Kirstin R MitchellpersName, Ruth LewispersName, Lucia F O'SullivanpersName, J Dennis FortenberrypersName (2021date). “What is sexual wellbeing and why does it matter for public health?.” The Lancet Public Healthtitle·j.
Object of study — sexual wellbeingterm·dom as a concept distinct from sexual healthterm·dom in public healthterm·key
Research question — in what ways sexual wellbeingterm·dom is relevant to the core functions of public healthterm·key
Contribution — sexual wellbeingterm·dom placed beside sexual healthterm·dom, sexual justiceterm·dom and sexual pleasureterm·dom as one of four pillars of public healthterm·key enquiry
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | sexual wellbeing conflated with sexual health in public health approaches — “the conflation of sexual wellbeing and sexual health obscures the diversity of experiences—not clearly addressed in definitions of sexual health—that people identify as relevant to their broader wellbeing.” | |
| claim-type | critique — “The long-standing conflation of sexual health and sexual wellbeing has affected our ability to address everyday sexual issues.” | |
| method — evidence | — “Domains were identified and refined through intensive engagement with wide-ranging literature, including a review of sexual wellbeing definitions and measures.” | |
| object of study — evidence | — “We propose sexual wellbeing as a distinct and revolutionary concept that can be operationalised as a seven-domain model.” | |
| research question — evidence | — “Acknowledging these issues, we set out four ways in which sexual wellbeing is highly relevant to core functions of contemporary public health.” | |
| contribution — evidence | — “We situate sexual wellbeing alongside sexual health, sexual justice, and sexual pleasure as one of four pillars of public health enquiry.” | |
| mechanism | commodification Selling products as sexual wellbeing narrows what people judge a good sex life to be. — “This commodification probably influences public understanding and focuses attention on a narrow set of assessment criteria to judge whether a sex life is going well.” | mechanisms[0] |
| sense | sexual wellbeing (the authors' concept) - its own concept, not an extension or subclass of sexual health — “A guiding premise of our argument is that the concept of sexual wellbeing demands recognition, not as an extension, subclass, or alternate form of sexual health, but as a distinct and revolutionary concept” | senses[0] |
| sense | sexual wellbeing (in commerce) - a banner under which pharmacies sell products — “Pharmacies sometimes sell products, such as vaginal tightening gel, nutritional supplements, and fertility aids, under the banner of sexual wellbeing.” | senses[1] |
| sense | sexual wellbeing (as a population measure) - a marker of population wellbeing, given sexual inequities — “Sexual wellbeing is an appropriate marker of population wellbeing, given inequities related to sexuality and sexual expression.” | senses[2] |
| relation | sexual wellbeing —distinct-from→ sexual health — A guiding premise of our argument is that the concept of sexual wellbeing demands recognition, not as an extension, subclass, or alternate form of sexual health, but as a distinct and revolutionary concept — “A guiding premise of our argument is that the concept of sexual wellbeing demands recognition, not as an extension, subclass, or alternate form of sexual health, but as a distinct and revolutionary concept” | concept_edges[0] |
| weight | sexual wellbeing —distinct-from→ sexual health — 0.85 — “A guiding premise of our argument is that the concept of sexual wellbeing demands recognition, not as an extension, subclass, or alternate form of sexual health, but as a distinct and revolutionary concept” | concept_edges[0] |
| relation | sexual wellbeing —operationalised-as→ seven-domain model — We propose sexual wellbeing as a distinct and revolutionary concept that can be operationalised as a seven-domain model. — “We propose sexual wellbeing as a distinct and revolutionary concept that can be operationalised as a seven-domain model.” | concept_edges[1] |
| weight | sexual wellbeing —operationalised-as→ seven-domain model — 0.8 — “We propose sexual wellbeing as a distinct and revolutionary concept that can be operationalised as a seven-domain model.” | concept_edges[1] |
| replication | not-applicable | |
| limitation | Critics see wellbeing as too subjective and context-dependent to be a public health goal. — “Critics refer to the subjective and variable qualities of wellbeing, necessarily influenced by social and cultural contexts, and played out in individual attitudes and actions.” | limitations[0] |
