Incorporating pleasure in educational sexual health programs can have positive effects on attitudes and safer sex behavior

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Sexual health programs that include sexual desire and sexual pleasure can improve knowledge and attitudes around sex, as well as condom use compared to those that do not, according to research published in the open access journal PLOS ONE.

The meta-analysis of research literature from 2005-2020 finds that incorporating pleasure in such programs can have positive effects on attitudes and safer sex behavior and recommends revisiting sexual education and health intervention approaches that do not acknowledge that sexual experiences can be pleasurable.

Billions of dollars are spent around the world each year on sexual and reproductive health and rights services and programs. Yet with fewer than ten years to achieve the UN Sustainable Development Goals, which target sexual and reproductive health and reproductive rights, there is still a huge global burden of sexually transmitted diseases and HIV.

Researchers from The Pleasure Project, WHO’s Department of Sexual and Reproductive Health and Research and colleagues review 33 unique interventions targeting STI/HIV risk reduction that incorporate pleasure, and meta-analyze eight.

They find evidence that including pleasure can have significant positive effects across information- and knowledge-based attitudes, including participants’ self-belief in behavior change, and motivation to use condoms, as well as in behavior and condom use.

While the authors searched for interventions across a spectrum of sexual health interventions (including contraception and family planning interventions), the review ultimately included only STI/HIV-related programs targeting populations traditionally considered ‘vulnerable’.

The authors note that future work is needed to incorporate and evaluate pleasure-inclusive interventions in the reproductive health space and for general populations.

The team argues that continuing to avoid pleasure in sexual health and education risks misdirecting or ineffectively using resources. The researchers call for a fundamental rethink of how programs are oriented.

The authors add: “Pleasure has been over-looked and stigmatized in health promotion and sex education, despite its obvious connection to sexual health and well-being.

Our systematic review and meta-analysis, the first of its kind, shows that including sexual pleasure considerations in sexual and reproductive health services improves condom use and so may also improve sexual and reproductive health outcomes.

Policymakers and program managers should more readily acknowledge that pleasure is a key driver of sexual behavior, and that incorporating it in sexual and reproductive health services can reduce adverse outcomes.

Eight years out from the Sustainable Development Goal deadline, innovative strategies that can accelerate progress towards SRHR targets, including for STI and HIV prevention, are urgently needed. Programs adopting a sex-positive and pleasure-inclusive approach is one such innovation that should be urgently considered.”


Adolescence is a period of critical importance for psychosexual development as increased curiosity, exploration and involvement in the relational and sexual spheres contribute to shaping a persons’ sexual sense of self (Tolman & McClelland, 2011). During this period, the representations of self, relationships and sexuality that form through the interpretation of sexual and relational experiences provide an important foundation for sexuality development into adulthood.

While positive sexuality development in adolescence is critical for sexual health—that is, a state of physical, emotional, mental and social well-being in relation to sexuality (WHO, 2006)—current understanding of adolescents’ sexual dispositions that fall under normative development is surprisingly limited.

However, studies that have examined the contribution of various psychological and relational factors to sexual health have consistently highlighted the role of the sexual self-concept (Hensel & Fortenberry, 2013), the capacity to negotiate relational dynamics (van de Bongardt & de Graaf, 2020) and attitudes toward sexual pleasure (Horne & Zimmer-Gembeck, 2005). Despite these efforts, knowledge is lacking about the nature and variability of their expression among adolescents.

Thus far, research has shown that these psychosocial dimensions of sexuality develop through sexual exploration and practices, which may shape or reinforce adolescents’ perceptions and feelings towards themselves and their sexuality (Hensel et al., 2011). Yet, the type and variety of sexual practices adolescents engage in, either by themselves or with partners, remain understudied as research has mostly focused on vaginal intercourse and sexual behaviors that are considered problematic or risky (Best & Fortenberry, 2013).

