Introduction

The last two decades have been marked by mass globalization, the dominance of the internet and the power of social media, as well as the sexualization of the public sphere. All this has occurred against a backdrop of commercial and political interest—with sexuality becoming a political good, the subject of culture wars and electoral campaigns, and the focus of an enormous growth in scientific knowledge on the (non-)medical aspects of sexuality within a context of growing respect to neurodiversity and non-binarity. Paradoxically, though, interest in health related to sexuality has, as it were, drawn the short end of the stick (Ballester-Arnal et al. 2021; Brown and Stenner 2009; Coombe et al. 2021). Most of what is currently available to those wishing to investigate subjects’ sexuality from the aspect of health is a sexual health apparatus introduced by WHO in 1975 and addressing education, information, counselling and sex therapy, that has been later (1987) the subject of extensions towards sexual rights and responsible sexual behaviour (Giami 2002). Giami (2002), followed by Edwards and Coleman (2004), offers a comprehensive analysis of the cultural/scientific/political development towards a globally agreed conceptualization of sexual health. The difficulty in reaching a global agreement on the comprehensive definition of sexual health is evident from the fact that the recent definitions presented further, developed through a consultative process with international experts, a Technical Consultation on Sexual Health in January 2002, initiated by WHO, do not represent an official position of WHO. They reflect an evolving understanding of the concepts and build on international consensus documents such as the ICPD Programme of Action and the Beijing Platform for Action. These working definitions are offered as a contribution to advancing understanding in the field of sexual health.

Sexual Health and ‘big’ and ‘small’ data

According to the WHO (2022a), ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. It also provides a definition of sexuality and sexual health:

Sexuality is a central aspect of being human throughout one’s life, and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always universally experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors. (WHO 2001)

Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (WHO 2002)

Sexual rights embrace human rights that are already recognized in national laws, international human rights documents and other consensus statements. They include the right of all persons, free of coercion, discrimination and violence, to:

  • the highest attainable standard of sexual health, including access to sexual and reproductive health care services;

  • seek, receive and impart information related to sexuality;

  • sexuality education;

  • respect for bodily integrity;

  • choose their partner;

  • decide to be sexually active or not;

  • consensual sexual relations;

  • consensual marriage;

  • decide whether or not, and when, to have children; and

  • pursue a satisfying, safe and pleasurable sexual life.

The responsible exercise of human rights requires that all persons respect the rights of others. (WHO 2002).

Relatively remote from the broad-encompassing above-mentioned definitions that are a sort of political-and-value declarations that address not only physical but also political, cultural, psychological and human rights aspects, substantive discussions on sexuality in the context of public health are predominantly saturated by data from two quantitative approaches: (1) demographic statistics on, e.g. the median age of sexual debut, abortion rate, teenage pregnancy rate, or incidences of STIs and sexual violence, and (2) local, regional and international research efforts exploiting quantitative measures, as well as the clinical sexology measuring instruments. For an easier distinction, we call these two complementary approaches ‘big data’ and ‘small data’ sexual health paradigms.

Under its global authority, The World Bank, in collaboration with the Population Division of the United Nations, regularly monitors international sexual health statistics, collecting data from all its member countries. Let’s have a look at one example of sexual health measurement concerning our region (Slovakia). The United Nations (UN 2021) presents the development of fertility in adolescent women aged 15–19 (Fig. 1). Apart from the fact that in comparison with countries like USA, France, Germany and the United Kingdom, Slovakia has currently the highest incidence of teenage pregnancy (26%), Slovakia is the only one of these five countries where the incidence of teenage pregnancy has not been dropping, but has been increasing during the last two decades. These data may well inform public health policies in particular countries, indicating a quite negative trend in Slovakia. Very little, if anything at all, does it, however, say about sexual health (in terms of its complex WHO definition requirements concerning, e.g. “well-being, not merely the absence of disease, … respect, safety and freedom from discrimination and violence,… gender identities and roles, sexual orientation,… human rights”) of any individual person in any country. Moreover, as several authors call attention to, queer individuals (towards who’s sexualities-and-identities’ expectations the big data approaches are frequently „blind “) are in a multiply disadvantaged position as the term "queer" is still used as a slur and queer identity continues to be stigmatized, which is supported by the fact that up to 3 out of 4 queer women have experienced discrimination, violence, or harassment based on their sexuality (Worthen 2023) and queer people are at an increased risk of sexual violence compared to heterosexual, cisgender people (Messinger and Koon-Magnin 2019).

