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

In a seminal 1993 article, Ruth Dixon-Mueller questioned the reproductive health field's conceptualization of sexu-ality, arguing that it had treated intercourse as a sanitized, emotionally neutral act. 1 If one were to learn about human sexuality by reading family planning research and program manuals, she suggested, one would have no idea that sex leads to great enjoyment—as well as pain—for human beings. She called for a more gender-sensitive approach to sexuali-ty 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 " sex-uality 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 the nearly 15 years since Dixon-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 Most symbolically, the phrase " reproductive health " has been superseded by " sexual and reproductive health, " and the terms " sexual health " and " sexual rights " increasingly appear in public health and human rights discourse.* 2 In addition, 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. 3 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 well-being have been especially well documented during the past 10–15 years. An impressive body of work 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, 4–9 nonvolitional sex 10,11 and relationship power imbalances 12,13 all have been associated with reduced sexual autonomy and thus greater vulnerability to unintended pregnancy, HIV and other STIs, and reproductive morbidity 14 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. 15–17 This literature has significantly deepened our understanding of how experiencing sexual …