Jennifer Hirsch
Emory University

With the exception of looking at sexual activity as a risk factor for fertility and disease, sexuality (conceived of as the meanings, practices, identities, relationships and institutions related to sexual intimacy, rather than just sexual behavior) has not necessarily been a central topic of DBSB-supported research. Sexuality/sexual behavior cuts across almost all of DBSB's ongoing research areas. Following are some suggestions for topical and theoretical areas in which the branch might consider supporting research.

Topical areas of opportunity

1. What are people really doing when they have sex? In spite of the strides made over the past decade in developing comprehensive models of reproductive health, a lot of sexual behavior research seems to focus either on disease prevention or fertility regulation, as if these happened in different populations or different sex acts. Researchers working on sexuality and sexual behavior could do more to explore how people simultaneously manage the challenges of protecting health and regulating fertility, in other words, to do more to integrate these two major areas of DBSB-supported work. Supporting more research on dual-method use would be one specific way of doing this.
   
   
2. What are people's motivations to have sex? On the face of it this might seem like a question only a social scientist could ask (everyone else already knows why people have sex!), but lurking within much sexual behavior research there are a set of unexamined assumptions about sexual motivations, and it would be enormously useful to have some empirical work in this area. People might have sex because they are forced to out of poverty, or because they are overpowered by their own lust, or to establish social status with a peer group, but they might also have sex because they love the other person, or at a minimum, because they are just a bit fond of them. We can't reasonably think about preventing someone from doing something unhealthy until we have a better understanding of what drives them to do it in the first place.
   
   
3. We need to "study up," exploring the implicit assumptions about sexuality around which public health programs are organized. In one form or another, most U.S. sex education programs seem to teach that sex is a "dirty rotten thing" that you should only do to someone you love after you marry . These American values about sex and pleasure have guaranteed that our health education programs will make condom use about as erotic as remembering to floss. Studying up would mean exploring the exotic sexual cultures of the professionals in Washington and New York, who generate programs based on assumptions about sex and relationships learned in Towson and Scarsdale, and also studying the sexual world-views of different advocacy groups and institutions. For example, on both sides of the sex-education playing field there is a set of underlying assumptions about what "health sexuality" really means that shapes research and programs. Since all knowledge about sexuality is inherently political, we may as well make these politics explicit.
   
   
4. The sex about which we know the least, and the sex that is made invisible and normalized by most socio-cultural research, is adult heterosexual sex. Most of what we know about sexuality theoretically comes from research on sexualities that are visible because someone finds them problematic, gay sex, commercial sex, or sex among the poor or among adolescents, sex that we can in some way think about as an identity or a risk group. Perhaps it's been hard to generate interest in research on something that: a) people are supposed to do; b) is not supposed to have any bad consequences; and c) we all know is not very interesting anyway. This lack of research, though, has seriously distorted our theoretical approaches to sexuality and sexual health. There are also public health reasons to support more work on adult heterosexuality; perhaps one of the reasons that we know so little about how couples simultaneously manage the risk of pregnancy and disease transmission is that we have studied these as separate outcomes, rather than as mutually dependent outcomes which take place in the context of the same relationship. Furthermore, for many women around the world, their highest risk of HIV infection comes from having sex with their husbands, and we know very little that is useful in addressing that issue.
   
   
5. To address heterosexual transmission of HIV, what is really of crucial importance is men's multiple partnerships. We need research that explores the social and cultural factors shaping men's multiple partnerships, rather than just assuming that any man, given the opportunity, would have multiple partnerships. (see Point #2, above).
   
   
6. If we are to take seriously the idea that healthy sexuality is a vital part of overall health, then we need to know more about sexuality across the life course, particularly in the post-reproductive years. There are health aspects of this (older women and men are still at risk for infection with HIV and other STDs). This could be done not just from an individual "attitudes and behaviors" perspective, but also sociologically (looking at the institutions that regulate sexual behavior among older populations, including rules about sexual interaction among residents of nursing homes) or culturally (what is really behind the American distaste for thinking about people of a certain age as sexually active? We speak so glibly about prohibitions against sexual activity among African grandmothers, but know so little about our own grandmothers).
   
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   ¹ I borrow this phrase from Susan Newcomer.

Theoretical areas of opportunity

The DBSB could expand its current portfolio of sexuality-related by supporting research on social and cultural aspects of sexuality. What is needed, though, is not just more socio-cultural research on sexuality, but also different research: current approaches to sexuality research limit both our ability to capture how social change affects sexual health and our capacity to use our research to promote the improvement of sexual health.

1. Much current work on sexuality suffers from too much emphasis on culture, and not enough attention to social structure. Over the past decade there has been a proliferation of research within public health, claiming to explore cultural influences on sexuality. Much of this has been related to explaining the failure of our prevention programs to stem the HIV pandemic, as I am certainly not the first to point out. Culture is invoked to explain why people do things which we think they should no; we hear about cultural barriers, but not cultural facilitators. This is, of course, an improvement over thinking about sex as exposure to the risk of conception-but all this attention to culture, to ideology, especially when employed naively, without much theoretical attention to what culture really is, or where it comes from-produces static, ahistorical portrayals of sexual cultures. More importantly, it allows us to ignore the way sexuality is shaped by social inequality, leading to what Paul Farmer calls a criminal exaggeration of individual agency.
   
   Consider the black women in East Harlem who are infected with HIV at a rate that is astronomically higher than white women who live only five miles away on the Upper East Side. What these women think about sex and relationships is probably not irrelevant to the risk of becoming infected with HIV, but it's not the key determinant of these women's risk for infection with HIV. Culture, and its programmatic corollary cultural appropriateness, have been embraced by public health because they are an easy pill to swallow; they suggest that if we could just tell people how to be healthy in the right words, they would listen and all would be well. A more social perspective on sexuality, in contrast, might force us more in the direction of political economy, and this is hard because at this moment, we are not doing a great job in public health of providing truly social interventions to improve sexual health. The single most important step the DBSB could take to improve sexuality research would be to support work on the structural determinants of sexual behavior and on structural interventions to promote healthy sexuality. This could include not just work on poverty and sexuality, but also research on how institutions (such as schools, the legal system) regulate sexual behavior. This focus on social structure, of course, fits in well with the broader emphasis on disparities elimination.
   
   
2. Research on the links between gender inequality and sexuality would be one particularly important kind of structurally-oriented research to support. In spite of the growing interest in the influence of gender inequality on reproductive health, much of the intervention work in this area draws on the underlying assumption that the way to address gender inequality is to convince men to think differently about themselves and about women, sort of a global consciousness-raising approach. These "gender-think" interventions miss the point that gender is a structural aspect of social organization, so that research on gender and sexuality should look not only at gendered identities but at how gender shapes access to resources, etc. Furthermore, frequently the men towards whom these interventions are targeted are among the poorest and most vulnerable members of society. This is not to deny the importance of gender inequality at the household level, or to say that it might not be useful for individuals to develop a critical awareness of their roles in reproducing gender inequality, but the DBSB might help push the sexuality research field- which at the moment seems a bit stuck theoretically-to think more broadly about the determinants of sexual behavior.