Bringing sexy back — to fight HIV

NEW YORK — Efforts to make sex safer almost always focus on the bad stuff: what to do to avoid a terrible infection or potentially deadly virus. They rarely acknowledge the good stuff: usually the reason people have sex in the first place.

And that’s why safe sex campaigns throughout the world aren’t as effective as they could be.

Research shows that when safe sex campaigns acknowledge pleasure — by talking about sex as something that makes life good, or showing how condoms can be erotic — more people use a condom the next time they have sex.

That is what the World Health Organization (WHO) and a small nongovernmental organization, the Pleasure Project, found when they reviewed the results of safer-sex trials and experiments over the past 15 years. They assessed more than 7,000 interventions for their treatment of pleasure (and lack thereof). The peer-reviewed findings were published in the journal Plos One.

“Sexual health education and services have traditionally promoted safer sex practices by focusing on risk reduction and preventing disease, without acknowledging how safer sex can also promote intimacy, pleasure, consent and well-being,” said Ms Lianne Gonsalves, a co-author of the paper and an epidemiologist who researches sexual health with the WHO. “This review provides a simple message: Programs which better reflect the reasons people have sex, including for pleasure, see better health outcomes.”

The stakes are high. Sexually transmitted infections are at record levels in the United States and rising around the world since Covid-19 pandemic closures set back testing and treatment. Globally, 1.5 million people were diagnosed with HIV in 2021, a rate of new infections that has hardly budged in the past four years. Taking a daily pill known as PrEP, or pre-exposure prophylaxis, offers the promise of preventing some infections, but condoms remain a simple and surefire way to do it.

When people use them.

The Pleasure Project has for years maintained that recognizing the role of pleasure would have a major impact on condom use, reducing not only sexually transmitted infections but also unwanted pregnancies. Still, Ms Anne Philpott, a British public health specialist who founded the initiative in 2004, said the strength of the results of the analysis came as a surprise even to her.

“If you had a pill or a vaccine where you could show this kind of effect, everybody would be talking about it, it would have all the headlines,” she said. “Now we have evidence: Ignoring this blind spot, all the way through the Aids pandemic, has led to less condom use, and deaths we could have prevented.”

But the pleasure message, she noted, is a comparatively cheap and easy addition for programs. It’s a change in conversation, rather than a new drug or device that needs regulatory approval and infrastructure to be delivered to far-flung places.

I’ve been crossing paths with Philpott at global gatherings on Aids for nearly two decades. But her message is only slowly taking root in the vast sexual and reproductive health community that delivers safer-sex messages and technologies in much of the world.

There is some progress. In September, the International Planned Parenthood Federation, the largest sexual and reproductive health organization in the world, endorsed what are called the Pleasure Principles, guidelines for centering enjoyment in healthy sex. It was the first move by a global sexual health organization to embrace the P-word explicitly in delivering its services.

There are scattered programs around the world taking this approach — projects such as Phénix, in Montreal, which taught “erotic skills” to men who have sex with men, using videos that made condoms sexy and fun.

The best demonstration of the pleasure message I’ve seen comes from Ms Arushi Singh, a co-director of the Pleasure Project. To convey what it means to eroticize safer sex, she pulls a little blue pouch out of her bag. “This is a sex toy I was introduced to by sex workers at an Aids conference in Bangkok,” she says in the tone of a friend with a delightful discovery to share.

“It’s small, convenient, you can carry it in your bag, insert it by yourself, or your partner can help,” she explains. “It’s nicely lubricated. It comes with two rings — one anchors against the cervix. And this outer ring is the secret: When a penis or a dildo goes into your vagina, the outer ring is pressing against the clitoris.”

She gives a little shimmy. “That’s what does it.”

The toy Ms Singh is demonstrating is, in fact, a female condom. And that, she says, is how you flip the narrative and make a conversation about disease prevention first about having a good time.

So why, given the millions of dollars spent globally every year to change how people have sex, is the actual point of sex mostly left off the agenda?

Philpott has a theory. “People who work in sexual health often come from a biomedical background, and they focus on death, danger and disease,” she said. “They’re not encouraged to think of themselves as sexual beings.”

That most sexual and reproductive health programs are delivered by big aid agencies doesn’t help, she added. “There’s an international development narrative that historically comes from a very sex-negative place or a Christian colonial perspective aimed at saving the ‘poor unfortunates.’”

Ms Sonali Silva, who until recently did advocacy work for the Pleasure Project in Sri Lanka, told me that during the years she worked on sexual health-related issues, including abortion rights and HIV, with big international organizations such as the WHO, she kept running into the same phenomenon.

“The big elephant in the room that nobody wants to make eye contact with is why people have sex in the first place,” she said. “We’re all just going to act like it’s only for reproduction. As long as people have been alive, they’ve been having sex for pleasure, but the world of international development is not having that conversation.”

Mr Mahmoud Garga, who leads strategic communications in the Africa office of the International Planned Parenthood Federation, recently started a social media campaign called “Treasure Your Pleasure,” which I love. It was designed for East Africa, but he and his colleagues have been asked to expand it to Southeast Asia.

The campaign features words for orgasm in different African languages, emphasising that pleasure is not an imported idea.

“We want to debunk that myth that sexual pleasure is a Western theme that is pushed on other cultures,” Garga said. “It’s simply not true. I’m Egyptian, so I’m familiar with Arab literature, and there was just this history of erotic poetry.”

Mr Garga told me that the topic was never part of sexual health education when he was growing up in Egypt, and that even in progressive environments like Planned Parenthood, sexual health typically means “contraception, sexually transmitted infections, and unwanted pregnancies, going to clinics and consulting with doctors. That, I mean, I don’t find that sexy at all.”

“But when you shift the narrative from that fear-based framing,” he said, “when you talk about sexual pleasure as a big component of sex and your sex life, then you turn it into something that needs to be talked about.”

“Using a condom,” he added, “frees up your mind to feel pleasure.”

This article originally appeared in The New York Times.