A more integrated understanding of adolescents’ psychosocial dispositions towards sexuality and sexual experiences is necessary for the promotion of positive sexual development and health. As part of this effort, the present study provided a descriptive analysis of adolescents’ sexual self-concept, perceived capacity to negotiate relational dynamics, attitudes towards sexual pleasure, and sexual practices.

The Sexual Self-Concept
Two dimensions of the sexual self-concept have been shown to influence adolescents’ positive and negative evaluations of their sexual thoughts, feelings and behaviors, sexual esteem and sexual anxiety (Deutsch et al., 2014). Sexual esteem consists in the evaluation a person makes of themselves as a sexual being and their capacity to express their sexuality and relate sexually to partners. It has been described as including body esteem, the perceptions a person holds towards their sexual attractiveness. Adolescents with higher sexual and body esteem hold more positive feelings toward sexual pleasure and experiences (Horne & Zimmer-Gembeck, 2005) and report more sexual satisfaction (Mastro & Zimmer-Gembeck, 2015), safer sex practices and a greater sense of competence in negotiating intimate relationships (Auslander et al., 2012; Oattes & Offman, 2007). Adolescents’ growing involvement in autoerotic and partnered sexual practices tends to be associated with increasing sexual esteem and decreasing sexual anxiety—that is, the tendency to feel discomfort or anxiety about one’s sexuality (Snell, 2001). Sexual anxiety is associated with more attitudes supportive of sexual abstinence, fewer sexual encounters (O’Sullivan et al., 2006) and less sexual satisfaction in adolescence (Hensel et al., 2011), as well as sexual dissatisfaction and dysfunctions in adulthood (Brassard et al., 2015; Dang et al., 2018). While sexual esteem and anxiety are considered instrumental in positive development and sexual health, it remains difficult to establish normative tendencies and variations based on available data.

Perceived Capacity to Negotiate Relational Dynamics
Sexual communication increases sexual satisfaction by fostering intimacy and the sharing of partners’ sexual likes and dislikes, which can favor the experience of sexual pleasure (MacNeil & Byers, 2009). Studies show that between 30 to 50% of adolescents feel confident in addressing sexuality topics with their partners (Guzmán et al., 2003; Widman et al., 2006) and that those who engage in these open discussions report more sexual satisfaction (Théorêt et al., 2017) and safer sex practices (Noar et al., 2006). In addition, the rare studies examining youth relational skills in the context of sexuality show that those who have more voice in their intimate relationships present a stronger sexual self-concept (van de Bongardt & de Graaf, 2020), more positive feelings towards sexual pleasure (Horne & Zimmer-Gembeck, 2005) and greater perceived ability to use protection (Buzwell & Rosenthal, 1996). For their part, youth who employ ineffective relational strategies, such as self-silencing, display poorer global communication patterns (Shulman et al., 2018). While adolescents’ sexual communication skills appear to vary, their sense of self-efficacy regarding sexual communication and their capacity to have a voice in intimate relationships must be investigated.

Attitudes Towards Sexual Pleasure
During adolescence, youth evaluate whether and how sexual pleasure should fit into their lives. Adolescents and adults who derive a sense of entitlement and efficacy toward sexual pleasure present a more positive sexual self-concept, manifested by greater sexual and body esteem and fewer negative feelings toward sexuality (O’Sullivan et al., 2006; Zimmer-Gembeck & French, 2016). Individuals who hold these attitudes are also more likely to have positive emotional responses to sexual experiences (Mastro & Zimmer-Gembeck, 2015) and tend to favorably assess their sexual communication skills (Kohlberger et al., 2019) as well as their capacity to express themselves within intimate relationships (Horne & Zimmer-Gembeck, 2005). In addition, youth who have positive attitudes toward sexual pleasure and are well acquainted with their sexual desires are less likely to engage in undesired sexual activity or risky sexual behaviors (Impett et al., 2006; Kettrey, 2018). Lacking, however, is an understanding of how youth generally appraise sexual pleasure and how it fits into their larger subjective experience of sexuality. The rare studies examining adolescents’ narrative pertaining to sexual pleasure suggest that some view it as a means to access physical and emotional satisfaction, while others view it negatively and feel a disconnect between their expectations relative to sexual pleasure and their ability to access it during sexual contacts (Saliares et al., 2017). However, these data were obtained primarily from girls, in qualitative studies, which does not provide a general sense of adolescents’ perceived entitlement and ability to experience sexual pleasure and how these dispositions may vary.