Fig. 1
figure 1

Incidence of teenage fertility (source: UN 2021) (births among 1000 women ages 15–19)

Full size image

And along with global big data, there are numerous local, regional and international research efforts producing small data on sexual health. Let’s have a brief look at one component of sexual health—sexual violence data. Krahé, Berger, Vanwesenbeeck, Bianchi et al. (2015) found in a quantitative study conducted in 10 European countries (Austria, Belgium, Cyprus, Greece, Lithuania, the Netherlands, Poland, Portugal, Slovakia and Spain) that on average around one-third of respondents (aged 18–27) reported experiencing unwanted sexual activity. In our country, these findings were refined in a later study by Karkošková and Ropovik (2019), who found that 17.7% of male students and 40.6% of female students in the last year of secondary school (mean age was 18.6) in Slovakia had encountered non-contact sexual violence. Sexual violence with physical contact but no penetration was experienced by 30.2% of girls and 11.6% of boys, while experience of sexual violence and penetration was reported by 5.6% of girls and 1.3% of boys. We dare to doubt, however, what these data are telling us specifically about the sexual health status and sexual satisfaction of particular individuals in these countries. And yet, the events captured in the statistical data, mediated via public discourses, may have a contextual effect on the sexual subjectivity of the affected individuals (Bianchi 2022). Hence, it is important to investigate the issue qualitatively by focusing on the individual’s subjectivity. For this purpose, we are proposing the conceptualization of healthy sexuality.

The limitations of the “small data” sexology apparatus.

In clinical sexology, which operates predominantly in a positivist paradigm, there are a number of tools for assessing narrow aspects of human sexuality. Most of these were designed for pathological reasons—they are predominantly used to assess progress in sexology therapy. And it is automatically assumed that they are indicators of sexual health. Milhausen et al. (2019) divided them into the following 29 categories of instruments of potential sexuality-related health threats (see Table 1).

Table 1 The 29 categories of measuring instruments used in sexology (according to Milhausen et al. 2019)
Full size table

What is the purpose of these instruments? Let us look for example at the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) questionnaire (Rust and Golombok 1985). It was designed to measure the effect of sex therapy. The female version of GRISS scale focuses on anorgasmy in women in an effort to establish whether an individual is able to orgasm, or suffers from vaginism, or to investigate sexuality conversations between partners, frequency of intercourse, sex rejection, the measuring of pleasure experienced through touching and love-making, and overall satisfaction or dissatisfaction with one’s sexual partner (ibid). From current perspective, this version is, however, ignorant towards transgender persons. These items relate to sexual satisfaction in clinical patients suffering from orgasm and erectile dysfunction, which form just one part of sexual subjectivity. Ellis (1960) concludes that sexual satisfaction is not necessarily linked to interaction with another person but also relates to masturbation and other autosexual activities, sexual dreams and conscious and unconscious thoughts. Another measuring instrument, the Interpersonal Exchange Model of Sexual Satisfaction Questionnaire (Milhausen 2019) is a more up-to-date comprehensive instrument, but it also ignores the autosexual activities endorsed by Ellis (1960). The 20-item New Sexual Satisfaction Scale and Its Short Form (Milhausen 2019), the three-item Sexual Pleasures Scale (ibid) and the Quality of Sex Inventory (ibid) all have similar limitations. Anxiety and condom use are measured by the Sexual Anxiety Scale (ibid), also mentioned in Milhausen et al. (2019). In fact, there are four different questionnaires on this issue, but none is sufficiently complex, and they all concentrate on a particular problem, on finding an effective therapy, or only on narrow aspects of sexual performance detached from its contexts. Some also reflect sexual norms (rooted in binary gender, sex within a relationship and so on) and so do not reflect the diversity of sexual subjectivities.

Nonetheless, each of the 29 categories may be important in investigations of the potential for a healthy sexuality. However, as we will show later, even a complete list of the quantitative data for each category of sexology measurement is insufficient for determining whether a sexual subject has the potential for healthy sexuality. Data from such sexology measurement do not cover all positive and negative experiences gradually lived over one’s individual lifetime, through key events in the sexual career which form the basis for becoming a sexual subject (Bianchi 2022). Moreover, sexology measurement does not allow an examination of the individual’s perceptions of sexual satisfactions via sexuality discourses (Stanton 1992), sociocultural specifics (contexts), sexual scripts (Simon and Gagnon 1984) and subjective meanings (Bianchi 2020). Nor can we learn what sexuality means to that particular person, since sexual satisfaction is subjective and so has to take account of all the different aspects of individuality (ibid).

