Framing sexual health research: adopting a broader perspective

The results of the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3), in The Lancet, provide extensive data from a large, representative population sample collected with the aim of better understanding sexual lifestyles and improving sexual health. Major advances in research on sexuality and sexual lifestyles have been made in the past 25 years. When the fi rst large-scale surveys of sexual behaviour were undertaken in the 1980s— the impetus provided by the emergence of the HIV epidemic—they were politically controversial in the UK and elsewhere. Since then, sexual behaviour has been surveyed worldwide; sampling strategies, question standardisation, and computer-assisted methods of data collection have improved data quality, and biological measures, such as prevalence of sexually transmitted infections (STI) and hormonal status, have been added to behavioural measures. These studies have documented the extraordinary changes in sexual behaviour that have occurred in the latter half of the 20th century, characterised, at least in wealthier nations, by a fall in age at fi rst intercourse, increasing numbers of lifetime sexual partners, and changes in patterns of partnership formation and childbearing. Natsal-1 charted not only generational changes in sexual behaviour, but also changes in HIV risk behaviour during the 1980s. Natsal-2 captured the resurgence in risk characterised by increasing numbers of sexual partners, increasing proportions of men paying for sex, and increases in risk behaviour among men who have sex with men since 1990 as treatments for HIV became available and the widespread fear of AIDS in the 1980s diminished. Just as sexual behaviour is shaped by its social and historical context, so too is research in this specialty. The aims and content of Natsal and other sexual behaviour studies have evolved as the lens through which we view sexual health has changed. Natsal-3 used WHO’s defi nition of sexual health to frame the design, analysis, and interpretation of the study; this approach views sexual health as not merely the absence of disease but recognises the importance of having pleasurable and safe sexual experiences that are free of coercion, discrimination, and violence. This comprehensive formulation avoids framing sexual health exclusively in terms of the prevention of adverse sexual health outcomes, and widens the remit to include enhancement of the quality of sexual experience and relationships. Despite being widely cited, however, this defi nition of sexual health has yet to be incorporated into public health practice. Unplanned pregnancy, HIV, and STIs have to date been the staple endpoints of interventions to improve sexual health, whereas sexual violence has received attention only recently and sexual wellbeing and satisfaction are rarely considered. The case for adopting a more holistic approach to sexual health has generally been made on the grounds of the benefi ts for control and prevention of STIs, HIV, and unplanned pregnancy. Evidence that lends support to such claims is growing. For example, studies have reported associations between sexual violence against women and risk factors for acquisition of HIV and STIs and unplanned pregnancy. Mechanisms to explain these associations are both direct (forced sex is likely to be unprotected) and indirect (repeated abuse might lead to a reduced sense of self-worth and acceptance of high risk practices). And the links are bidirectional: sexual violence might lead to increased risk of unintended pregnancy and STIs, and disclosure of unintended pregnancy or infection to an intimate partner might trigger abuse. There has been limited research on the relation between the quality of sexual experience and risk of