What is sexual health? That we would need to ask is itself surprising, given how much uptake this term has received. Sexual health is the topic of thousands of scientific journal articles, and the phrase now appears in the names of professional associations, journals, research centers, treatment centers, conferences, protocols, and statistical surveys. However, the points of reference and purposes range widely. A search for the Twitter (2020) hashtag #sexualhealth brings up posts on topics as diverse as where young people can find condoms, “what you need to know for using a penis pump,” how to promote intimacy and create “space for pleasure” among those who have suffered from sexual trauma, and how “accessories … can make everything better,” including cars, outfits, “man caves,” and sex.
Since 1974, the World Health Organization (WHO) has encouraged efforts by experts and advocacy groups to define and promote sexual health. Revised over the years, the WHO “working definition” – not officially endorsed by the organization because its 194 member states have not voted on it, but posted on its website – reads as follows:
Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.
(WHO 2006: 5)
This definition is not the only contender, but it is widely disseminated because of the influence of the WHO. Notably, this definition seems all over the map – ranging, as stated, from the physical to the emotional to the mental to the social. It aligns with very contemporary emphases on promoting health and wellness, but it treads far beyond the usual connotations of “health,” zooming off toward destinations that include pleasure, safety, freedom, and rights. When we think of sexual health, we most typically think about preventing and treating STIs. But the WHO working definition is far more expansive and goes well beyond biomedical concerns (Tiefer 2012).
At least since the 1970s, health professionals, researchers, governments, advocacy groups, foundations, commercial interests, and many individuals increasingly have embraced the quest for something called sexual health (Giami 2002; Edwards and Coleman 2004; Sandfort and Ehrhardt 2004; Carpenter 2007), and this aspiration has served as an engine of productivity. Behind this omnipresent and multipurpose banner, a wide array of programs have been launched, investigations undertaken, and commodities sold. This chapter, which summarizes themes from my book (Epstein 2022), examines how our ideas about sexual health have taken shape, describes the very different goals to which sexual health practices are oriented, and considers how the pursuit of this elusive goal has transformed many aspects of everyday life. I argue that conjoining “sexual” with “health” changes both terms: It alters how we conceive of sexuality, but it also transforms what it means to be healthy and prompts new expectations of what science and medicine can provide.
Put another way, it is insufficient to approach sexual health from the vantage point of how our sexuality nowadays has been medicalized – turned into an object of medical attention. Of course, there is a large and important literature on the medicalization of sexuality (see Roberts, Chapter 44 in this volume). However, claims about what it means to be healthy do not necessarily depend on biomedical definitions (Epstein and Timmermans 2021) and views on sexual health, as already noted, may encompass ideas of rights, pleasures, and other notions that are outside the traditional purview of biomedicine. Moreover, if we focus too much on the question of how sexuality has been medicalized, we may miss the corresponding question of how health has been sexualized – that is, how health professionals increasingly are encouraged and trained to address sexual matters, and how sexual issues have been incorporated into medical concerns in ways that change understandings of what it means to be healthy or ill.
Before proceeding further, however, we need to ask two interrelated questions: Why does sexual health matter? And, what is at stake more broadly in our investigation of the many worlds of sexual health?
There are at least three reasons why it is important to think about sexual health as a social phenomenon. The first is because, as a practical matter, sexual health or its absence touches on many people’s lives. At least before the advent of the COVID-19 pandemic, over one million cases of STIs such as chlamydia, gonorrhea, and syphilis were being reported each day around the world (Pollack 2019). Although the greatest burden of disease falls on those countries with the fewest resources to confront it, cases in the United States were also at a record high (Stack 2019). Meanwhile, nearly two million people become newly infected with HIV across the globe each year. In recent years, the rise of the #MeToo movement has ruptured the long silence surrounding sexual harassment and assault in the United States (O’Neil et al. 2018), while the debate over access to abortion and birth control has cast a shadow across the terrain of domestic politics in the United States as well as its foreign policy (Cousins 2018). These are life-and-death concerns, but the stakes of sexual health are also financial and personal: The global market in “sexual wellness” products was estimated at nearly $75 billion in 2019 (Cision PR Newswire 2020). These are just a few indicators, but there can be little doubt that sexual health is consequential.