Sexual subjectivity

Sexual subjectivity has already been mentioned several times during the presentation of the traditional sexual health conceptualization. In addition, sexual subjectivity and its ontological nature are the starting points for alternative thinking about health related to sexuality. Sexual subjectivity can be derived from human subjectivity as formulated and expressed in “discourses materializing the whole range of possible values, norms, cultures, goals, criteria, figures and images; these are captured in words, texts and their tectonics, which each subject has to cope with. That is the background and context of sexual subjectivity” (Bianchi 2022, p.42). Sexual subjectivity can be defined as ‘our understanding of the sexual self—our sexual selves and others’ sexual selves’ (ibid). Figurative expressions of our sexual subjectivity contain the subjective meaning of sex (what sex means to us), sexual satisfaction/pleasure, sexual agency, sexual taboos, sexual risks and justifications, the distinction between wanted and unwanted sex, and the roots of sexual violence. Such an approach can be seen as a continuation of William Simon’s 1996 study that observed that ‘contextualizing contingencies’ dominate over the biological/scientific and the sexological in the constructing of human sexuality. In noting that ‘It may be something of an irony that human sexuality, frequently viewed as constant across the human record, is actually among the forms of behaviour most dependent on contextualizing contingencies’, Simon (1996) opened the Pandora’s Box of endless variability in sexuality (Simon 1996, p. 115–116). This variability is well illustrated for example in a historic perspective by Alain Corbin (2007), who, investigating the development of human sexual pleasure, looks at the times between enlightenment and the emergence of medical sexology in the mid-nineteenth century. Corbin identifies three ways for understanding sexual pleasure in this historic perspective: medicine, theology and pornography, each of them “producing” complementary aspects of human sexuality—fever, ecstasy and bewilderment. Corbin also addresses the cultural anomalies, e.g. perception of female pleasure—seen through the male gaze that determined also the female self-reflection; in this perspective, female pleasure was residing in the lower part of the body while the upper part remained in a kind of hiding simulacrum. Further it would be possible to analyse the nosocomial effect of institutionalized medicine/sexology on human sexuality and sexual pleasure; this was presented by Bianchi (2020) in his analysis of the earliest scientific books on sexuality, both titled Psychopathia sexualis by the German physicians Heinrich Kaan (1844) and Richard Von Krafft-Ebing (1886) pinpointing masturbation and homosexuality, respectively, as the central pathological element in human sexuality. Although these historical aspects could be highly relevant to any consideration of human sexuality, in this article, we will remain in the present.

Sexual subjectivity with the three constitutive characteristics: (1) its plurality, (2) its self-generative nature and (3) its necessity to be lived (Bianchi 2022, p. 25)—figuratively speaking—jumped out of this Pandora’s box of endless variability, including any queer experiences. It opens our awareness of the permanent process of becoming a sexual subject along the lifelong sexual trajectory, a process consisting of experiences with our body, our sexuality free from heterosexual normativity, our social relationships, as well as their emotional accompaniments (joy, pain, fear, shame, ridicule, guilt, etc.) resulting in the individual’s extent of satisfaction and determining the potential for our health in sexuality—how healthy our sexuality is. The main aim of the conceptual analysis offered in this paper is to create an operationalizational framework for understanding, interpreting and exploiting the potential of healthy sexuality. It is rooted in a process-ontological view of human sexual subjectivity, builds on a narrative understanding of the sexual trajectory of the subject and makes use of the phenomenological elements of reflection and interpretation of the events/occasions that form part of becoming a sexual subject. In contrast to the dominant authoritative, and predominantly medical, conception of sexual health used to assess aspects of the sexual health of national (sub)populations, our approach targets the psychological and the individual with respect for inclusiveness.

What we have learnt thanks the subjectivity approach to sexuality

The journal Subjectivity has, through the years, offered a platform for the publication of subjectivity-related studies on sexuality. The introductory paper, “Creating Subjectivities” by Lisa Blackman, John Cromby, Derek Hook, Dimitris Papadopoulos and Valerie Walkerdine (2008), was followed by Kaye Mitchell’s (2008) exploration of Judith Butler’s ‘legacy’ regarding gender, sexuality and subjectivity in the context of ethics, politics and identity. Since then, various articles have investigated aspects of queer-and-trans sexual subjectivity and the psychological mechanisms of shame and pain as constitutive elements of queer subjectivity. An overview of these studies is in the following frame.

