Towards a psychology of sexual health

Towards a psychology of  sexual health

 

Increased  attention  has  been  made  in  recent  years to issues of sexual and reproductive health in relation to broader social and political envi-ronments  and  human  rights  issues.  The  World  Health  Organization  (WHO,  2015)  has  indi-cated that we cannot consider sexual and repro-ductive health concerns such as HIV and other sexually  transmitted  diseases,  sexual  violence,  sexual  problems,  unwanted  pregnancies  and  unsafe abortions, without considering discrimi-nation and inequality. Many individuals around the world may be actively discriminated against and even abused on the basis of their sexual and gender  identity,  who  they  choose  to  have  sex  with  and  their  sexual  practices.  Within  this  framework,  sexual  health  is  not  to  be  under-stood only in terms of the absence of sexual dis-ease or dysfunction, but rather more holistically in  terms  of  physical  as  well  as  psychological  and social well-being. Sexual health is not just about  disease,  but  also  identity  and  relation-ships.  As  the  WHO  (2015)  states,  ‘For  sexual  health to be attained and maintained, the sexual rights  of  all  persons  must  be  respected,  pro-tected and fulfilled’ (p. 5). This inclusive defini-tion  of  sexual  health  demands  an  imaginative  sexual  health  psychology  that  theorises  the  individual as embedded within their psychoso-cial,  sociocultural  and  geopolitical  contexts.  This  inclusive  definition  also  demarcates  the  rather impoverished attempt to develop a sexual health psychology to date. Much of the existing work  on  sexual  health  psychology  has  for  the  most  part  aligned  with  funding  opportunities  which  address  the  proximal  determinants  of  sexual  ill-health.  Such  approaches  align  them-selves with the medical profession and focus on behavioural determinants of unsafe sex and the transmission  of  sexual  infections,  the  determi-nants  and  psychological  consequences  of  sex-ual violence, and understanding the causes and psychological  treatments  of  what  are  termed  ‘sexual  dysfunctions’  (e.g.  Miller  and  Green,  2002).  These  are  all  important  areas  of  work,  but their overall focus on the proximal determi-nants   of   sexual   ill-health   elides   other,   and   potentially more important determinants of sex-ual  health.  Moreover,  a  biomedical  focus  on  sexual health alone and a tendency to only use the  individual  as  a  unit  of  analysis  and  theory  amplifies and interpellates notions of individual responsibility  and  culpability.  It  can  diminish  and obscure social and other structural determi-nants of sex (e.g. Campbell, 2003 and Tomlinson et al., 2010 in relation to HIV) and lead to the medicalisation of sexual difficulties (Moynihan, 2003;  Tiefer,  2006).  Such  partial  understand-ings  of  sexual  health  can  severely  delimit  the  ways we can imagine and develop sexual health interventions (Marks et al., 2018).It  could  be  further  argued  that  much  of  the  work  on  sexual  and  reproductive  health  has  often  drawn  on  heteronormative  assumptions  about  sex,  behaviour  and  ‘normality’,  whereas  the  sexual  lives  of  marginalised  others  may  often  be  conceptualised  in  terms  of  ‘risk’  and  unconventional,  or  ‘problem’  behaviour  (e.g.  unprotected  sex  between  men  who  have  sex  with  men).  Furthermore,  other  non-normative  groups   are   typically   barely   considered,   for   example, the sexuality of people with disabili-ties are routinely overlooked.We  would  argue  that  in  order  to  develop  sexual   health   psychology,   the   sexual   and reproductive  health  of  individuals  cannot  be  properly   understood   in   isolation   from   the   socio-political  contexts  in  which  people  are  embedded.  Furthermore,  so  as  not  to  perpetu-ate  dominant  models,  reproduce  inequalities  and power relations or to reify oppressive theo-ries  (Hepworth,  2006),  a  pluralist  approach  is  required.  A  psychology  of  sexual  health  must  encourage  a  diversity  of  analytic  foci  and  an  inclusive approach to both methods and theory. In this way, a new psychology of sexual health can encompass the inclusive focus of the WHO definition.The  collection  of  16  papers  in  this  special  issue  presents  a  first  step  towards  such  a  psy-chology of sexual health. The special issue pre-sents  a  focus  on  many  differing  aspects  of  sexual  and  reproductive  health  from  a  broad  range  of  perspectives.  The  papers  report  on  research conducted in a range of national con-texts  not  only  the  developed  world,  including  Argentina,  Australia,  Canada,  Ghana,  India,  Ireland, Kenya, New Zealand, South Africa, the United  Kingdom,  and  the  United  States,  and  utilise   differing   quantitative   and   qualitative   methods.  The  papers  construct  a  sexual  health  psychology  that  understands  multiple  dimen-sions  of  sexual  health  and  situates  sexual  and  reproductive health within multiple wider con-texts; the broader context of social and cultural normative   assumptions   about   sexuality   and   gender;  political  discourses  about  rights  and  choices; and the role of power in shaping sexual health.The first two papers make a critical analysis of how research knowledge on sexual health is generated  and  reported  on  both  making  a  cri-tique  on  the  continuing  tendency  to  focus  on  medical  understandings  and  pathologise  indi-vidual  behaviours  in  relation  to  sexual  health.  These papers trouble the foundations on which sexual  health  knowledge  is  generated,  shared  and  utilised.  Stelzl  and  colleagues  present  a  critical discursive analysis on human sexuality textbooks  from  the  United  States  and  Canada  and  point  out  how  sexual  problems  were  con-ceptualised and represented in traditional, indi-vidualised  biomedical  ways.  Such  textbooksperpetuate  and  delimit  the  ways  sexual  health  can   be   understood   and   reify   problematic   assumptions  that  constrain  change.  Similarly,  epidemiology,   as   a   powerful   truth   system,   shapes funding agendas and drives the produc-tion    of    knowledge    about    sexual    health.    Edelman’s  critique  of  this  foundational  episte-mology   similarly   emphasises   the   dominant   focus  on  the  individual  in  epidemiology  and  calls for a re-envisioning of the focus of epide-miological studies to studies that focus more on sociocultural context and that counter the con-structions   around   sexual   health   ‘risks’   that   pathologize individuals and certain behaviours. Edelman  outlines  the  need  for  approaches  that  connect   epidemiology   to   lived   experience,   intersectionality and salutogenesis. New epide-miological  models  would  generate  new  evi-dence about sexual health and in turn generate new priorities.The   next   three   papers   focus   on   young   people’s sexual health, within specific sociocul-tural     contexts.     LeGrice     and     colleagues     challenge  the  predominance  of  a  ‘one  size  fits  all’  approach  to  sexual  health  education  in  New  Zealand,  which  excludes  Maori  student’s  cultural  understandings  of  sexuality.  Any  cul-tural   considerations   for   Maori   students   are   included as an extra ‘add on’. Sexuality educa-tion in this context adopts a Western, colonising perspective. Their study shows how Maori cul-tural  values,  such  as  fluid  understandings  of  gender and sexuality, should be integrated into sexual health education in a manner beneficial for  all.  