| limitation | A multi-dimensional measure may meet resource limits and political resistance. — “There might be resource constraints to monitoring that requires a multi-dimensional measure, and political resistance to giving prominence to sexual wellbeing alongside risk-focused outcomes.” | limitations[1] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | In French surveys over four decades, more people said sex was essential to feeling good about themselves. — “For example, in four decades of French national surveys (1970s to 2006), the proportion of people reporting that sexual intercourse was considered essential to feeling good about oneself increased from 48% to 60% for women and from 55% to 69% for men.” | content_tags.findings[0] |
| quantity | 48% to 60% (women); 55% to 69% (men) — — “For example, in four decades of French national surveys (1970s to 2006), the proportion of people reporting that sexual intercourse was considered essential to feeling good about oneself increased from 48% to 60% for women and from 55% to 69% for men.” | content_tags.quantities[0] |
| key-terms | sexual wellbeing, sexual health, sexual pleasure, sexual justice, sex positivity, health equity, population wellbeing, public health |
| concept | sexual wellbeing — the cognitive and emotional evaluation of an individual’s sexuality — “Laumann and colleagues defined sexual wellbeing as “the cognitive and emotional evaluation of an individual’s sexuality”, and used four satisfaction judgments.” | concepts[0] |
| concept | sexual justice — represents larger global efforts to ensure social, cultural, and legal supports for equitable, person-centred sexual and reproductive experiences — “Sexual justice represents larger global efforts to ensure social, cultural, and legal supports for equitable, person-centred sexual and reproductive experiences.” | concepts[1] |
| concept | sexual pleasure — addresses the diverse physical and psychological satisfactions of sexual experience — “A recent definition of sexual pleasure addresses the diverse physical and psychological satisfactions of sexual experience” | concepts[2] |
| concept | sexual health — not defined in this paper's own words; the WHO's broad notion of health in sexual life, reaching past the mere lack of illness to rights and enjoyment — “The widely-adopted definition of sexual health developed by WHO is expansive.” | concepts[3] |
| concept | Trauma-informed, sex positive practices — perspectives and approaches that emphasise contributions of sexuality and sexual expression to overall wellbeing — “Trauma-informed, sex positive practices refer to perspectives and approaches that emphasise contributions of sexuality and sexual expression to overall wellbeing.” | concepts[4] |
| concept | sex positivity — not defined in this paper's own words; an affirming stance that treats consensual sexuality as a good in people's lives — “Sex positivity is central to a public health relevant concept of sexual wellbeing” | concepts[5] |
| concept | seven-domain model — not defined in this paper's own words; the authors' breakdown of sexual wellbeing into seven areas that can each be measured — “We propose sexual wellbeing as a distinct and revolutionary concept that can be operationalised as a seven-domain model.” | concepts[6] |
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What is sexual wellbeingterm·dom and why does it matter for public healthterm·key?
Abstract Sexual healthterm·dom has provided a guiding framework for addressing sexuality in public healthterm·key for several decades. Although the WHO definition of sexual healthterm·dom is revolutionary in acknowledging positive sexuality, public healthterm·key approaches remain focused on risk and adverse outcomes. The long-standing conflation of sexual healthterm·dom and sexual wellbeingterm·dom has affected our ability to address everyday sexual issues. This Viewpoint provides a way forward to resolve this impasse. We propose sexual wellbeingterm·dom as a distinct and revolutionary concept that can be operationalised as a seven-domain modelterm. We situate sexual wellbeingterm·dom alongside sexual healthterm·dom, sexual justiceterm·dom, and sexual pleasureterm·dom as one of four pillars of public healthterm·key enquiry. We argue that sexual wellbeingterm·dom is imperative to public healthterm·key as a marker of health equityterm·key, a meaningful population indicator of wellbeing, a means to capture population trends distinct from sexual healthterm·dom, and an opportunity to refocus the ethics, form, and practices of public healthterm·key.