Heteronormativity, queer exclusion/silencing and its consequences

Rutvica Andrijasevic (2009) has examined feminist issues and political subjectivity from a sexuality and gender perspective and considered the link between immigration regulations and queer exclusion. Shanna T. Carlson (2010), writing from a psychoanalytic background, offered a gender-deconstruction of the roles in the Oedipus myth, arguing that the terms ‘mother’ and ‘father’ lend themselves to normative interpretations that prove damaging when applied to questions about queer sexualities and families. Marjo Kolehmainen (2012) analysed postfeminist and neoliberal articulations of gender and sexual subjectivity in a TV drama series and pinpointed the perseverance of gender dichotomy and heteronormativity in portrayals of the concepts of gay, straight, femininity, and masculinity. Two years later Celia Roberts (2014) questioned the simplistic medical sociology discourse on the medical blocking of early onset puberty. She warns against taking an excessively mechanical view of the need to postpone early onset puberty. In her exploration of these discourses, Roberts questions whether the queer and feminist perspective is sufficiently considered in articulating sex/gender, sexuality, age and health, or whether it is insensitive to the needs of those undergoing atypical and transsexual development. Melissa Stepney (2015) applied Jessica Benjamin’s psychoanalytic approach (1988) in her study of hyper-sexual feminine clothing and binge drinking in young British women, and found they were entirely reasonable responses to the wider contradictions young women face in Western society, particularly in Britain where feminism is not easily accepted. She also analyses the participants’ sexual subjectivity and states that Western culture (still) eliminates the possibility of intersubjectivity (a space of ambivalence) and mutual recognition, through the increasing rationalization of a society immersed in masculinity. In 2017, Annukka Lahti reported on how excessive sexual practices, ones that bisexual female participants have described as being “too much”, act as a tool to become sexual subjects. Although the excessive practices were pleasurable, they could be overwhelming. Lahti (2017) concludes that the excessive nature of the women’s sexual experiences was constituted by bisexuality and monogamy-related norms that restrict female sexuality. Ana Dragojlovic (2018) explored possible ways of challenging intergenerationally transmitted heterosexual kinship-positive affect memories in order to facilitate and empower queer positive affects and politics and to intentionally mobilize silenced histories of abuse, violence and shame by means of a photographic sculpture installation (Romantic Detachment) by Naro Snackey.

Shame damage to sexual subjectivity

The journal Subjectivity further published Katherine Johnson’s (2012) psychosocial reading of ‘shame’ and ‘insult’ in contemporary representations of gay male sexuality. Using textual sources from the comedy sketch shows ‘The Catherine Tate Show’ and ‘Little Britain’, her study considers queer subjectivity in the light of a history marked by shame and insults. It illustrates how humour and comedy are used to challenge social norms and air contemporary anxieties about changing social values in relation to sexuality in a UK context. The analysis is located within a critical reflection on the transformative politics of the Gay Shame movement, which is an alternative movement to Gay Pride. The article concludes by considering the distinction between a cultural ‘coming out’ of shame and the affective consequences that ‘shame’ can have in individual narratives of sexual identity formation and suicidal distress. The role of shame in (queer) sexual subjectivity has also been discussed by Wen Liu (2017). The author proposes moving towards a concept of shame that identifies shame as a curious engagement beyond disciplinary boundaries and circulates through different sexualized and racialized bodies. In moving towards this concept and away from one that sees shame as undesirable and a problem requiring elimination, we can work towards a queer psychology of affect that breaks open the binarism of pride and shame.

Pain reconsidered

The first issue of Volume 9 of Subjectivity, published in 2016, contained a symposium of papers on Elaine Scarry’s 1985 book The Body in Pain, exploring the configuration of subjectivity in relation to contemporary body practices and socio-political change. It also is expanding the takes on pain, language and the body. The following two papers in the symposium are concerned directly and indirectly with sexual subjectivity. Michael McIntyre (2016) questions two of the core suppositions of The Body in Pain: first, that the pain is only aversive, and second, that those who inflict the pain are, in some sense, unaware of the pain they inflict. The first of these suppositions, which is particularly relevant to our analysis, is simply empirically incorrect. In everyday life there are many practices to which pain is not a mere concomitant, but intrinsic, and these practices include mainstream activities such as those associated with BDSM, kink and other sexual practices within which pain can figure as attractive or alluring. McIntyre also argues that ‘some of these practices of pain-infliction are undertaken in full awareness, in the expectation of … shared fulfilment’ (ibid). McIntyre further highlights both parallels and distinctions between the sensations of pain and those of sexual pleasure, arriving at a form of somatic-affective communication based primarily in embodied empathy, shared sensation, and dynamic self-other feeling. In this communicative mode, lovers (including those who practice BDSM) aim to share and extend each other’s worlds; in the language of subjectivity, we could phrase this sharing as providing new becomings for the sexual subjects involved. Clifford van Ommen (2016) analysed entertainment via consuming narratives of suffering bodily pain while watching a commented on—for comedy effect—TV series. The author links these practices to neoliberal processes of subjectification—which may or may not be sexual—that reflect Charles Fourier’sFootnote 1 libertarian defence, formulated in the first half of the nineteenth century, that all sexual expression should be enjoyed so long as there is no abuse; after all, affirming one's difference can actually enhance social integration.

Crime vs. non-normativity

Another group of studies on sexuality within Subjectivity focused on crime and non-normativity issues. Steven Angelides (2009) questioned the automatic criminalization of sexual relationships between teachers and students (over the age of sex consent) from the perspective of intersubjectivity, suggesting that it forecloses critical questions of subjectivity and intersubjective dynamics. An alternative model of multi-dimensional inter/subjective power relations is proposed as a way of analysing interpersonal relationships, giving due weight to adolescent agency, encouraging responsible sexual citizenship and preventing unnecessary prosecutions and collateral damage. In 2021, Sherianne Kramer and Brett Bowman published their analysis of the confessions of victims of female-perpetrated sexual abuse (FSA), providing psychologized, gendered accounts of the damage reflected in trauma, revictimization, memory loss, and the cycle of abuse and deviance. An analysis of these accounts demonstrated how confessional sites, such as the (psychological) interview, anchor victim worthiness in damage so that ‘non-normative’ victims of violence are able to see themselves in sexual violence discourse as forever compromised subjects whose healing requires a rethinking of the relationship between gender, sexuality and violence.

