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Description
In a seminal 1993 article, Ruth Dixon-Mueller questioned the reproductive health field's conceptualization of sexuality, arguing that it had treated intercourse as a sanitized, emotionally neutral act. (1) If one were to learn about human sexuality by reading family planning research and program manuals, she suggested, one would have no idea that sex leads to great enjoyment--as well as pain--for human beings. She called for a more gender-sensitive approach to sexuality in research and programming, including greater attention to the ways in which women want to maximize sexual enjoyment and minimize sexual harm, and to how these desires influence their reproductive health behaviors. Such an approach--which Dixon-Mueller called establishing the "sexuality connection" in reproductive health--not only would garner a more accurate understanding of sexuality and sexual risk reduction, but also would acknowledge women as sexual agents rather than merely as sexual victims or as "targets" of contraceptive programs and HIV prevention efforts.
During the nearly 15 years since Dixon-Mueller's article was published, many important developments regarding sexuality have occurred within the family planning field. Most symbolically, the phrase "reproductive health" has been superseded by "sexual and reproductive health," and the terms "sexual health" and "sexual rights" increasingly appear in public health and human rights discourse.* (2) In addition, the HIV/AIDS epidemic has highlighted the desperate need for better data on sexual behaviors and spurred collaborations between clinicians and social scientists who study sexuality. (3) Thus, at least at first glance, the reproductive health field has opened its doors to deeper explorations of sexuality.
Threats to women's sexual and reproductive well-being have been especially well documented during the past 10-15 years. An impressive body of work reveals the ways in which women's sexual autonomy--and thus their pregnancy and disease prevention practices--are limited by gender inequalities at both individual and structural levels. At the individual level, gender-based violence, (4-9) nonvolitional sex (10, 11) and relationship power imbalances (12, 13) all have been associated with reduced sexual autonomy and thus greater vulnerability to unintended pregnancy, HIV and other STIs, and reproductive morbidity (14) and mortality. At the structural level, the combination of poverty and gender inequality leads many women to exchange sex for money, clothing, gifts and other goods--yet another risk factor for HIV infection and other adverse reproductive health outcomes. (15-17) This literature has significantly deepened our understanding of how experiencing sexual harm influences women's sexual and reproductive health and risk.
However, the ways in which the positive aspects of sexual experience contribute to women's sexual health and risk are little understood. Despite a few notable exceptions, (18, 19) the public health research community has largely failed to explore the factors that contribute to optimal sexual functioning for women or the ways in which sexual pleasure-seeking (as opposed to love-seeking or money-seeking) influences women's risk for unintended pregnancy and disease. This "pleasure deficit" inspired a 2006 review in The Lancet, (20) in which the authors called for the promotion of pleasure in HIV and other STI prevention programs, and warned that negative messages about sexuality can undermine, rather than promote, effective condom use.
Notably, the authors of the Lancet review suggested that acknowledgment and discussion of pleasure has been absent from all areas of HIV and other STI programming, and not just those pertaining to women. However, at least some research has focused on the ways in which the desire for pleasure motivates men to take sexual risks. For example, several studies have examined the role of pleasure in men's decisions to have anal intercourse with other men without using condoms ("barebacking"), (21-23) and others have documented heterosexual men's lack of interest in using male condoms during vaginal sex because they diminish sexual pleasure. (24-27) These studies provide some insight into the ways in which men's desires for sexual enjoyment shape their willingness to use male condoms. They also explore how cultural norms about masculinity, such as the social benefits for men of sexual conquest and virility, can influence men's pleasure-seeking. (28-30) In stark contrast, relatively little research has examined women's pleasure-seeking and how it influences their sexual and contraceptive behaviors.
Below, we discuss in greater detail some examples of the "pleasure deficit" for women in sexual and reproductive health research and programs, and highlight areas for future research.
RESEARCH AND PROGRAMMING
Women and Male Condoms
The public health approach to women and their partners' use of male condoms has evolved significantly since the beginning of the HIV/AIDS epidemic. Many public health programs seek to strengthen women's skills to negotiate with male partners for condom use. However, a large body of research suggests that gender inequality (particularly in the social and financial realms) makes it difficult--and sometimes impossible--for women to ensure condom use. (13, 31-34) Furthermore, even when women are able to negotiate for condom use, they may not want to do so, because some women view condoms as incompatible with sex that is intimate, loving and monogamous. (35-39) Thus, women's social, emotional and financial dependence on both men (13) and romantic relationships (40) can make it difficult for them to encourage male partners to use condoms.
In comparison, women's sexual resistance to condoms has been relatively unexplored. Theorists within the HIV field have developed behavioral models that directly (41) or indirectly (42) acknowledge the role of pleasure for both partners in shaping uptake and use of male condoms. In particular, the AIDS Risk Reduction Model asserts that how condoms feel matters to both women and men. (41) Certainly, the empirical literature suggests that many men do not like using condoms because they curtail sexual sensation. (24-26) A 14-country study by the Joint United Nations Programme on HIV/AIDS found that men's most frequently reported reason for not using condoms... |
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