Maori  ontologies  and  epistemologies  invite a reconsideration of sex and sexual health with particular implications for a new psychol-ogy  of  sexual  health.  In  Kenya,  the  paper  by  Ssewanyana and colleagues looks at sexual risk behaviours of adolescents in Kilify County. The researchers  adopt  an  ecological  system  model  to  explore  how  certain  sexual  risk  practices,  such  as  early  sexual  debut  and  transactional  sex, are shaped by social and structural environ-ments, particularly poverty, community insecu-rity  and  under-resourced  healthcare  systems.  They highlight gender inequality as a key driv-ing  factor  for  many  sexual  risk  behaviours,particularly  for  females.  Constructions  around  gender  and  sexuality  are  highlighted  in  the  study by McVittie and colleagues on the under-standings  of  sexual  risk  among  HIV  volunteer  support workers in South Africa. They analyse how  the  HIV  volunteer  workers  discuss  and  conceptualise  sexual  risk  in  largely  heteronor-mative,  gendered  norms  that  perpetuate  con-structions  of  masculinity  and  femininity.  Talk  about  men  centre  around  their  innate  sexual  drive  and  sexual  power  and  irresponsibility.  This  may  in  turn  position  women  as  being  responsible for ensuring their own sexual health and  that  of  their  male  partners.  The  authors  argue that this reliance on heteronormative and gendered  constructions  around  sexuality  may  perpetuate the invisibility of other forms of HIV sexual transmission and prevent the promotion of alternative constructions of femininities and masculinities.Gender  inequality  and  gendered  relation-ships  and  power  dynamics  are  a  key  concern  also  explored  in  the  next  five  papers  that  deal  with  women’s  sexual  and  reproductive  health  more  specifically.  The  first  paper  by  Bowling  and colleagues look at the acceptability among men and women of the use of female condoms in  urban  India  in  relation  to  sexual  pleasure.  They found that women felt they could not trust their  male  partners  with  using  male  condoms,  and so, the use of the female condom increased their sexual pleasure by giving them more sense of  control  and  reducing  anxiety  about  preg-nancy  and  infections.  Men  indicated  mixed  reports about sexual pleasure and the use of the female  condom,  with  some  saying  that  it  felt  less  constraining  than  the  male  condom,  but  others  saying  that  the  inner  and  outer  rings  of  the  female  condom  caused  discomfort  to  their  penis.  Interestingly,  they  found  that  both  men  and  women  did  not  necessarily  prioritise  male  sexual pleasure, although acknowledging it as a cultural  norm.  More  important  for  the  experi-ence of sexual pleasure was longer duration and privacy for sex and sex which was stress free The paper by Moran and Lee looks at sexual health from the perspective of body image and socially  constructed  norms  of  the  aesthetics  of the  vagina.  They  explore  Australian  women’s  constructions and dissatisfaction with their gen-ital appearance. They report on how the women tended to view their genitals in terms of social constructions   of   the   ‘normal’   vagina   that   emphasise  the  male  gaze,  against  which  they  position themselves as inadequate. They further observe the women’s difficulties in challenging these normative assumptions. The authors argue for the need to promote an awareness of natural genital  diversity  and  challenge  the  messages  that female genital cosmetic surgery is safe and beneficial.The  next  papers  point  to  the  influence  of  political  and  social  power  and  disenfranchise-ment  on  control  over  sexual  and  reproductive  choices  and  its  impact  on  identity  and  psycho-logical well-being. Marston and colleagues take a dialogical approach to exploring how a sample of  women  in  Ghana  regulate  their  fertility  and  how  this  relates  to  their  social  identity.  They  report on how the women navigate the conflict-ing  traditional  versus  modern  social  identities.  On one hand, they are positioned as having obli-gations  to  bear  children,  on  the  other  hand  having  modern  educational  and  employment  responsibilities.  The  women’s  fertility  regula-tion practices and choice around pregnancy are shaped   by   sociocultural   norms   and   are   in   response  to  men’s  expectations  on  them.  The  papers by Msetfi and colleagues and Sambaraju and colleagues both look at women’s reproduc-tive rights in the context of Ireland’s anti-abor-tion   policies.   Msetfi   and   colleagues   take   a   quantitative  approach  to  investigating  the  rela-tionship  between  political  disenfranchisement,  reproductive  control  and  psychological  well-being. They show that limiting women’s access to  reproductive  healthcare  may  damage  their  health and well-being. They thus show how per-ceived      socio-political      disenfranchisement      (rather  than  specific  lack  of  access)  can  have  important  negative  implications  for  women’s  sexual health. Sambaraju and colleagues present a  discursive  analysis  on  online  readers’  com-ments to news items on debates around reform-ing abortion laws. They show how some of the debates between readers commenting on a news item  centre  around  conflicts  around  matters  of  ‘choice’.  However,  often  the  debates  between  readers centre around the legitimacy of a wom-an’s  ‘choice’.  Notions  of  legitimacy  are  made  with  reference  to  particular  outcomes  (such  as  medical risk) and motivations. Different orienta-tions to legitimacy of choice are made in terms of  constructing  women  as  either  independent  agents  or  as  bound  up  to  their  pregnancy.  The  authors  make  a  case  for  such  legitimisation  work  as  socially  embedded  and  forms  a  focus  for a sexual health psychology that can address sexual health rights.Thereafter,  two  papers  focus  on  people  with  disabilities,  a  group  generally  excluded  in  the  sexuality literature. Both papers aim to challenge the assumptions that may be held about the sexu-ality of people with disabilities. Ilyes presents an impassioned analysis and challenge to how sex-ual  consent  is  understood,  conceptualised  and  policed for people with learning disabilities, call-ing  for  a  more  emancipatory  and  inclusive  way  of working with matters of consent and sexuality. Hunt  and  colleagues  report  on  a  photovoice  study on the sexuality experiences of people with physical  disabilities  in  South  Africa,  revealing  how   normative   assumptions   about   sexuality,   masculinity  and  femininity  shape  much  of  the  participants’ experiences and have to be renego-tiated and challenged. Exploration of sexuality in the  context  of  disability  provides  a  dynamic  opportunity   to   interrogate   concepts   such   as   embodiment,  pleasure,  intimacy,  mutuality  and  what it means to be sexual.There are two papers looking at sexual health matters within samples from sexual and gender minorities. Aristegui and colleagues explore the resources  used  by  a  sample  of  gay  men  and  transgender  women  in  Argentina  to  cope  with  their HIV-positive status and marginalised iden-tity.  They  report  on  how  participants  not  only  draw on individual and interpersonal resources for  coping  with  stigma  but  also  how  broader  contextual  and  institutional  processes  had  a  positive  impact  on  coping  with  stigma.  These  include   political   changes   around   laws   and   human rights. Grant and Nash’s paper focus on a   sample   of   lesbian,   bisexual   and   queer

