasing patients’ sexual self-esteem, sexual self-confidence, and safe choices (Table 1). Importantly, a pleasure-based approach does not mean STI adverse effects, prevention and treatment are not accurately communicated; rather it supports the development of trusted patient–provider relationships that encourages bidirectional communication of this information.

BARRIERS TO SEXUAL HEALTH SERVICES

Stigma and Shame

Seeking and engaging in sexual health services is important to overall health and well-being. However, multiple barriers exist that can prevent individuals accessing these services, the most predominant of which has been stigma and shame. Sexual pleasure has been viewed as a threat to social, political, and religious order throughout history. Discourse around sex in medical, academic, and clinical settings focused solely on disease, risk, and shame can contribute to stigma not only related to STI/HIV acquisition but all aspects of sexual health and well-being.⁷ Factors such as trepidation about social capital, negative perceptions surrounding STI/HIV, and concerns about personal reputation may make patients less likely to engage with needed sexual health services.⁸ In a study with patients exploring physician-inspired shame and guilt, more than half of the respondents reported experiencing shame over their sexual habits. The study found 45% of patients who experienced shame reacted negatively by either terminating treatment with, avoiding, or lying to their physician as a result of the incident.⁹ In addition to avoiding “stigma by association,” marginalized communities frequently opt not to seek sexual health care services because they do not want to face stigma from care professionals about their sexual practices as they pertain to their gender and sexual identities.¹⁰ For example, people who are most vulnerable may be hesitant to seek care because they do not want to be stigmatized as promiscuous because they seek sexual health services in health care clinics.

Cultural Mistrust

Cultural mistrust is another obstacle to sexual health service interest and utilization among vulnerable, marginalized communities.¹¹ Many people delay obtaining medical care because they lack trust in the health care system or are hesitant to build trustworthy connections with doctors; others opt to avoid dealing with the health care system entirely.¹¹ This mistrust stems from historical events, ongoing biases within the system, and the stigmatization of groups based on their race/ethnicity, gender, sexual orientation, and economic status, all of which make it difficult for marginalized communities who are disproportionately affected by adverse health outcomes to seek health care.^12,13 Providing health care that is more holistic, and embraces the entire person, as opposed to reductionist or focusing solely on specific body systems and components is essential to combating, stigma, discrimination, and oppressive cultural and societal norms associated with creating barriers to engagement in sexual health services and practices.^14–16

Poor Access

Access to patient-centered services is essential; however, individuals may experience challenges accessing welcoming and knowledgeable providers, especially if they are members of minoritized and stigmatized groups, including transgender and gender diverse individuals,¹⁷ sex workers,¹⁸ and even the elderly.¹⁹ Practical concerns, such as geographic distance and lack of transportation, can result in individuals not having adequate access to sexual health services.

Before interventions can be undertaken to reduce barriers to sexual health services, clinicians must be attuned to the patient’s circumstances and past experiences with health care.

BEYOND SEXUALLY TRANSMITTED INFECTIONS: SEX AND THE BIDIRECTIONAL ASSOCIATIONS BETWEEN MENTAL AND PHYSICAL HEALTH

Complex and bidirectional associations exist between physical and mental health, and these relationships have important influences on sexual health and more specifically sexual functioning. Understanding these relationships is essential to optimizing quality of life and underscores the need to use a holistic approach that includes discussions of sexual health and pleasure in all aspects of health care.

In 2018, almost half of Americans aged more than 20 years were living with cardiovascular disease (CVD), with rates increasing by age.²⁰ Both existence of and underlying risk factors for CVD (eg, diabetes mellitus, dyslipidemia, and hypertension) as well as the medications use to treat them (eg, beta blockers, angiotensin-converting enzyme inhibitors and thiazide diuretics, among others) have known associations with sexual dysfunction.^21–25

Similar interactions with mental and physical health and sexual function are seen for many other physical conditions, such as cancer, chronic kidney disease, chronic obstructive pulmonary disease, and HIV. Physical health conditions on their own can directly result in anxiety, depression, and other mood disorders.²² Even more challenging is that the primary treatments for some mental health conditions, for example, selective serotonin reuptake inhibitors and antipsychotics can further exacerbate impediments in sexual function, desire, and satisfaction.²⁶ Often patients will not report these symptoms or side effects unless directly questioned so that the known prevalence of these associations is underreported.²⁶ Research has shown that sexual dysfunction is often associated with mood disorders, even when these are untreated.²⁷ These complex bidirectional relationships underscore the need for clinicians to conduct a comprehensive assessment of physical and mental health conditions as well as to document all prescribed and nonprescribed (ie, over the counter) medications to understand all potential factors that may contribute to sexual health and well-being.

