Sexual Pleasure Matters (Especially for Women) — Data from the German Sexuality and Health Survey (GeSiD)

Why does sexual pleasure matter for sexual and public health? First and foremost, sexual pleasure is an integral part of sexual well-being and overall well-being (Anderson, 2013; Robinson et al., 2002). Integrating sexual pleasure into public health policies and sex education was found to increase people’s knowledge about sexuality, sexual communication, and safer sex behaviors — all crucial aspects of sexual and public health (Ford et al., 2019; Higgins & Hirsch, 2007; Landers & Kapadia, 2020). For instance, one sexual health model predicts that women and men who enjoy and seek sexual pleasure are more likely to make adaptive, health-promoting decisions (e.g., to negotiate safe-sex practices) (Robinson et al., 2002). That said, sex education is more effective when combining healthy images of desire and pleasure alongside safer sex messaging (Philpott et al., 2006), rather than just focusing on negative consequences of sex. Despite the theoretically established importance of sexual pleasure in the context of sexual health, there remains a paucity of empirical research concerning its associations with specific sexual health outcomes. In the present study, we aimed to test the assumptions made by prior research empirically. More precisely, we investigated whether people who experience sex as more pleasurable are more likely to make sexually healthy decisions (e.g., communicate about STI risk with a new partner, negotiating condoms use, use condoms).

Of course, the sexual pleasure discourse is broader than merely its relationship with sexual health behavior. A second aim of this paper was to investigate, in line with other representative surveys (e.g., National Survey of Sexual Health and Behavior (NSSHB)), pleasurable sex and its associations with different sexual behaviors. For instance, different waves of NSSHB assessed the prevalence and general predictors of pleasurable sex. This US nationally representative survey asked about participant’s experience with pleasure during the last partnered sexual event among ethnically diverse samples (Townes et al., 2021) and various age groups (Schick et al., 2010). Another line of research examined sexual behaviors (Herbenick et al., 2019) and sexual techniques related to (women’s) sexual pleasure (Herbenick et al., 2018), as well as lack of pleasure relative to sexual pain (Carter et al., 2019).

Sexual pleasure is crucial in shaping individuals’ sexual well-being (Abramson & Pinkerton, 2002). For instance, women are more likely to report higher rates of sexual desire when their pleasure is prioritized (Rubin et al., 2019). Experiences of sexual pleasure are, however, embedded in a gendered context that disadvantages women (i.e., the pleasure gap; for a review, see Laan et al., 2021), and in most contemporary societies, women’s sexual pleasure is still generally subordinated to men’s pleasure (Hall, 2019; Hall & Graham, 2012). Evidence suggests that in the heterosexual context, sex that women experience is different, and substantially less positive than the sex that men experience (Conley & Klein, 2022). Research shows that women experience orgasms at far lower rates than men (e.g., Conley et al., 2011; Frederick et al., 2018), that pain associated with sex is much more common among women (Carter et al., 2019; Elmerstig et al., 2013), and that women are subject to far more violence in heterosexual sexual encounters than their male counterparts (Brunner et al., 2021; World Health Organization, 2013). We aimed, therefore, to investigate the relationship between sexual pleasure and sexual health outcomes for women and men separately to examine, whether there are gender differences in these relationships.

Using a representative population sample, we examined the association between sexual pleasure and sexual health outcomes, with a special focus on gender. Sexual pleasure can be experienced through different kinds of rewards and sexual behaviors such as feeling sexually aroused or connected to a partner (Pascoal et al., 2016). Most national representative sex surveys so far have mostly used only one item measures to assess sexual pleasure. For instance, the National Health and Social Life Survey (NHSLS; Laumann et al., 1994) that surveyed adults in the USA included one item on pleasure (“…how physically pleasurable did you find your sexual relationship…?”) (for a critical discussion, see McClelland, 2010). In the present study, we used seven items from the original Amsterdam Sexual Pleasure Index (ASPI; Vol 0.1; Werner et al., 2021) that operationalize pleasure in a more in-depth and multifaceted way. Defining sexual pleasure broadly as “the enjoyment one derives from (individually or mutually) rewarding sexual activities” (e.g., Pascoal et al., 2016; Philpott et al., 2006), the ASPI assesses individuals tendency to experience sexual pleasure (Werner et al., 2021).

The aims of the present study were twofold. First, we examined gender differences in reported sexual pleasure. Second, we tested the hypothesis that sexual pleasure has a positive relationship with sexual health outcomes. To do so, we included various indicators of sexual health, long with more classic sexual health indicators, such as communication about sexually transmitted infections (STIs) and condom use. Since the expansive definition of sexual health developed by the WHO includes concepts such as the absence of disease, we conceptualize sexual health and well-being more broadly by additionally assessing the absence of sexual problems (e.g., arousal difficulties, pain during sex).

Having a more pleasure-inclusive concept of sexual health and well-being, we additionally examined the relationship between pleasure and orgasm frequency and engagement in oral sex. Orgasm frequency and orgasm consistency have been shown to increase women’s well-being and satisfaction (e.g., Laan et al., 2021). So as not to suggest that pleasurable sex is or should be limited to penetrative sex, oral sex engagement was also included, as oral stimulation of the glans clitoris is the most reliable source for women’s orgasm experiences (e.g., Frederick et al., 2018).

We asked participants: “Do you currently have condoms at home or in your bag?” on a binary scale (yes/no).

Partnered individuals additionally answered the item: “Did you use a condom when you had sex with (…) for the first time?” Again, participants were provided with a binary yes/no response format.

Participants indicated if they had an orgasm during their last sexual encounter (“Did you have an orgasm the last time you had sex?”). The response scale included the options (“No,” “Yes, once,” or “Yes, several”). We merged “yes, once” and “yes, several” into a single “yes” category.