The second reason is more abstract but no less important. Sexual health can potentially be pursued in many different ways. Such activities may be “sex positive” if they emphasize the place of pleasure in people’s lives, or “sex negative” if they construe sexuality as a domain of risks to be averted. In addition, sexual health discourses may encourage us to leave it up to the experts to draw conclusions about how our lives should be lived and to tell us what is “normal,” or they may expand the boundaries of who counts as an expert and may redefine normality in the process. Keeping these different renderings of sexual health in mind is important and helps us assess how the investments in sexual health affect our ideas about both sexuality and health.
Finally, it is valuable to study sexual health from a sociological standpoint because sexual health projects affect different groups in society differently. The potential benefits and harms of sexual health initiatives are unevenly distributed and vary depending on a wide variety of characteristics, including race, ethnicity, social class, gender, sexual identity, disability, citizenship status, nationality, and degree of interest in having sex. Therefore, thinking about sexual health – and how that goal can best address the needs of everyone – is part of a larger concern with assessing pathways to social equality and justice.
The idea of achieving sexual health builds on a longer history of linking sexuality and disease, and it draws on different traditions in different societies. We can point to several specific roots in nineteenth- and early twentieth-century Europe and the United States. These include marital and sex advice manuals that circulated widely (Neuhaus 2000), the rise of a new field of science known as sexology (Fuechtner et al. 2018), and public health efforts to prevent sexually transmitted diseases that were undertaken under the euphemistic label of “social hygiene” (Luker 1998). By the 1970s, numerous social changes were placing questions of sexuality at the forefront of popular attention. The sexual revolution, fueled by political, cultural, and technological developments – including the invention and mass marketing of new modes of contraception such as “the Pill” – had put sex on the agenda as an important and prized dimension of human experience. Moreover, new social movements, including second-wave feminism and the emergent gay rights movement, were foregrounding questions of sexual rights and freedoms in new and profound ways around the globe. At the same time, along with the rise in attention to reproductive health also came “First World” alarm about the economic consequences of “Third World” population growth. Increasingly, as reformers and advocates took stock of these varied social changes that, importantly, now seemed to take on a global character, “sexual health” seemed like an appropriate thread to stitch together many of these concerns.
The term “sexual health” began to circulate more widely after 1974, when the WHO convened a panel of experts to discuss how to better educate medical professionals about sexual matters. The participants at the meeting issued what became the first iteration of the WHO working definition of sexual health (WHO 1975). Each time the definition has been revised, advocates of sexual health have grappled with vexing issues concerning the normative stakes of their definitions and the role of scientific expertise (Should we specify what constitutes “healthy sex”? And if so, who gets to say?), the problem of universalism (Is there just one way to be sexually healthy?), and the relative emphases placed on the pleasures and dangers of sexuality.
Uptake of the term was relatively slow for the first decade and a half after the 1974 meeting. Then, in the early to mid-1990s, sexual health seemed to “go viral.” A key impetus was the global HIV/AIDS epidemic, which functioned as a powerful relay to move the concept and term sexual health into broader circulation (Parker et al. 2004). Perhaps more than any other single development in recent decades, the spread of AIDS – but also the political activism that emerged to confront it – has forced the institutions of biomedicine and public health to grapple with sexuality as something that fundamentally matters (Altman 1986; Patton 1990). Moreover, the language of sexual health offered crucial legitimacy to the necessity of zeroing in on sexual topics in order to address the epidemic. For example, “sexual health” could be mobilized as a respectable, if euphemistic, way of discussing gay sexuality.