EMPHASIS ON WELL-BEING

The medicalization of social problems has ethical implications for practitioners providing sexual health care.²⁸ Physicians are trained to ask, “What is this patient’s primary problem?” Although treating the patient’s current concern is critical, it is also important to broaden the therapeutic emphasis to include approaches that maximize and reconnect patients with their sense of completeness, embodiment, health, and structural integrity. The concept of sexual well-being can be defined as the maintenance of physical, mental, and emotional balance, and stability, encompassing more than the lack of disease. This perspective situates sexual well-being within the realms of sexual pleasure and sexual justice, recognizing their collective significance in addressing the underlying factors contributing to sexual inequities.²⁹

Physicians have a responsibility to strike a balance between their pursuit of patient care and respect for patient’s autonomy and the realities of institutional and structural discrimination that patients face. Because HCPs are trained to treat individuals with sexual health problems or negative health outcomes, they may contribute to the replication of problematic trends in health care by ignoring structural barriers to care.²⁸ Learning to address these hurdles and incorporate language and behaviors in clinical settings that facilitate sexual health interviewing will become easier with practice. Although HCPs cannot change the variety of sociocultural and interpersonal factors in their patients’ lives, they can help them understand the influence these circumstances may have on their sexual health. Clinicians and staff should be trained in culturally sensitive terminology, gender-affirming care, structural humility, and assessment of personal internal biases to improve patient interactions to build a clinical environment that reassures patients that the practice is confidential, safe, affirming, and nonjudgmental.

WHEN SHOULD SEXUAL HEALTH DISCUSSIONS BE INITIATED?

Pleasure-based conversations about sexual health can be integrated into different types of primary care visits and should not be relegated only to specific visit types (eg, only when a person presents with symptoms of an STI). Opportunities can arise during any health maintenance visit or follow-up for chronic conditions. Adverse effects, including on sexual health, should be disclosed when new medications are prescribed, as often they may not be apparent to the patient (eg, individual who initiates finasteride for androgenetic hair loss may not realize that this drug may cause sexual dysfunction). Clinicians should also discuss potential changes in sexual function that might occur with certain health conditions. For example, diabetes mellitus may be associated with low libido, erectile dysfunction, ejaculatory dysfunction, and painful receptive vaginal sex as a result of microvascular disease, nerve damage, immune dysregulation, and infection that can often be managed through close monitoring and effective treatment.³⁰ Sexual health and well-being should be discussed after during pregnancy, the postpartum period, menopause, and after genital (including anal) surgeries. Many patients may have concerns about the safety of reengaging in sexual activities after being hospitalized, and starting these conversations early is important to provide appropriate information and allay patient fears. Focusing on pleasure to help patients with illness-related sexual changes may improve not only sexual health but overall health.

RECOMMENDATIONS FOR CENTERING SEX-POSITIVE PATIENT CARE

Applying a sex-positive approach that encompasses both elements of structural competency and pleasure in clinical interactions can assist with addressing barriers to sexual health care engagement. Sex positivity is defined by the International Planned Parenthood Federation as “an attitude that celebrates sexuality as a part of life that can enhance happiness, bringing energy and celebration.”³¹ Combining structural competency with pleasure-based approaches may improve clinician sensitivity to social determinants of health, foster generative self-reflection, and open doors to patient solidarity. Here, we apply structural competency elements³² with a pleasure-based approach to provide a framework for sex-positive health care (Fig. 1) and recommend the following.

Fig. 1.

Sex-positive health care framework.