Australian  women.  The  authors  observe  how  public health messages of safe sex and risk tend to  focus  on  heteronormative  practices,  against  which  women  identifying  as  lesbian  are  con-structed as ‘low risk’. They take a sociological framework to explore how participants’ under-standing  and  meaning  about  safe  sex  and  risk  are shaped by gendered heteronormative sexual scripts.  Safe  sex  and  risk  are  understood  pri-marily in terms of sex with men, rather than sex with  women.  The  authors  point  to  the  absence  of sexual scripts and sexual health literacy that are meaningful for lesbian, bisexual and queer identities.The  final  two  papers  of  this  special  issue  focus  specifically  on  matters  of  men’s  sexual  health.  The  paper  by  Own  and  Campbell  pre-sents  a  discursive  analysis  of  how  masculinity  and  the  penis  are  constructed  in  a  sample  of  popular    men’s    magazines    in    the    United    Kingdom.   Their   analysis   demonstrates   how   constructions of the penis create a sense of anxi-ety  and  fear  about  the  reader’s  manhood.  They  identify two main discourses: the ‘Laddish’ dis-course  which  focuses  primarily  on  size,  domi-nance  and  superiority  and  the  ‘Medicalized’  discourse  which  focuses  on  functionality  and  aesthetics. They argue how both discourses cre-ate  anxiety  and  fear  around  a  masculine  ideal  that is unachievable and runs the risk of trauma and  damage  when  penis  surgery  goes  wrong.  This  may  leave  male  readers  wrestling  with  a  fragile sense of manhood. Finally, the paper by Tutino  and  colleagues  focus  at  the  level  of  the  individual, but point out how research on men’s sexual  health  has  typically  focused  on  sexual  functioning  with  much  less  attention  given  to  broader  dimensions  of  men’s  sexual  health.  They examine the relationship between psycho-logical variables and sexual health outcomes of a  sample  of  undergraduate  male  students  in  Canada.  Using  a  quantitative  approach,  they  found  that  difficulties  with  emotional  regula-tion,  greater  anxiety  sensitivity  and  increased  psychological  distress  predicted  poorer  sexual  health outcomes, particularly sexual functioning and sexual quality of life. The authors argue for a need to take a broader, psychosocial  perspective