These are just four areas of sexual subjectivity that have been shown above to be relevant to (to facilitate or inhibit) satisfaction-and-health aspects of sexuality: queer identity, pain, shame and crime. In the final part of this paper, we will present in detail the conceptualization of healthy sexuality and introduce its other potential facilitators and inhibitors.

What, then, is healthy sexuality?

In order to talk about whether or not we have a healthy or unhealthy sexuality, we need to focus on subjectivity. These days, there is increasing discussion regarding unwanted sex (Tuerkheimer 2019) and about how satisfied people actually are with their sexuality and their sex life (Wright et al. 2021). Another hot topic of current discussions around sexuality/health/satisfaction is the multiply disadvantaged position of queer people (addressed already above), inclusive obstacles to introducing legislation on access to medical transition in numerous countries including Slovakia (Amnesty international, Slovakia 2022, 2024). In this article, with the aim of determining the level of sexual satisfaction and the ‘pathways’ leading to satisfaction or dissatisfaction, and the prospects for future satisfaction, we are concerned with conceptualizing healthy sexuality with the individual in mind, rather than statistical samples (Bianchi 2020). We therefore argue that the potential for healthy sexuality should be identified phenomenologically based on the sum/weight/subjective importance of experiences of sexual events (positive and negative) along the individual’s life trajectory (ibid). In conceptualizing healthy sexuality, the final goal is to identify the most appropriate form of help for those who need it to obtain sexual satisfaction. Thinking about healthy sexuality in this way requires us to reflect on our incomplete knowledge of the facilitators and inhibitors of health sexuality.

In 2010, K. A. Fenton, adopting a medical statistical approach, called for the promotion of individual healthy sexual experience: ‘As “sexual health” becomes a more relevant defining paradigm within public health, we may better understand approaches to supporting healthy sexual experience while minimizing the adverse consequences of sexual trauma, unplanned pregnancy and sexually transmitted infections’ (Fenton 2010). But, contrary to statistical reasoning, a different epistemological approach is used in our unfolding of healthy sexuality; it concerns the way in which the individual events are phenomenologically processed (body experience, sexual body experience, the emergence of sexual identity, gender identity, sexual orientation, sexual debut, sexual interaction and intimate relations, contraception and reproduction).

Fortenberry (2014), when writing about sexual learning, sexual experience and sex among adolescents, came up with a definition of healthy sex. He stated that it was about the way in which adolescents learn that sex is a complex set of social interactions that are reiterated through repeated sexual experience. For adolescents, sex is based on accumulating experience, which includes but is not limited to sexual intercourse. They then think about the meaning and interpretation of that experience as they acquire more experience. Hence, Fortenberry thinks it is extremely important for sex education and sexual learning to form a baseline from which to build on and that includes sexual health in adulthood. In an earlier paper, Hensel and Fortenberry (2013) wrote about ‘healthy sexual development’. Later Fortenberry (2014) would talk more broadly, not just of healthy sexual development, but also of healthy sexuality. This concept included several domains: the emotional domain, including relationship quality, the physical domain, concerning sexual satisfaction and the absence of (unwanted) genital pain, the mental/attitudinal domain, comprising sexual anxiety, sexual respect, effective condom use and attitudes to preventing pregnancy, and the social domain, including sexual autonomy and sexual communication.