1. Patient-centered and tailored approaches should recognize the structural elements influencing clinical interactions.

2. Use extra-clinical language that is affirming over a judgmental and discriminatory tone.

3. Sexual wellness discussions begin with sexuality.

4. Incorporate models of sexual history taking that work best for your patients.

Patient-Centered and Tailored Approaches Should Recognize Structural Elements

Although the patient–provider relationship remains important, developments in the health care system show that a greater range of clinical, structural, and interpersonal factors can all influence the patient’s experience. On a structural level, health care structures should provide calm welcoming spaces that accommodate patients’ needs and offer inclusive resources and services. It is essential that patients can navigation through the system from intake to discharge. This means that when a patient enters your clinical setting, services begin. For example, the name and pronoun(s) that a transgender patient uses can be included in their electronic records to improve their experience in the clinical setting and minimized the risk of being misgendered and creating another barrier to sexual wellness discussions (see also Ard and colleagues³³ article on care for transgender and gender diverse populations and Cherabie and colleagues³⁴ article on sexual history taking in this issue). These structural elements support patient–provider relationships that promote communication on sexuality and intimacy to encourage patients to ask questions about sexual health (ie, inquiring about doxycycline post-exposure prophylaxis [Doxy-PEP] for STI prevention). Sex-positive messages with same- and different-gender couples, as well as persons of different ethnicities, gender expressions, and physical abilities, should be featured on posters, pamphlets, and other materials. Providers have a responsibility to establish a conducive environment that fosters a sense of ease for clients to openly discuss matters related to sexuality, free from any apprehension of being judged. This facilitates individuals in confidently exchanging and evaluating their sexual and reproductive health needs.

Use Extra-Clinical Language that Is Affirming over a Judgmental and Discriminatory Tone

Clinicians can construct a vocabulary of the structural elements that goes beyond the clinical symptoms, signs, and pathophysiology of disease. This language is called extra-clinical language. For instance, clinicians are able to observe how the “structure” of a patient’s environment might limit a patient’s ability to make decisions that are beneficial to their immediate disease condition and, eventually, their overall health. Using culturally appropriate terminology to convey pleasure could help sexual pleasure be more integrated within certain cultural and social contexts. For example, using gender neutral terms for anatomy for transgender and gender diverse patients would reduce stigma and support sexuality, autonomy, and individuality (also see Ard and colleagues article on care for transgender and gender diverse populations and Cherabie and colleagues article on sexual history taking in this issue).

Sexual Wellness Discussions Begin with Sexuality

To engage patients in sexual wellness discussions, HCPs need to cultivate structural humility by understanding their limitations and understand the implications of their explicit and implicit biases. This approach to communication acknowledges how unjust social determinants influence access to resources needed to make health changes and choices, such as the differential treatment patients receive from health care institutions and professionals based on race, gender, sexual orientation, class, or immigration status. In order to effectively help individuals in achieving sexual empowerment and experiencing sexual satisfaction, it is imperative for providers to possess a comprehensive understanding of sexuality, including sexual pleasure, as well as a familiarity with the prevalent physical and mental challenges encountered by clients across various sexual orientations and age groups. Health practitioners should pursue professional development opportunities to improve their skills in caring for transgender and gender nonconforming people. Although gender-affirming treatment is not always related to sexual health, sexual health providers should receive additional training in queer and trans health and provide these vital services (Table 2 for educational resources).

Table 2.

Online sex-positive educational resources for health care providers

Area of Interest	Source	Link
Pleasure	The Pleasure Project	https://thepleasureproject.org
	American Sexual Health Association	https://www.ashasexualhealth.org
	Global Advisory Board for Sexual Health and Wellbeing	https://www.gab-shw.org
	National Coalition for Sexual Health	https://nationalcoalitionforsexualhealth.org/tools/for-healthcare-providers/compendium-of-sexual-reproductive-health-resources-for-healthcare-providers
	The Center for Sexual Pleasure and Health	https://thecsph.org
	The Pleasure Principal	https://thepleasureprincipal.org/resources/
Transgender Health	World Professional Association for Transgender Health	https://www.wpath.org
	Human Right Campaign Safer Sex-for Trans-Bodies	https://www.hrc.org/resources/safer-sex-for-trans-bodies
	USCF Center for Transgender Health	https://prevention.ucsf.edu/transhealth/resources
Youth	Sex Positive Families	https://sexpositivefamilies.com
	National Sex Ed Conference	http://sexedconference.com/about-cse/