in  men’s  sexual  health  and  clinical  psychology  practice.This  special  edition  provides  an  initial  step  towards imagining a new psychology of sexual health. At its heart is an inclusive understanding of what sexual health can be and an invitation to  psychologists  to  respond  to  this  dynamic  opportunity.  Critically,  sexual  health  psychol-ogy  should  encompass  far  more  than  attempts  to reduce the onwards transmission of sexually transmitted diseases alone. Of course, such dis-ease prevention work is vital, yet we believe it is short sighted to address such issues in isola-tion.  Deracinating  people  and  pathogens  from  the  contexts  in  which  they  are  embedded  will  not  improve  sexual  health.  Sexual  health  psy-chology  must  assist  in  troubling  systems  of  truth and knowledge. Sexual health psychology must  question  the  social  organisation  of  sex,  bodies  and  gender.  Sexual  health  psychology  must  articulate  how  the  scope  of  individual  agency  is  globally  patterned  by  diverse  social  structures. Sexual health psychology must con-nect the complexities of the discursive realm to everyday lived experience. We believe that it is only  through  such  holistic  and  multifaceted  understandings that we can imagine and deliver pluralistic  sexual  health  interventions  to  genu-inely improve sexual health.

Poul Rohleder University of EastLondon, UKPaul FlowersGlasgowCaledonian University UK

https://doi.org/10.1177/1359105317750162Journal of Health
 Psychology2018, Vol. 23(2) 143 –147© The Author(s) 2018Reprints and permissions
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