Instead of the Fortenberry domain-approach to healthy sexuality, let’s have a look at the structure we are proposing. Human subjects go through life gradually, albeit at different speeds, experiencing events and occasions that may be accompanied by positive or negative experiences or a combination of both. These events in the subject’s behavioural repertoire may first occur in varying order, overlap, last for different lengths of time, with some perhaps not occurring at all (See Fig. 2). A “working list” of sexual events for being monitored from the point of view of healthy sexuality, informed by various sources (Gillen, Markey 2019; Holland et al. 2021; van den Brink et al. 2018; Sagarin 1971; Grinde 2021; NCSBY 2024) begins with non-sexual body experiences and continues with sexual body experience, issues regarding sex and gender identity and sexual orientation, the formation of erotic and intimate ties with another, the experiencing of sexual pleasure and orgasm, sexual satisfaction, mutual sexual satisfaction and, lastly, reproduction. Negative as well as positive experiences accompanying each of these events—whether during the first occurrence or later on—may inhibit or facilitate thoughts of dis/satisfaction and so function as indicators of the extent to which the subject experiences healthy sexuality. These emotional experiences include unwanted pain and shame, fear, feelings of guilt, regret, (unsolicited) punishment, but also pleasure and enjoyment. In some cases, it is impossible to normatively and categorically establish and indeed accept the assumed polarization of positive vs. negative emotions. That is especially true where pain is concerned. Here, we have to consider Elaine Scarry’s (1985) question about whether pain is only aversive, and Michael McIntyre’s (2016) point that ‘in everyday life there are many practices to which pain is not merely concomitant but intrinsic, and these practices include … mainstream activities such as those associated with BDSM, kink and other sexual practices within which pain can figure as attractive or alluring’. On the other hand, the proposition that shame is a negative emotion and therefore a strong inhibitor of healthy sexuality has been confirmed in recent analyses by Johnson (2012) and Wen Liu (2017), as noted above. Besides its general negative psychological effect, in heteronormative society, shame has an exceptionally negative effect on the sexual subjectivity of queer people. It is therefore all the more important to identify, both individually and phenomenologically, the facilitators and inhibitors of a person’s healthy sexuality. That type of reflexion can then provide a valuable resource for further sexual becoming, in which the subject can refocus on activities and interactions that represent positive sexual experiences.

Fig. 2
figure 2

Healthy sexuality as a function of sexual acts reflected in sexual health parameters

Full size image

An individual’s potential for healthy sexuality depends on the manner in which they encounter the various episodes in their life and which of these events they do or do not experience, how they occur, what were their outcomes, and how they deal with them. Negative experiences in a person’s sexual career erect obstacles or barriers to achieving healthy sexuality, while positive and enjoyable events and the anticipation thereof encourage or facilitate a shift towards healthy sexuality (Bianchi 2020).

Important events related to sexuality can vary depending on sexual orientation or gender identity. In a heterosexual-oriented population, experiences similar to coming out of individuals who are sexually attracted to the same sex, which entails publicly declaring a non-heterosexual orientation, would be hard to find (Weeks 1977). In the case of homosexuality or bisexuality, it's not just about informing others about one's sexual orientation but also about a crucial inner coming out. This involves discovering one's sexual orientation and self-identification with it, touching upon the core of one's sexual subjectivity. These processes are significant components on the axis of life episodes in the context of sexuality among non-heterosexual populations (Lefkowitz & Vasilenko 2014). Similar experiences occur across the queer population, not only among homosexual or bisexual individuals but also among people with non-cisgender identities (Richards et al. 2016), individuals on the asexuality spectrum (Przybylo 2019), and so forth. When conceptualizing healthy sexuality, we acknowledge its aspects related to queerness/queer identities and consider it important for further research to be devoted to healthy sexuality among queer individuals. Similar to the cisgender heterosexual population, it may be mainly about a balance of its facilitators and inhibitors.

As illustrated in Fig. 2, in a traditional approach a subject’s sexual trajectory can be categorized into four types of behaviour. Adapted from diverse normative and clinical sources (Sagarin 1971; Grinde 2021; NCSBY 2024), the four behavioural categories are autoeroticism-masturbation, mutual eroticism-masturbation, penetrative sex and reproduction (horizontal axis). These behaviours may be, but need not be, marked by manifestations of risk factors, in terms of the statistical parameters of sexual health in the population (sexual debut before the age of 16, sexually transmitted diseases/non-use of condoms/dental dams, sexual violence, abortions, unplanned parenthood, infertility—vertical axis). As far as sexual subjectivity is concerned, these are the events mentioned above (own bodily experience, genital self-pleasure, processing one’s sexual and gender identity, intimate erotic bonding, experiencing sexual pleasure and sexual satisfaction, mutual sexual satisfaction, and reproduction—diagonal axis); each of these episodes may be marked by the presence or absence of (unwanted) pain, fear, shame, ridicule, guilt and (unwanted) punishment, joy, pleasure and success and thus serves as either an inhibitor or a facilitator of healthy sexuality.

A concept map for the placing of healthy sexuality in the sexuality/intimacy arena may help to illustrate its functionality. Figure 3 shows relationships of relevant concepts: intimacy, sexuality, sexual subjectivity and healthy sexuality, along with the dynamic concepts of facilitators/inhibitors (a kind of “independent” variables) and satisfaction vs. frustration (a kind of “dependent” variables). This visualization shows that healthy sexuality emerges from sexual subjectivity in the context of our broad sexuality, framed by transforming (so called plastic sexuality, pure relationships and disclosing intimacy; Giddens 1992) and transmuting (intimacy with others is being replaced by intimacy with the self and is experienced as an excessive focus on the person’s unique identity; Bianchi 2020).Footnote 2 The specific determinants of our healthy sexuality are positive and negative experiences in sexual episodes (facilitators and inhibitors), resulting in a particular state of satisfaction (determined by experience with facilitators and/or absence of experience with inhibitors) or frustration (determined by absence of experience with facilitators and/or experience with inhibitors); satisfaction and frustration may be, however, also directly saturated from intimacy and sexual subjectivity.

