The pleasure deficit: revisiting the "sexuality connection" in reproductive health.

In a seminal 1993 article, RuthDixon-Mueller questioned the reproductive health field’s conceptualization of sexuality, arguing that it had treated intercourse as a sanitized, emotionally neutral act. If one were to learn about human sexuality by reading family planning research andprogrammanuals, she suggested, onewould have no idea that sex leads to great enjoyment—as well as pain—for human beings. She called for a more gendersensitive 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 thenearly 15 years sinceDixon-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 Most symbolically, the phrase ‘‘reproductive health’’ has been superseded by ‘‘sexual and reproductive health,’’ and the terms ‘‘sexual health’’ and ‘‘sexual rights’’ increasingly appear in public health and human rights discourse.* 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. This very journal changed its name from Family Planning Perspectives to Perspectives on Sexual and Reproductive Health in 2002, reflecting that its focus encompasses topics related not only to pregnancy prevention but also to HIV/AIDS, sexuality and men’s reproductive health, among others. 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 wellbeing have been especially well documented during the past 10–15 years. An impressive bodyofwork 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, nonvolitional sex and relationship power imbalances all have been associated with reduced sexual autonomy and thus greater vulnerability to unintended pregnancy, HIV and other STDs, and reproductive morbidity 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. 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, 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 loveseeking or money-seeking) influences women’s risk for unintended pregnancy and disease. This ‘‘pleasure deficit’’ inspired a 2006 review in The Lancet, in which the authors called for the promotion of pleasure in HIV and other STD prevention programs, and warned that negativemessages 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 STD 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’’), and others have documented heterosexual men’s lack of interest in using male condoms during vaginal sex because they diminish sexual pleasure. These studies provide some insight into the ways in which men’s desires for sexual enjoyment C O M M E N T