Introduction The widely-adopted definition of sexual healthterm·dom developed by WHO is expansive. It includes concepts such as the absence of disease and coercion, and draws attention to sexual rights and to the possibility of sexual pleasureterm·dom. 1 Yet, wellbeing is mentioned as an adjunctive element of sexual healthterm·dom; the unique elements of wellbeing— distinct from sexual healthterm·dom—are not identified.
The WHO definition of sexual healthterm·dom reduces stigma by helping researchers, educators, clinicians, and policy makers acknowledge positive sexuality and sexual experiences as key public healthterm·key outcomes. However, public healthterm·key approaches to sexuality remain rooted firmly in the medical and biological sectors, with their focus largely on adverse health outcomes and concomitant risks. This risk-focused approach has come to be viewed as the standard for public healthterm·key, eclipsing other aspects of sexuality, even though health is seldom—if ever—the primary reason for engaging sex. 2 Such a public healthterm·key vision overlooks a contemporary body of evidence from scientific research supporting perspectives far broader than those associated with sexual healthterm·dom. 3 In practice, perspectives on what constitutes normal sexuality are understood through a public healthterm·key lens. 4 In research, confusion and inconsistency across different studies, often in reference to the same issues, make it difficult to advance the science in this area. Most importantly, the conflation of sexual wellbeingterm·dom and sexual healthterm·dom obscures the diversity of experiences—not clearly addressed in definitions of sexual healthterm·dom—that people identify as relevant to their broader wellbeing. This truncated perspective ultimately limits our ability to understand and address everyday sexual issues.
The absence of a sharp distinction between sexual wellbeingterm·dom and sexual healthterm·dom has created ambiguity in policy rhetoric, and hindered conceptualisation of sexual wellbeingterm·dom as a valid outcome of public healthterm·key interventions. For more than a decade, advocates and thought leaders have acknowledged the need to expand the scope of inquiry and intervention in public healthterm·key from a singular focus on sexual healthterm·dom to attention on sexual wellbeingterm·dom as a distinct concept. The call to make this shift partly emerged from a WHO–UN Population Fund meeting in 2007. At that time there was considerable difficulty agreeing on the meaning of sexual wellbeingterm·dom. Since then, efforts to adopt sexual wellbeingterm·dom as part of a comprehensive, holistic, and progressive goal for public healthterm·key have stalled indefinitely, awaiting additional justification, articulation, and operationalisation.
This Viewpoint constitutes a long overdue effort to effectively resolve this impasse. We build on increasing awareness of the limits and constraints of a sole focus on sexual healthterm·dom, and an emerging body of research on the relevance of sexuality to wellbeing. This emerging interest mirrors the greater attention given to population wellbeingterm·key of late. A more nuanced, multi-dimensional framework is required.
Our conceptualisation of sexual wellbeingterm·dom resonates with the biopsychosocial–cultural framework based in people’s perspectives on sexual wellbeingterm·dom in mid and later life. 5 This perspective locates sexual wellbeingterm·dom firmly in relation to sexual healthterm·dom, and in relation to two other pillars of public healthterm·key focused inquiry—sexual pleasureterm·dom and sexual justiceterm·dom—each needed to address structural determinants of sexual inequities ( figure ). Here, we describe the interconnections of these four pillars and the conceptual overlap with sexual wellbeingterm·dom.
A guiding premise of our argument is that the concept of sexual wellbeingterm·dom demands recognition, not as an extension, subclass, or alternate form of sexual healthterm·dom, but as a distinct and revolutionary concept that challenges our accepted thinking, and has far-reaching global applications in public healthterm·key that have been neglected to date. However, our interest in expanding recognition of the public healthterm·key relevance of sexual wellbeingterm·dom does not undermine the importance of sexual healthterm·dom, sexual pleasureterm·dom, and sexual rights. Rather, we believe sexual wellbeingterm·dom brings conceptual clarity to our shared understanding of sexual healthterm·dom, identifies areas of conceptual difference, and clarifies a much broader public healthterm·key perspective on sexuality beyond sexual healthterm·dom alone.