Fig. 3
figure 3

Concept map of healthy sexuality and relevant related concepts

Full size image

Since there is a risk of misunderstanding the double meaning of the term ‘healthy sexuality’ (as a target condition, as well as an agenda worthy of attention), the dialectics of conceptualizing a healthy sexuality can be ideally captured by applying the principles of A. N. Whitehead’s process ontology. Whitehead (1933) set about tackling a very similar issue, the concept of freedom (the ideal, the value of freedom), as related to Plato, who preached about freedom while he himself had slaves. As Whitehead puts it,

The power of an ideal consists in this: (when) we examine the general world of occurrent fact, we find that its general character, practically inescapable, is neutral in respect to the realization of intrinsic value. The electromagnetic occasions and the electromagnetic laws, the molecular occasions and the molecular laws, are all alike neutral. They condition the sort of values which are possible, but they do not determine the specialties of value. When we examine the specializations of societies which determine values with some particularity, such specializations as societies of men, forests, deserts, prairies, icefields, we find, within limits, plasticity. The story of Plato’s idea is the story of its energizing within a local plastic environment. It has a creative power, making possible its own approach to realization. (Whitehead 1933, p. 53).

In other words, as paraphrased by Paul Stenner, holding a value (freedom, healthy sexuality) which is not exemplified in life allows that life to be problematized and improved (in line with the value); the value does not guarantee the change will thus take place, but without that idea/value, there can be no change. The role of a value is to shape and encourage the actualization of valued experiences (healthy sexual experiences) and to make them more likely. We can (even) have a value (as an ideal) that is not fully exemplified in life, but whose value serves to encourage such exemplification (towards healthy sexuality) (Stenner 2023).

In this sense, it is possible, at any point in time, to think about the ‘state’ of the subject’s sexuality in terms of health, as determined by selective fulfilment on certain occasions (experiences of inhibitors and facilitators—pain, shame, punishment, guilt, pleasure, joy, etc.); however, this state is both simultaneously and immediately overcome by a continuation of the sexual experiences in which the inhibitors and facilitators continue to interact, and the subjective sexual experience, depending on the inhibitor/facilitator ratio, becomes more or less satisfying and healthy. The subject’s state of healthy sexuality usually exists without the full exemplification of a potentially healthy sexuality. A person’s potential for achieving a healthy sexuality, the changing contexts, and the facilitators and inhibitors involved, therefore, exists in a dynamic process of becoming. Therefore, we can talk about healthy sexuality as (1) an optimal desired state, characterized by minimal barriers, a maximum number of facilitators and a high level of sexual satisfaction, in tandem with a (2) processual approach to the individual’s sexual subjectivity, determined by the barriers and facilitators that create the potential for the subject’s healthy sexuality and thereby sexual satisfaction.

Our intention to introduce the conceptualization of healthy sexuality may raise doubts about the usefulness of this innovative approach. This would be due to a reflection of the phenomenon of healthism, linked to medicalization,Footnote 3 that reflects the emerging preoccupation with personal health within the middle-class in the United States of America since the 1970s (Crawford 1980). This phenomenon was saturated mainly by two new popular health movements: holistic health and selfcare. Crawford (1980) defines healthism as “the preoccupation with personal health as a primary—often the primary—focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of life styles, with or without therapeutic help”.

Crawford, however, clearly distinguishes between the ‘new health consciousness ’, a complex societal/psychological fabric, and healthism—the preoccupation with personal health. “Health consciousness … cannot be reduced to the thread of healthism… ” (Crawford 1980).

Our suggestion to introduce the concept of healthy sexuality in no way aims at contributing to the “preoccupation ” with personal health; on the contrary, due to persisting tabuisation of discussing sex/uality in intimate partnerships it is rather meant to enable self-reflexive dialogue with sexual partner and with a (medical) expert in order to facilitate a learning process towards a higher quality of sexual life and a towards becoming a more satisfied sexual subject.

Moreover, Robert Crawford has further elaborated and softened his critique of healthism and its negative consequences on socially fair access to health in his 2006 published paper Health as a Meaningful Social Practice (Crawford 2006). Here, he extends his original analysis of the 1970s ‘ historical period (Crawford 1980) into the twenty-first century. In the twenty-first century “health consciousness has become increasingly unavoidable ”,… with doubts about causality between “[on the one hand] fortifying our body and lessening our exposure to harm and [on the other hand] becoming more secure in our health ”. (Crawford 2006, pp 415–416). Crawford also identifies here 5 strategiesFootnote 4 leading to fulfilment of the healthism ideal (resembling later Steve Epstein’s critique of commodification and governance of sexual health within the medicalization and healthization framework of the current neoliberal regime (Epstein 2022, p. 207). In each of these strategies, problems and solutions are located within the realm of individual action and are consistent with the morality and ideology of personal responsibility.” (ibid, p. 416).