Incorporate Models of Sexual History-Taking that Work Best for Patients

It is vital to incorporate regular inquiries regarding sexual well-being and pleasure. The determination of the impact of sex on patients’ quality of life remains unknown in the absence of soliciting their perspectives. Without inquiring, it is impossible to ascertain the exact kind of sexual activities that contribute to an individual’s pleasure nor can providers make assumptions on their prioritization of sexual functioning within the framework of their medical treatment.

The acquisition of a sexual history provides an opportunity to evaluate the various connections between sexual pleasure, sexual health, and sexual rights. There are three essential aspects during the assessment of sexual wellness with patients. What are your sexual wellness goals? What does the word “sex” mean to you? What types of sexual activities are significant for enhancing personal and mutual satisfaction within intimate relationships?

Clinicians should take an inclusive, comprehensive routine sexual history with all patients and be proactive about sexual health, not only problem-focused sexual health appointments by using pleasure positive messaging to communicate effectively and positively. For example, when taking a sexual history using a pleasure-based approach, the “6Ps” technique offers for a complete and inclusive foundation for discussion. This is an extension of the traditional recommendation for sexual history taking by adding the “plus” as the sixth “P,” which includes Pride, Pleasure, and Problems (Table 3 and Cherabie and colleagues in this issue for additional details on best practices in sexual history taking).

Table 3.

Examples of sex-positive framing of questions for initiating sexual assessment

	Areas of Sexual Health History	Recommendations	Example Questions
Pleasure-based 5Ps	Partners	Ask questions about the patient’s partner(s) without assumptions about the patient’s sexual orientation, the gender identity of the patient or partners, or their relationship framework. Allow the patient to define their own relationships.	Are you currently involved in any sexual relationships? Are you and your partners on the same page about what’s pleasurable?
	Past History of STIs	It is important to refrain from exacerbating feelings of guilt and shame in your patients because they may be already experiencing these feelings and there is no need to add fuel to the fire. An attitude that is negative and risk-based might make it even more difficult for individuals to discuss the topic or to participate in sexual activities that bring them pleasure.	Have you tested positive for a STI in the past? If yes, do you remember what it was? Where was it? How was it treated?
	Protection from STIs	Clinicians should determine the appropriate level of sexual health counseling for each patient, but they also need to acknowledge their own bias and minimizing assumptions based on patient’s sexual orientation, gender identity, or relationship framework. Ask about sexual health practices to strike a balance between addressing the unwanted consequences of sex and enjoyment of the sexual relationship.	Do you and your partners talk openly about sexual desires and boundaries? Do you and your partner have a relationship agreement? If you use prevention tools (ie, PEP, PrEP, HIV/STI testing, condoms), what methods do you enjoy using the most? Are there some kinds of sex where you do not use barriers methods (that is, internal and/or external condoms? Why?
	Practices	Ask open-ended questions about the patient’s sexual practices that are focused on the information you need to know based on what you already know about the patient. You can decide where to take the conversation based on the responses.	Are you able to advocate for sexual pleasure in your relationships? Do you use toys (dildos or vibrators) inside your [insert preferred language for genitals] or anus, or do you use them on your partners? Which behaviors might expose you to your partners’ fluids?
	Pregnancy Intention	All patients at reproductive age should be asked about their intentions to conceive regardless of their sexual orientation or gender identity. Gender-inclusive language should be used throughout the discussion.	Are you actively trying to conceive, or do you think that you may conceive at some point within the next year? Have you considered using a surrogate? What are you and your partner(s) doing to prevent pregnancy?
Plus	Pleasure	The discussion should include two important elements: events (eg, key features of a sexual occasion, such as the repertoire, timing, and spacing of different sexual practices, occurrence of orgasm, use of a condom or contraception) and people (eg, interactional elements of sexual pleasure, which encompass interpersonal dynamics such as communication, negotiation, and trust).	How is your sex life? Is the sex you’re having pleasurable for you? If no, why not? Anything else you feel to be important that we did not address?
	Pride	The discussion should recognize and honor someone’s sexual and gender identity from an intersectional perspective (eg, historical context, cultural, structural). Providers and staff should use chosen names, pronouns, and body parts, and respect their patients’ partnering decisions.	What are your pronouns? When referring to your genitals, are there specific terms that you use? Are you currently on hormone therapy? Have you had any gender-confirming surgeries or procedures? What support, if any, do you have from your family and friends about your gender identity and/or sexual orientation?
	Problems	The discussion should address difficulties related to sex (eg, pain, discomfort, vaginal dryness, lack of arousal, lack of orgasm, lack of erection, low or high level of interest in having sex, mismatched sex drives) as well as sexual violence.	What concerns do you have about your sex life? Are you having any difficulties when you have sex (eg, pain, discomfort, vaginal dryness, lack of arousal, lack of orgasm, and lack of erection)? Do you feel safe in your current relationship? Are you engaging in sex for pleasure or has anyone ever forced or compelled you do anything sexually that you did not want to do?