Four pillars for a comprehensive public healthterm·key approach to sexuality Sexual healthterm·dom Our model follows key issues identified in the WHO definition of sexual healthterm·dom: fertility regulation, prevention and management of sexually transmitted infections (STIs; including HIV), sexual violence prevention, and sexual functions (including sexual desire and arousal). 6 The relevance of these issues to global public healthterm·key were underlined by the 2018 Guttmacher– Lancet Commission on sexual and reproductive health and rights focusing on the role of the Sustainable Development Goals in promoting specific areas of sexual healthterm·dom. 7 The WHO Working Group to Operationalize Sexual Healthterm·dom 8 explicitly linked these aspects of sexual healthterm·dom to “physical, emotional, mental, and social wellbeing in relation to sexuality”, centred within an interconnected framework of sexual healthterm·dom influences, including attention to human rights and positive approaches to sexuality.
Sexual pleasureterm·dom Sexual pleasureterm·dom is related to both sexual healthterm·dom and sexual wellbeingterm·dom but its distinct relevance to public healthterm·key is increasingly recognised. 9 , 10 A recent definition of sexual pleasureterm·dom addresses the diverse physical and psychological satisfactions of sexual experience, and key enabling factors, such as self-determination, consent, safety, privacy, confidence, and the ability to communicate and negotiate sexual relations. 11 Furthermore, this definition specifies that pleasure requires fundamental social and cultural conditions of sexual rights in terms of equality, non-discrimination, autonomy, bodily integrity, and freedom of expression. To improve the operationalisation of sexual pleasureterm·dom, we propose the inclusion of two key elements ( figure ): 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 pleasureterm·dom, encompassing interpersonal dynamics, such as communication, negotiation, and trust). These elements illustrate the conceptual relationships of pleasure with sexual healthterm·dom and sexual wellbeingterm·dom, and help to summarise the diverse factors associated with sexual pleasureterm·dom without privileging pleasure as the cornerstone of wellbeing. 12 , 13 Sexual justiceterm·dom Sexual justiceterm·dom represents larger global efforts to ensure social, cultural, and legal supports for equitable, person-centred sexual and reproductive experiences. Public healthterm·key plays an instrumental role in documentation and mitigation of adverse outcomes associated with disparities in human rights. Public healthterm·key also contributes to the promotion of equal access to distributive and restorative justice, helping combat historical restrictions of sexual citizenship on the basis of ethnicity, sex, and sexual and gender identity. 7 , 14 Among many specific examples, public healthterm·key has played a central role in addressing violence and discrimination linked to sexuality among people living with HIV. 15 With regard to the pillar of sexual justiceterm·dom, we propose trauma-informed, sex positive public healthterm·key practices as a specific tool for enacting social justice. This practice implies restorative approaches that acknowledge and address adverse sexual experiences, trauma that resonates through the life course, and the effects on sexual wellbeingterm·dom. 16 , 17 Sex positivityterm·dom is central to a public healthterm·key relevant concept of sexual wellbeingterm·dom. Trauma-informed, sex positive practicesterm refer to perspectives and approaches that emphasise contributions of sexuality and sexual expression to overall wellbeing.
Sexual wellbeingterm·dom in the context of sexual healthterm·dom, sexual pleasureterm·dom, and sexual justiceterm·dom We believe it is now imperative for the field of public healthterm·key to adopt and integrate sexual wellbeingterm·dom in efforts to address pervasive inequities related to sexuality and sexual behaviour, in particular, those driven by gender and sexual identity. Our framework allows distinct attention to the role of sexual wellbeingterm·dom in overall wellbeing 18 and better support for operationalisation, measurement, and potential public healthterm·key intervention.