Sexual Practices
Evidence suggests that adolescents engage in sexual practices that follow a linear trajectory from autoerotic behaviors to activities with sexual partners that progress from holding hands, hugging and kissing to more intimate touching, and genital sexual behaviors (de Graaf et al., 2009). Recent studies also show that a growing number of adolescents integrate digital technologies in their sexual life, as many report viewing pornography (Bothe et al., 2020) and exchanging sexualized text messages (sexting) (Dake et al., 2012). However, little attention has been given to the diversity of sexual experiences in adolescence as studies to date have mostly focused on independent subsets of practices (e.g., intercourse, pornography).

Studies consistently show that the accumulation of sexual experience among female adolescents is associated with a stronger sexual self-concept (Hensel et al., 2011), more positive attitudes towards sexual pleasure (Zimmer-Gembeck et al., 2011) and a more favorable assessment of their relational abilities (Horne & Zimmer-Gembeck, 2006). However, research has also found that some adolescents with a large sexual repertoire have a poorer sexual self-concept and relational skills deficits, while the opposite is true for some adolescents with little sexual experience (Thorsen, 2018). Thus, a better understanding of the diversity of adolescents’ sexual practices and their association with psychosocial dispositions is needed.

Age, Gender and Sexuality
Comparative and longitudinal studies show that sexual esteem, relational skills and favorable attitudes towards sexual pleasure increase and sexual anxiety decreases with age and sexual experience (Hensel et al., 2011). However, a study with older adolescent girls (16–25) indicates that sexual body esteem remains relatively stable through time (Zimmer-Gembeck et al., 2011). Although these trends are of great interest, current understanding of the impact of age on adolescents’ sexual and psychosocial dispositions remains limited. While the literature suggests that autoerotic and partnered sexual practices increase incrementally with each additional year (Herbenick et al., 2010), lacking is a general overview of age-related trends for a combination of autoerotic, partnered and technology assisted behaviors.

With regards to gender, some studies have found similarities between boys and girls relative to sexual assertiveness (van de Bongardt & de Graaf, 2020), sexual body-esteem (Zimmer-Gembeck & French, 2016), and rate of participation in sexual activities with a partner (de Graaf et al. 2009). Gender differences pertaining to sexual esteem and anxiety have been identified in the literature, but findings are mixed. More consistent differences have been identified relative to adolescents’ perceptions of their relational skills, attitudes towards sexual pleasure and sexual practices. Compared to girls, boys display greater feelings of self-efficacy and entitlement to self-pleasure (Zimmer-Gembeck & French, 2016) and are more likely to engage in autoerotic practices (Robbins et al., 2011). By contrast, girls view their relational skills more favorably (van de Bongardt & de Graaf, 2020; Widman et al., 2014) and report a higher sense of entitlement to sexual pleasure with partners (Zimmer-Gembeck & French, 2016). These results emphasize the need to examine between and within age and gender group variability concurrently in order to move toward a more complete understanding of adolescents’ experience of sexuality.

reference link :https://link.springer.com/article/10.1007/s10964-021-01543-8


More information: Zaneva M, Philpott A, Singh A, Larsson G, Gonsalves L (2022) What is the added value of incorporating pleasure in sexual health interventions? A systematic review and meta-analysis. PLoS ONE 17(2): e0261034. doi.org/10.1371/journal.pone.0261034

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