SUMMARY

Sex-positive health care is an essential component in the effort not only to prevent and manage STIs but also to achieve health equity. It has the potential to save lives and enhance community and individual health by providing scientifically grounded information within the context of the pleasure and shifting the burden of addressing health inequities from individuals to organizations and systems. It is essential for providers to acknowledge that patients are consistently learning about themselves and their bodies, navigating the health care system, and developing healthy intimate relationships in a rapidly changing social and political landscape. Clinicians must consistently assess whether the messages conveyed to patients align with either a risk-based or pleasure-based approach. Sex-positive providers ask questions that are open and inclusive without contributing to shame, hold space for experiences that go beyond our societal gender binary, use language that is appropriate for their patients, and remain aware of potential barriers. Sex positivity is a framework that promotes individual preferences while rejecting the traditional taboo of discussing sex, specifically sexual pleasure. It doesn’t matter if someone has multiple sexual partners or if they prefer to be celibate; sex positivity counteracts STI-related stigma and encourages safer sex practices and engagement in care. As a result, sex-positive health practitioners are uniquely positioned to address their demand for holistic services and care that consider their experiences and prioritize health equity.

We need more evidence on the integration of sexual pleasure into STI prevention, sexual health-related education, promotion, policies, programs, and services. It is important to evaluate sex-positive and pleasure-inclusive sexual health care for its impact on a range of outcomes, in different contexts and with a wider range of groups of people, with diverse sexual identities. As new data emerge in the constantly evolving sexual health sector, it is critical to seek professional development opportunities whenever possible to remain inventive and competent for patient care.

KEY POINTS.

• Sexual health should not only be discussed in relation to sexually transmitted infections (STIs/HIV) and unintended pregnancy but also to promote pleasure and address structural challenges to health care engagement.

• Sexual health is an important area of primary care that is often neglected in clinical settings and medical training. Many health care professionals lack training and knowledge to provide sex-positive health care.

• A sex-positive approach to sexual health care and well-being includes the prioritization of pleasure and integration of structural competence practices in clinical settings.

CLINICS CARE POINTS.

• Healthcare providers have the responsibility to establish an environment that promotes a welcoming environment for patients to openly engage in discussions pertaining to sexuality, without any fear of being subjected to judgment during their clinical interactions.

• Clinicians have the ability to develop an understanding that extends beyond clinical symptoms, signs, and pathophysiology of ailments to address the obstacles posed by a patient’s environment, allowing them to make decisions that promote their holistic well-being.

• To ensure successful support in promoting sexual empowerment and satisfaction, it is critical for providers to possess an extensive knowledge of sexuality, including sexual pleasure, and to be open to learning about common physical and mental challenges encountered by clients belonging to diverse cultural backgrounds, sexual orientations, gender identities, age groups, and individuals with disabilities.

• Clinicians should conduct a comprehensive and inclusive routine sexual history with every patient and employ a proactive approach towards sexual health, transcending problem-focused sexual health consultations through the use of positive and pleasure-based messaging to foster effective and constructive communication.