The Public Health of Pleasure: Going Beyond Disease Prevention

A thin but critical slice of thinking has emerged and persisted in the field of sexual health and relationships: that healthy relationships and sexuality are about not merely the absence of sexually transmitted diseases and intimate partner violence but also the presence of pleasurable and satisfying occurrences in the closest relationship that humans have with one another. As noted by Gruskin and Kismödi (p. 159), the World Association for Sexual Health Congress Declaration on Sexual Pleasure explicitly calls for “an intersectional, interdisciplinary and multi-sectorial approach to research, programs, service delivery, and advocacy that fully takes into account the links between sexual health and sexual rights and pleasure.” The intersectional aspect reminds us that to achieve this not only must programming and research take a wider approach on this subject, but laws, policy, and practices must be examined and addressed as well.

DISEASE PREVENTION VERSUS HEALTHY SEXUALITY

Kantor and Lindberg (p. 145) explore how US-based national surveillance surveys do not ask questions that reflect skills related to sexual activity, such as refusal and what consent means, or questions that might relate to the pleasurable aspects of sexuality or relationships. They focus almost exclusively on whether HIV and other sexually transmitted infections or pregnancy prevention education is provided, even when venturing to ask about this topic for lesbian, gay, bisexual, transgender or questioning students. Because questions are often ambiguous, a student or school may report receiving education about birth control (although even this is less frequently addressed than sexually transmitted infection and pregnancy prevention) but not differentiate between programs that provide information about reproductive methods and those that promote abstinence only.

When we talk about the history of public health, the first paradigm is often tied to the concept of sanitation. From John Snow to the formation of the US Environmental Protection Agency, a seminal focus on clean water, air, and land permeated our field. The basis for this foundation was disease prevention—from cholera and typhoid to asthma and emphysema. Yet there was undeniably pleasure to be had in breathing clean air, drinking purified water, and seeing skies unblackened by smog.

EXPANDED PURVIEW OF PUBLIC HEALTH

Public health has undergone a broad expansion in its reach. Today we include many topics that were not historically seen as within its realm, including immunization, prevention of health care–acquired infections, reduction or elimination of sexually transmitted diseases, adolescent pregnancy prevention, and prevention and control of chronic disease, including mental health and substance use disorders.

Yet the field of sexual and relationship health continues to move toward an emphasis on acknowledging and measuring progress on achieving pleasurable sexuality and healthy relationships. As stated by Pitts and Greene (p. 149), the World Health Organization defines sexual health as a “state of physical, emotional, mental, and social well-being in relation to sexuality.”¹

This positive definition, focused on the “well-being” of the individual “in relationship to sexuality” does not describe healthy sexuality as merely the absence of disease. Yet we also know that even access to sexual resources that may prevent disease are not equally distributed in the United States or around the world. Boone and Bowleg (p. 157) point out that when the sexuality of Black gay and bisexual men who have sex men is discussed, the focus is rarely, if ever, on pathways to pleasure but instead on topics such as criminalization of sexual behavior by HIV-infected individuals or lack of access to biological HIV prevention methods, such as preexposure prophylaxis.

But, then, given the role of pleasure in healthy sexuality, what stance should public health take on the issue of pornography? Does pornography itself cause harm sufficient to make it an issue to be addressed by public health? Nelson and Rothman (p. 151) argue that pornography is not a public health crisis although 17 states have introduced resolutions to that effect in their state legislature. The authors argue that it is not a public health crisis and that naming it one carries its own particular risks of misused resources or abuse of property or personal rights. In a public health vignette, Rothman et al. (p. 154) describe a framework for addressing concerns about pornography, presenting a curriculum that she and others developed to improve pornography literacy among adolescents. The curriculum is set within a framework that asserts that healthy pornography is possible and can impart positive messages about sexual health and portray the pleasure and variety of consensual sex.

FUNDING FOR HEALTHY RELATIONSHIPS

This year, the Commonwealth of Massachusetts passed its fiscal year 2020 budget, which includes an amendment saying:

For a domestic violence and sexual assault prevention program focused on teens in high-risk communities; provided, that the programming shall be aimed at promoting healthy relationships and addressing teen dating violence; provided further, that the department shall partner with domestic violence and sexual assault service providers, other community-based organizations or school-based organizations to develop evidence-based and outcomes-focused prevention strategies; . . . and provided further, that funds may be expended for a competitive grant program . . . $1,000,000.²

This further reinforces the idea that promoting healthy relationships and healthy, consensual sex does indeed lie within the purview of public health.

“Wellness” has become part of the lexicon of public health, along with “healthy communities” and, of course, “the social determinants of health.” Each of these addresses the environment portion of the “epidemiologic triad”—which includes place, race, and income inequality—which we now consider responsible for a majority of the health problems affecting any given population.³ Access to healthy relationships and sexuality is yet another aspect of how environment affects the health of individuals and populations.

As the field of public health expands its reach into problems as diverse as gun violence, intimate partner and community-based violence, and human rights, why shouldn’t it also be on the leading edge of efforts to support healthy sexuality and healthy relationships? Although many groups have professional concerns about addressing topics such as sexual pleasure, public health has proven repeatedly that it is particularly adept at discussing and developing strategies to address sensitive but necessary topics.