But, further on, Crawford (2006) himself openly mitigates his criticism of the individual-action-and-personal-responsibility based healthism when stating that “Perhaps I overstate my case. The ideological benefits of making individualized health practice a preoccupation and personal responsibility its principal ethic are incontrovertible”. (ibid, p.416).

As a political scientist, Robert Crawford, however, remains outside of the reach of theories and mechanisms that may be relevant to individual coping with the current societal health-awareness tendency and which we expect to operate towards healthy sexuality. This concerns mainly the psychological conceptualization of agency by Roger Frie (2008). This conceptualization is sensitive to both individual and societal/contextual/political inputs and allows to incorporate all aspects of an inclusive and non-stigmatizing, non-binary and non-discriminative approach to health as a subjective goal. Agency plays a crucial role in becoming sexual subjects (McQueen 2015), in a dialectic interaction where agency and subjectivity are mutual prerequisites for each other (Chmielewski et al. 2020).

Why would we want to conceptualize healthy sexuality—in contrast to the established, albeit contradictory concept of sexual health? A healthy sexuality is one that is free of (unsolicited) pain and shame, fear, ridicule, guilt and (unwanted) punishment, and where the subject has positive experiences of getting to know their body, releasing their sex drive, achieving sexual gratification and being satisfied with their sexuality and reproduction. In this paper, we elaborate Bianchi’s (2020) claim that a healthy sexuality consists in the potential for fulfilment and depends on the resulting sum of positive and negative experiences individuals gradually acquire over the course of their life via significant sexual events/occasions. The concept of healthy sexuality can both express the desired, ideal condition while also framing the potential that is fulfilled to various degrees—over the life trajectory of the sexual subject.Footnote 5

Conclusion

This paper highlights the narrative sexual subjectivity open to interpretations of meanings in sexuality. In contrast to the statistically rooted concept of sexual health, it proposes an operational framework for identifying resources for individual healthy sexuality rooted in a process-ontological view of human sexual subjectivity; it emphasizes the importance of reflection and interpretation of events and occasions that contribute to an individual's sexual trajectory. This approach aims to understand and interpret the facilitators and inhibitors of an individual's healthy sexuality. By understanding and interpreting the facilitators and inhibitors of healthy sexuality, the paper suggests that it becomes possible to shape and encourage valued experiences in sexual interactions and thereby promote healthy sexual experiences. Various factors impact intimate and sexual relations, including changing relationship dynamics, technological influences and the breaking down of sexual taboos. The paper also acknowledges the rise of non-binary sexual identities and queer sexuality within new ethical and normative systems. With the numerous critical studies of sexuality presented here, this initiative is gaining traction—this conceptualization of healthy sexuality respects the subjective making of meaning in cultural contexts and is open to the subject’s interpretation of active myths relating to sexuality, thus protecting them from indoctrination in stereotypical meanings and symbols (cf. Carlson 2010), particular cultures (Andrijasevic 2009) and masculinity (Stepney 2015). It also allows being sensitive to shame, a potential inhibitor of healthy sexuality (in line with Johnson’s (2012) recommendation), to take into account sexual perpetrations by a female partner (Kramer and Bowman 2021), the differential impact of the criminalization of sexual interaction (Angelides 2009), an individualized subjective perception of pain associated with sexual interaction (McIntyre 2016; van Ommen 2016), as well as impacts of heteronormative expectations and norms. In this context, we would like to draw attention to the broader social-psychological aspects of heteronormativity and any binary conceptualizations. As illustrated by Baumeister and Leary (1995), the humans need to belong or fit in extends to groups that divide people on the basis of sexual orientation. When there is a mismatch between what heterosexual people experience and what social norms regarding heterosexuality require, discomfort can emerge (Krueger et al. 2018). This discomfort can be, however, heightened through heterosexism and monosexism, which create structural pressures for heterosexual orientation and attraction to exclusively one gender, which privileges heterosexual people as well as homosexual people, and systematically punishes people who are attracted to multiple genders (Eisner 2013; Hayfield 2020).

Also, the paper acknowledges the relevance of intimacy—evolving both in terms of content and form—to healthy sexuality. It highlights the shift from traditional notions of intimacy with others to a more contemporary focus on intimacy with the self. The paper discusses the limitations of existing sexology tools, which are primarily designed for clinical assessments and do not fully capture an individual's potential for healthy sexuality. These tools do not account for the complexity of an individual's sexual subjectivity. The conceptualization of healthy sexuality is seen as relevant to sexuality education, offering opportunities to instil values related to healthy sexuality from early childhood onward.