Participants indicated their engagement in oral sex as one option on a scale that measured different sexual behaviors (“Think of the last time you had sex. What type of sex did you have then?”) on a yes/no scale.

We asked for current relationship status dichotomized (i.e., single and married/in a relationship). In addition, the following question was used to address sexual identity: “Please select the answer which describes best how you see yourself at present?” Answers were anchored on a 7-point scale. The first five points ranged from 1 = exclusively heterosexual to 5 = exclusively homosexual/gay, while the final two points denoted asexual and other identities (see Table 1).

Research and sexual health policies have a long history of neglecting the role of sexual pleasure in preventing negative sexual outcomes (Ford et al., 2019). Our results point to the importance of sexual pleasure for sexual health — and even more pronounced for women. Aligning with the current public health discourse, sexual pleasure in our study was associated with making sexually healthy decisions (e.g., condom use, STI communication) and sexually satisfying experiences (e.g., oral sex engagement, absence of sexual problems, and orgasm frequency).

Although odds rations were overall small, sexual pleasure was associated with more sexual health indicators in women than in men. Ample evidence indicates that both women and men value men’s sexual pleasure more, and men are more likely to demand it during an encounter (McCabe et al., 2010; McClelland, 2011; Muehlenhard & Shippee, 2010). Globally speaking, men seem to have a better access to sexual pleasure and autonomy than women do (Hall, 2019; Higgins & Hirsch, 2007). Alingning with this assumption, in our study, men were more likely to report experiencing sexual pleasure than women. Based on those observed gender differences, it could be assumed that whereas men’s pleasure seems to be a “normal,” present condition, women’s sexual pleasure seems to be more often absent, an add-on, or at least less prioritized. That said, the results might not a function of pleasure being more important for women, but rather men’s scores lack variability (i.e., for men, sex is almost invariably pleasurable). This lower variability in scores might explain why sexual pleasure plays a more predictive role in women’s sexual health than in men’s.

Interestingly, pleasure had a greater influence on communication about STIs and condom use for partnered women than it did for single women. Public health research has emphasized that safer sex communication is interwoven with gendered power inequalities (Wingood & DiClemente, 2000). Women face more stigma when negotiating condom use (Peasant et al., 2015; Woolf & Maisto, 2008) as well as when expressing themselves in a sexually assertive manner (Klein et al., 2019). Women and men are especially likely to conform to traditional gender expectations surrounding sexual behavior (female submission vs. male dominance) in initial states of dating (Eaton & Rose, 2011). Sexual communication and safer sex negotiations, however, need some degree of assertiveness, which might undermine women’s conformity to gender norm expectations in the casual context. Nevertheless, the sample size of single women was small in the present study, what might explain the different role pleasure plays for single versus partnered women when it comes to communication about STIs and condom use.

Since our data are cross-sectional, all that is known is that sexual pleasure and the investigated sexual health indicators are associated. That said, it is possible that for instance being able to communicate about STI risk makes sex more pleasurable (by removing concerns about STIs etc.) or STI communication might be a good proxy for comfort with sexuality. There is also the possibility that sexual pleasure and safer sex practices may be linked via another third factor such as being comfortable with one’s sexuality. Moreover, we have focused on condom use as main safe-sex practice, which leaves out other safe-sex practices mostly practice by women who have sex with women such as dental dams and gloves. A closer examination of the interplay between sexual pleasure and sexual health among gender diverse samples would be an interesting venue for future research. Another limitation is that we have assessed some health behaviors such as condom use discussion retrospectively meaning that single and partnered people answered questions about different time periods. Consequently, we cannot exclude the possibility of recall biases. Although our cross-sectional, correlational study points to associations between sexual pleasure and sexual health behaviors, prospective studies that assess the influence of sexual pleasure on sexual risk and risk-reduction practices are warranted.

The present study included a large, representative sample with a balanced distribution of women and men; it is however important to keep in mind that our sample draws from Germany, a Western liberal country when it comes to sexual attitudes (i.e., acceptance of same-sex behavior, abortion, sex work; Klein & Brunner, 2018). Sexual pleasure has different meanings and varies in ascribed significance over different cultures (Hall & Graham, 2012), which limits the generalizability of our result to other cultural contexts. Societal and cultural judgements about sex, shame, and guilt have negative effects on both sexual pleasure and health (Hull, 2008).

Sex education as well as research on adolescent sexual development has primarily focused on the prevention of negative health outcomes (e.g., unwanted pregnancy, sexually transmitted infections), which has especially influenced the perception of young women’s sexuality (Fine & McClelland, 2006; Tolman & McClelland, 2011). Given that young women’s sexual development is taking place in a social context saturated by often conflicting messages about women’s sexuality, sexual desire, and pleasure (Fine & McClelland, 2006; Klein et al., 2018), our results point to the importance of comprehensive sexuality education programs that promotes women’s pleasure. In supporting young women and men to develop a satisfying, and pleasurable approach to sexuality and close relationships, sex education for young men about women’s pleasure is also needed. Promoting “cliteracy,” teaching girls and boys that biologically speaking no gender differences in the capacity for pleasure and the mechanisms of pleasure exist, should be an important part of pleasure-prioritized sex education (Laan et al., 2021).

Our results indicate that more effort is needed to close the pleasure gap between women and men. Continuing to underestimate pleasure as a means to a healthy sex life will only hinder our ability to understand how to improve sexual health, especially for women. In order to promote the sexual health of women especially, our results call for the implementation of policies and comprehensive education plans that focus on more positive aspects of sex, like pleasure, desire, and agency (Anderson, 2013; Ford et al., 2019; Gruskin & Kismödi, 2020).