Health professionals do not generally receive adequate training to address the sexual concerns of their clients,1 provide sexual and reproductive health and rights (SRHR) counselling and education or conduct comprehensive sexual history-taking. Many of them talk about sexuality with clients through a risk-based approach, addressing the negative consequences of sexual relationships, such as HIV, sexually transmitted infections (STIs) and unwanted pregnancies, as a way of influencing people to practice safer sex.2
Without underestimating the importance of discussing the risks associated with sexual relationships, health professionals should address sexual pleasure and well-being in sexual history-taking, SRHR counselling and education. Research has shown that ignoring sexual well-being in counselling with clients has a negative effect on safer sex practices and may confound contraceptive consultations.3,4
There is a growing movement of SRHR organisations and professionals that recognise the importance of sexual pleasure to effectively promote sexual health. The Pleasure Project, created in 2004, is one of the first groups of public health professionals that have advocated for the inclusion of sexual pleasure in sexuality education and safer sex programmes.2 The International Planned Parenthood Federation (IPPF) and the World Association for Sexual Health have included sexual pleasure as a dimension of sexual health and sexual rights in their respective Declarations of Sexual Rights.5,6 The working definition of sexual health of the World Health Organization (WHO) incorporates the “possibility of having pleasurable and safe sexual experiences.”7
Most recently, the Global Advisory Board for Sexual Health and Wellbeing (GAB) proposed the “triangle approach” as an innovative conceptual framework linking sexual health, sexual rights and sexual pleasure to strengthen SRHR policy and programming.8 In 2018, the GAB released a toolkit to train future health professionals entitled “Sexual pleasure: The forgotten link in sexual and reproductive health and rights.”9 The toolkit was piloted in a two-day workshop at the 2017 World Congress for Sexual Health with a group of 18 medical students from the International Federation of Medical Students Associations and received positive feedback. It was then reviewed by a panel of international SRHR experts (including professionals who have worked with organisations such as IPPF and WHO, sexologists and medical students involved in SRHR advocacy), edited, finalised and is now available online at www.gab-shw.org/resources/training-toolkit/.
As of September 2019, members of the GAB have facilitated six workshops based on the toolkit – four in India, one in South Africa and the pilot workshop in Prague – training a total of 96 medical students and 22 SRHR professionals. The toolkit has also been presented in front of diverse professional audiences in China, the Netherlands, Ethiopia, the United Kingdom and the United States.
The toolkit introduces the Pleasuremeter to guide the process of sexual history-taking and to provide SRHR counselling and education with the triangle approach in the context of services such as: HIV/STI testing, STI treatment, HIV medical care, Pre-Exposure Prophylaxis, provision of condoms and contraceptives, abortion and prenatal care.
The Pleasuremeter is based on the GAB’s working definition of sexual pleasure8 and on two motivational interviewing techniques: asking open-ended questions and using scales to assess readiness for change.10 The GAB’s working definition recognises the physical and psychological dimensions of pleasure and the possibility of experiencing it alone or with partners. It also identifies six key enabling factors for sexual pleasure to contribute to sexual health and well-being: self-determination, consent, safety, privacy, confidence and communication/negotiation. It acknowledges that experiences of sexual pleasure are diverse and that the sexual rights framework ensures that pleasure is a positive experience for those involved and not obtained by violating other people’s rights. Thus, the six enabling factors introduced by the definition are grounded on sexual rights and constitute conceptual links between sexual health, sexual rights and sexual pleasure. The GAB calls it a “working definition” to embrace the possibility that it might evolve or change in the future and presented it for the first time in a Symposium at the 2017 World Congress for Sexual Health.11
The Pleasuremeter explores how an individual experiences sexual pleasure and the six enabling factors contained in the GAB’s definition. These factors are used as entry points to discuss ideal sexual experiences. The client begins by scoring the level of sexual pleasure experienced in sexual relationships and then scores each enabling factor for pleasure to contribute to sexual health and well-being. The health professional can decide on the range of the scale they use in the questions (e.g. 1–5 or 1–10) and the given time frame to elicit reflection on past sexual experiences (e.g. last 3, 6 or 12 months) depending on what would be most useful for the client. The provider should use a spider-web diagram to document the scores provided by the client, serving as a visual aid during the counselling or education session (see Supplementary Material #1 to visualize the scoring process of the Pleasuremeter).
After the client scores each element, the service provider can use open- and closed-ended questions to discuss each area and obtain information about the client’s sexual history (see Supplementary Material #2 for examples).
After discussing each factor, the final step of the process in using the Pleasuremeter involves prompting the client with a further set of open-ended questions to reflect in more depth on ideal sexual experiences on the basis of their answers:
The Pleasuremeter is a novel conceptual tool to support health professionals in exploring the links between sexual health, sexual rights and sexual pleasure during sexual history-taking, SRHR counselling and education, following the GAB’s triangle approach. This broadens the conversation beyond risk factors, which are included under the safety section of this tool.
In clinical settings, the time that health professionals have for counselling, education and sexual-history taking varies. Depending on how much time the provider has with a client, the Pleasuremeter can be adapted by asking fewer or more questions. Scoring the elements of the Pleasuremeter is a subjective process and the provider should be ready to adapt the scale and the time frame given to reflect on the past sexual experiences based on the needs of the client.
This conceptual tool is meant to supplement, not replace, clinical or educational assessments in SRHR service delivery. It is not a validated quantitative scale and it is not a tool for clinical sexology. The results of the Pleasuremeter are intended to explore the client’s sexual experiences, identify gaps and ultimately contribute to a client-centred plan based on a sex-positive approach. As the Pleasuremeter involves asking about ideal sexual experiences, it can raise the expectations of the client in addressing issues that may inhibit their enjoyment of sexual relationships. Providers need to be prepared and willing to follow on these issues and refer clients to other services and professionals when needed.
Sexual history-taking can be the only opportunity for health professionals to discuss issues related to sexuality with the client and to provide counselling and education. However, the Pleasuremeter can also be used to facilitate a counselling or education session that does not require taking a sexual history.
The GAB’s training toolkit for future health professionals, which includes the Pleasuremeter, is in the process of being transformed into a digital training course with the aim of scaling up its implementation globally. The GAB is currently collecting self-reported data on the impact that the toolkit workshops are having on the attitudes and knowledge of participating health professionals and is also planning on collecting self-reported data once the toolkit is offered as an online training course.
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