By the 1990s, a remarkably diverse set of speakers was giving voice to sexual health matters, including scientists, doctors, public health officials, pharmaceutical companies, foundations, religious organizations, sex toy manufacturers, activists, and advocacy groups across the political spectrum. Just as significantly, the goal of sexual health referenced a divergent, if sometimes overlapping, set of practical concerns: containing the spread of STIs, addressing failures of sexual functioning (including via new treatments such as Viagra), controlling population growth and promoting autonomy over reproductive decisions, solving injustices linked to the lack of sexual rights, containing threats of “irresponsible” sexual behavior, and promoting sexual self-expression. Increasingly, whatever the social problem, sexual health seemed like the proposed solution (Epstein and Mamo 2017). As the phrase took on qualities of a buzzword, its ambiguous nature and flexibility permitted the term and concept to spread across domains, as well as to mobilize attention and resources. In all of these cases, the label “sexual health” proved especially useful because of the precarious status of sexuality in so many societies. In the compound term sexual health, health sanitizes the word sexuality, from stigma and cleanses its supposed dirtiness and messiness.
However, the effects of sexual health activities have differed significantly by social group. In some cases, campaigns to prevent HIV infection (often undertaken from within the communities positioned at risk) have been tied to projects of empowerment and challenges to structural inequalities. In other cases, specific groups – such as Black and Latino men who have sex with both men and women and who have been the objects of moral panic concerning “down low” sexual practices – are deemed threats to the social body that necessitate strategies of containment (see Vidal-Ortiz and Robinson, Chapter 57 in this volume). Another example comes from sexual health programs that address the sexual and reproductive health needs of racial and ethnic minorities. In countries like the United States, family planning campaigns sometimes presume that higher rates of pregnancy among young, unmarried women of color is a consequence not of structural inequalities and lack of access to abortion and contraception, but rather of supposed lifestyle choices shaped by “deficient cultural values” and an “underdeveloped ethic of responsibility” – or, as in the racist and sexist myth of the Black “welfare queen,” a desire to “game the system” and reap reward for excess procreation. Such biases may shape the particular kinds of sexual and reproductive health services offered to specific social groups (Barcelos 2020; Brian et al. 2020). In still another example of how sexual health programs may further entrench stereotypes, proponents of sexual health for people with intellectual and developmental disabilities complain that far too many approaches to the sexual education of such individuals begin with an implicit assumption: “You shouldn’t be doing this anyway, so therefore we’re not going to teach you about it” (Gill 2015; see Santinele Martino, Chapter 51 in this volume).
Activities launched under the sign of sexual health have wide-ranging effects on people’s lives and on the character of the society as a whole. Here, I describe three of the key aspects of the investment in sexual health: remaking medicine, expanding expertise, and optimizing the self.
Significant percentages of people around the world experience what they perceive to be sexuality-related medical problems, including sexual dysfunction, pain during intercourse, sexually transmitted infections, and issues related to contraception. Yet, an international study conducted in 2005 with 27,500 participants, in which half of those who were sexually active reported at least one “sexual problem,” found that only 19% had sought medical care, and only 9% had been asked about their sexual health by a doctor in routine visit over the previous three years (Moreira et al. 2005). Especially in the years since then, as interest in sexual health has flourished, advocates have sought to incorporate sexual matters into the very heart of medical concerns.
The growth of specialty areas such as sexual medicine, which focuses on sexual dysfunctions, has provided new niches within the medical profession within which physicians are prepared and trained to tackle sexual topics. However, for most patients, the entry point into the medical system remains their primary care physician, and these generalists may have little experience with sexual health issues or inclination to engage with their patients on such topics. A key barrier has been the relatively limited success in educating physicians about sexuality during their formal training in medical schools. As the sociologist Marie Murphy discovered through ethnographic observation at one major US medical school, sexuality had “an ‘absent presence’ within the formal curriculum” – not so much ignored as addressed occasionally, inconsistently, and often haphazardly in ways that “reinforced sexuality’s ambiguity and unknowability” (Murphy 2019: 205).