Operationalisation and measurement of sexual wellbeingterm·dom is challenged by diverse perspectives on its definition and meaning. Outside of professional spheres, people rarely refer to sexual wellbeingterm·dom per se, although the concept is inferred in the idea of a sex life that is supposedly good or going well. Pharmacies sometimes sell products, such as vaginal tightening gel, nutritional supplements, and fertility aids, under the banner of sexual wellbeingterm·dom. This commodification probably influences public understanding and focuses attention on a narrow set of assessment criteria to judge whether a sex life is going well. 19 However, definitions of sexual wellbeingterm·dom in academic literature attend to a broader range of aspects. Several measures have been developed, which inlclude unidimensional measures defined in terms of a global assessment of one’s sex life. 20 Laumann and colleagues defined sexual wellbeingterm·dom as “the cognitive and emotional evaluation of an individual’s sexuality”, and used four satisfaction judgments. 21 Muise and colleagues used a similar definition, but extended the domains to include satisfaction with sexual relationships and functioning, sexual awareness, sexual self-esteem, and body image esteem. 22 Syme and colleagues, in a study of sexuality in mid and later life, referred to sexual wellness with four dimensions: psychological (eg, cognitions, emotions, and concepts), social (eg, relationship and shared experience), biological and behavioural (eg, functioning, behaviours and scripted sexual activities), and cultural (eg, age or time in life, and gender and sexual orientation). 5 In operationalising sexual wellbeingterm·dom, we developed a model with seven core domains: sexual safety and security, sexual respect, sexual self-esteem, resilience in relation to past sexual experiences, forgiveness of past sexual events, self-determination in one’s sex life, and comfort with one’s sexuality ( table ). Domains were identified and refined through intensive engagement with wide-ranging literature, including a review of sexual wellbeingterm·dom definitions and measures. 62 In developing this new concept of sexual wellbeingterm·dom, we specified five criteria: (1) the concept should be distinct from sexual healthterm·dom, sexual satisfaction, sexual pleasureterm·dom, and sexual function; (2) the concept should be applicable to people regardless of whether they are sexually active; (3) the concept should apply to people irrespective of their partnership status (including those who are unpartnered); (4) the concept should be based in elements amenable to change through policy, public healthterm·key action, clinical support, or personal growth; and (5) the concept should focus both on a person’s summation of experience and assessment of prospects for sexual wellbeingterm·dom in the near future. For each of the seven domains, we provide a working definition and show its contribution to sexual wellbeingterm·dom, provide examples of relevance to public healthterm·key, and offer examples of how the domain might be operationalised ( table ).
Why is sexual wellbeingterm·dom imperative to public healthterm·key?
We anticipate some resistance to considering wellbeing as a valid goal of public healthterm·key. Critics refer to the subjective and variable qualities of wellbeing, necessarily influenced by social and cultural contexts, and played out in individual attitudes and actions. 63 Introduction of surveillance infrastructures and goals in diverse national and cultural settings will require persistence and careful data gathering. For example, the COVID-19 pandemic and the life-changing interruptions of migration have changed sexual priorities such that even delimiting appropriate sexual wellbeingterm·dom timeframes is challenging. 64 , 65 There might be resource constraints to monitoring that requires a multi-dimensional measure, and political resistance to giving prominence to sexual wellbeingterm·dom alongside risk-focused outcomes. Acknowledging these issues, we set out four ways in which sexual wellbeingterm·dom is highly relevant to core functions of contemporary public healthterm·key.