Perhaps the greatest impact of inadequate training with regard to sexual matters is a simple tendency not to want to ask patients direct, relevant questions, even when these might reveal significant health problems or risk factors. Therefore, a key area of emphasis has been to train physicians on how to take a sexual health history and how to incorporate it routinely into medical visits – asking about sexual partners and practices, as well as about any STI or pregnancy prevention methods that patients might use. In recent years, advocates of social change have pressed for even more inclusive forms of sexual history-taking that go beyond the gender binaries. These advocates have encouraged health providers to take sexual histories that “assess which parts go where instead of who is having sexual contact with whom” (Goodman 2018).
The push within modern medicine to grapple with sexual matters is a consequential development. However, one of the most striking features on the sexual health landscape is the diversification of sexual health expertise far beyond the health professions. Who gets to be called a sexual health expert? Nowadays, the kinds of people who make claims about how we should be sexually healthy range very far afield, from nutritionists to massage therapists to practitioners of kink to porn stars. These developments raise perplexing questions about who should be trusted and why. As new social circumstances arise – the COVID-19 pandemic is a perfect example – ordinary people struggle to determine who is the best source of advice about how to have sex in healthy ways.
Until recently, popular experts about sexual health often used their credentials to mark their expertise, sometimes accompanied by their first name to signal their accessibility: “Dr. Ruth” Westheimer, “Dr. Laura” Schlessinger, “Dr. Drew” Pinsky. In more recent years, with the arrival of new technological possibilities for the construction of audiences and the global dissemination of messages, sex advice is increasingly on offer from non-professional “social media influencers who share content specifically to break down the taboos surrounding sexual health” (Fear-Smith 2021). As the headline of a New York Times article expressed it in 2016: “The Sex-Ed Queens of YouTube Don’t Need a PhD.” The article described sexual health experts such as Laci Green, who began posting videos from her dorm room in 2008, and whose videos had been viewed a combined 131 million times (Hess 2016).
Sexual health expertise is not located only in individuals, however. Many community-based organizations have become authoritative voices on sexual health concerns. A defining example comes from the early days of the HIV/AIDS epidemic, when local organizations, rooted initially in LGBTQ communities, sought to educate the public about sexual health risks and remedies while simultaneously insisting on a conception of sexuality as something positive (Epstein 1996; see Barcelos, Chapter 79 in this volume). Since then, an increasing number of groups have sought to call attention simultaneously to sexual health needs and erotic rights, using a variety of platforms. In England, for example, the collectively produced Black Fly Zine, launched in 2016, has been described as “the foremost sex zine for people of colour” (Haidrani 2017). The collective behind Black Fly organizes workshops and considers itself as building a “community for sexual wellbeing.” According to one participant, Bui Mushekwa: “We work to validate and actively support the experience of ethnic minorities as they navigate their sexual health within the context of oppressive historical and colonial structures that often hinder the wellbeing of black and brown people across various identities” (Sassy Show 2020). Thus, while adopting the terminology and label of sexual health, the Black Fly collective presents a radical take on the idea that foregrounds both sexual pleasure and anti-racism.
By optimization, I refer to the desire or injunction to treat one’s life as a never-ending project of self-improvement, organized particularly around bodily enhancement. Of course, optimizing one’s health in general is an important contemporary goal, particularly among those who have the means to pursue it. Examples are abundant in the domain of sexual wellness: laser vaginal rejuvenation surgery, offered by many cosmetic surgery clinics, promises to enhance vaginal muscle tone, and hence improve sexual gratification, and penile enlargement by means of surgery, pumps, pills, creams, or exercises is a concept familiar to most readers of their email “spam” folders.