Sexual wellbeingterm·dom is a marker of health equityterm·key Within the field of public healthterm·key, population wellbeingterm·key approaches seek to establish measurable and achievable goals toward equity. 66 Sexual wellbeingterm·dom is an appropriate marker of population wellbeingterm·key, given inequities related to sexuality and sexual expression. These inequities include systemic and pervasive racial, ethnic, or immigrationbased discrimination, gender-based violence, sexual identity-based violence, and STIs and HIV. 7 A sexual wellbeingterm·dom approach recognises the transgenerational traumas that mark the unique needs of marginalised people. This recognition then supports implementation of population health approaches that are anti-oppressive, intersectional, and culturally and contextually adapted. 67 , 68 Sexual wellbeingterm·dom is a meaningful population indicator of wellbeing As population wellbeingterm·key continues to be an aspirational goal of public healthterm·key, sexual wellbeingterm·dom emerges as an important component of overall wellbeing. A populationbased study has shown the positive contribution of a measure of sexual wellbeingterm·dom in population surveys. 18 Sexual wellbeingterm·dom provides important insights into population wellbeingterm·key over the entire life course. Data on sexual wellbeingterm·dom would add new dimensions to community engagement in health issues, address structural determinants of health at local levels, and link local and larger public healthterm·key policy and practice related to sexual and reproductive health. 69 Sexual wellbeingterm·dom captures population trends distinct from sexual healthterm·dom measures Sexual wellbeingterm·dom incorporates outcomes that are increasingly recognised as important to, but distinct from, biomedically focused sexual healthterm·dom intervention. In a review of English-language sexual healthterm·dom promotion interventions published from 2010–14, four of 33 interventions’ stated goals were related to sexual wellbeingterm·dom; most interventions (n=28) either targeted sexual wellbeingterm·dom in addition to biomedical sexual healthterm·dom, or addressed sexual healthterm·dom outcomes through a focus on sexual wellbeingterm·dom. 70 Tracking sexual wellbeingterm·dom also shows key population trends in the importance of sex to broader wellbeing. For example, in four decades of French national surveys (1970s to 2006), the proportion of people reporting that sexual intercourse was considered essential to feeling good about oneself increased from 48% to 60% for women and from 55% to 69% for men. 71 Sexual wellbeingterm·dom refocuses the ethics, form, and practices of public healthterm·key Positioning sexual wellbeingterm·dom as a driver for cross-cutting public healthterm·key innovation challenges the structural origins of sexual inequities and requires acknowledging that sexual wellbeingterm·dom is experienced by people in relation to contexts and surroundings. 72 This suggests that surveillance of sexual wellbeingterm·dom, at individual and community levels, is required, and thus challenges the centrality of privacy in sexuality. Public healthterm·key surveillance is well established in sexual healthterm·dom prevention and control (eg, for STIs). However, extension to sexual wellbeingterm·dom refocuses such surveillance—and the capacity to offer intervention—into areas traditionally outside of public healthterm·key function. We contend that such surveillance is necessary to focus resources on populations of greatest need, and to track those who enter or exit intervals of greater need. 73 Such functions might require redefinition of relationships between communities and public healthterm·key entities to create trust and full engagement while protecting privacy. 74 Conclusion We believe that the adoption and integration of sexual wellbeingterm·dom as an essential concept in efforts to address sexual inequities is imperative for the field of public healthterm·key. A broad and consistent body of research supports the relevance of sexual wellbeingterm·dom as a distinct correlate of sexual healthterm·dom whose importance has been obscured by conflation of the two concepts. 75 Our conceptualisation of sexual wellbeingterm·dom relates to sexual healthterm·dom and pleasure (a primary motivation for sex), and to social, cultural, and political frameworks of sexual justiceterm·dom. By identifying trauma-informed sex positivityterm·dom as a central guiding public healthterm·key value, we anchor our approach to sexual wellbeingterm·dom with a corresponding recognition of the notable significance of both sexuality and sexual trauma in our lives. Inclusion of sexual wellbeingterm·dom as a public healthterm·key goal is attainable but requires an additional data-driven vision and specified objectives. Our initial steps toward an approach, and ultimately conceptualisation, of sexual wellbeingterm·dom builds on existing measures and intentionally focuses on dimensions and an organisational structure that might be addressed effectively by public healthterm·key policy and intervention.
The personal losses of illness and death, the threats to the health of families, the interpersonal effects of quarantine and physical distancing, and the pervasive economic consequences of the COVID-19 pandemic will almost certainly have enduring effects on sexual wellbeingterm·dom that have yet to be fully described and appreciated. Significant public healthterm·key resources will be needed, simply to meet the basic needs of many people. Our proposed shift in thinking about sexuality in public healthterm·key will facilitate movement forward in the process of reorganising social structures to meet these effects, including attention to population wellbeingterm·key.