A perusal of popular magazines reinforces the impression of a close link between sexual health and wellness, consumption practices, and lifestyle pursuits. The magazine Sexual Health, published by SHE Media (and with a readership reported to be 55% female), bills itself as “the must-read quarterly guide to sexual wellness for every walk of life.” Sandwiched between advertising for sex toys, mostly directed at women, the magazine provides articles on topics such as “overcoming boredom in the bedroom,” “why ‘who you are’ shouldn’t hold you back from sexual exploration,” and “new findings on men’s versus women’s response to sexual stimuli.” Such magazines link consumerism to broader aspirations for more satisfying sexual lives.
Although sexual wellness may seem like a private and individual pursuit, it can also align with political activities. In 2017 the marketers behind the “sexual health and wellness” brand Unbound launched a campaign to send vibrators to members of Congress to protest a health care bill that threatened to defund Planned Parenthood (Vagianos 2021). On college campuses, “Wellness to Go” vending machines offer condoms, pregnancy tests, and morning-after contraception, to the consternation of social conservatives. The vending machines commodify wellness but also destigmatize sexuality. “I really value the anonymity of having a vending machine,” one student told a reporter, “A lot of students like the judgment-free space and don’t have to feel the pressure of interacting with people” (Parvini 2021).
Sexual health is an elusive ideal because no single party monopolizes the definition of what it might mean, and various alternatives stand in contention. We see this clearly in the ways that groups on both sides of the political spectrum adopt the label and banner of sexual health. Christian conservatives have deployed the term to develop a moral critique of modernity and defend traditional family forms, while valorizing certain forms of sexual expression. For those on the left in the era of #MeToo feminism, sexual health provides a language to intervene in debates about sexual assault and consent while elaborating a progressive vision of gender relations. From the time that US Surgeon General David Satcher issued a landmark “Call to Action to Promote Sexual Health and Responsible Sexual Behavior” in 2001 (Office of the Surgeon General 2001), the US federal government has taken stands on sexual health, but in ways that vary significantly from one administration to the next. Indeed, under President Donald Trump, the State Department sought to ban the phrase “sexual and reproductive health” from international health policy documents (Toosi and Diamond 2021).
These debates matter because they reflect and help shape broader conceptions of what it means to be healthy and which expressions of sexuality are valorized. Yet, today’s sexual health discourses and practices have contradictory effects. Projects of sexual health turn sexuality and health into scientific concerns, but they also diversify the kinds of experts who might weigh in. These projects appear poised to tell us what is normal, but they also expand the range of ideas about what normality might entail. They emphasize sexual risks but also create new possibilities to imagine pleasures. Which tendencies will win out is hard to predict: The future of sexual health remains to be written.
Sexual health is therefore a political question – but one that is refracted through the broader politics of the society. In the end, sexual health calls attention to larger issues of equality and justice. With an eye to social inequalities, we can ask important questions about the targets of sexual health programs: Who is treated as objects of coercion, and who is seen, instead, as agents of their own destinies? Inequalities also point to corresponding concerns about access: Who is able to obtain Viagra, emergency contraception, pre-exposure prophylaxis for HIV (PrEP), or a safe abortion? Finally, with an eye to inequalities, we can ask whose perspectives are represented in sexual health initiatives. Currently, many groups, including sex workers, those confined in prison, gender nonbinary people, and asexual people, have been largely excluded from discussion of sexual health, and a commitment to social equality would seek to bring those viewpoints to the center. A sociological lens not only helps us understand the broader implications of sexual health but also helps clarify options for, and pathways to, social change.
Steven Epstein is Professor of Sociology and John C. Schaffer Professor in the Humanities at Northwestern University, USA. His areas of scholarly interest and teaching include the sociology of science and medicine and the sociology of sexuality. His publications have examined the politics of biomedical knowledge production, the impact of health activism, the political and scientific aspects of the HIV/AIDS epidemic, and the dynamics of sexuality, gender, and race in biomedicine. He is the author of The Quest for Sexual Health: How an Elusive Ideal Has Transformed Science, Politics, and Everyday Life (University of Chicago Press, 2022).