The Pleasure Deficit

One of the foundational experiences in Jenny Higgins’s career was reading a 1993 article by sociologist Ruth Dixon-Mueller, who posited that a visitor from another planet who relied on demographic and family planning journals for information would be “mystified about sexual behavior.” Higgins, who is associate professor in the Departments of Gender and Women’s Studies and Obstetrics and Gynecology at the University of Wisconsin–Madison, was particularly struck by the article’s contention that contraceptive researchers and family planning programs were ignoring the seemingly obvious fact that enjoyment is a central component of human sexuality and contributes to “risky” behavior. Higgins explored in depth this disconnect between contraceptive research and sexuality—a problem she called the “pleasure deficit”— in a 2007 article in Perspectives.


PSRH: What led you to address this issue?

JH: In college and graduate school I worked at two abortion clinics, one in Maine and the other in Atlanta. I frequently heard patients describe the ways in which contraceptives affected their sexual lives, and in turn the way their sexual lives affected how they used or didn’t use contraceptives. I very clearly remember one patient saying, “We have condoms in the bedside table, but sometimes it just feels better not to use them.” Another patient said that the pill diminished her libido and had stopped taking it. She said, “What’s the point of using birth control if you don’t want to have sex?”

In graduate school, I had some wonderful professors, including Jennifer Hirsch, my coauthor on the Perspectives paper. I think it was in Jennifer’s class that I read the Dixon-Mueller piece. It made so much sense to me. Contraceptive access and education are critical, but they don’t completely determine use. Let’s also think about whether sexuality can help explain contraceptive behavior. When, as researchers, we de-eroticize reproductive and sexual health, we’re not practicing good science—we’re completely decontextualizing the behavior. So Ruth Dixon-Mueller’s piece was very formative in my thinking. I remember seeing her at a conference, and it was sort of like meeting your favorite rock star.

PSRH: Why has this issue been ignored? Is it due in part to male bias?

JH: Absolutely, but there are some other historical roots as well. In the early 1900s, family planning proponents such as Margaret Sanger played down the sexually emancipatory aspects of birth control. They were trying to garner public support for contraception at a time when merely sharing information about contraception through the mail was illegal. Selling birth control in that environment by emphasizing how it would allow for sex without the consequence of pregnancy would have been even harder. So even within the feminist movement, there were efforts to separate contraception from sex and make it a medical good. Birth control advocates emphasized how contraception could save lives, ensure healthier birthspacing et cetera. Today, we still emphasize the medical benefits of contraception, as opposed to saying, “Hey, this allows people to have sex without getting pregnant.”

At talks I give on this topic, I sometimes run into similar obstacles. People may, understandably, say things like, “We’re losing insurance coverage for contraceptives, politicians are trying to defund Planned Parenthood—and you’re telling me we need to think about contraception and sexuality? You think that’s going to help? We’re barely getting contraceptives accepted as medical devices.” Very well intentioned public health advocates may play down the sexual aspects of contraceptives if they think it will help promote services.

But beyond that, there’s a huge bias in our culture about how we think about women’s sexuality. For decades, investigators have been trying to develop hormonal contraceptive methods for men, and one of the first questions that developers ask is, “Will this method in any away affect male sexual functioning?” Because if a guy can’t sustain an erection or have an orgasm, it’s a nonstarter. We would consider a study of a male hormonal contraceptive that didn’t examine male sexual functioning to be scientifically irresponsible, right? But there’s no parallel for methods for women.

A reviewer on one of my NIH proposals once said, “I’m just not convinced that sexuality is important to women.” It’s impossible to imagine a reviewer saying that about men’s sexuality.

PSRH: Are providers more attuned to these issues than researchers are?

JH: Perhaps, but there’s also some resistance in clinical circles. When I present this information to clinicians, people say, “I totally understand.” But often, providers feel unequipped to discuss sexuality with patients: “I don’t know if I have the right knowledge and skills to do it. And what if I say the wrong thing?” Similarly, studies suggest that reproductive health patients—for example, those at a contraceptive visit—would like their provider to ask them about sexuality, but feel afraid to bring it up themselves.

PSRH: Pleasure—and related concepts, such as the “sexual acceptability” of contraceptive methods—has remained a central theme in your research. What paths have you explored?

JH: In the Perspectives article, I mentioned the “sexual aesthetics” of contraceptives: how methods taste, feel and smell. Sexual aesthetics can be very important for methods such as condoms, but less so for methods such as IUDs. More recently, my colleague Nicole Smith and I tried to build a conceptual model of the “sexual acceptability” of contraception. This concept involves a lot of things: sexual functioning, such as lubrication and orgasm, but also psychological factors, partner factors and cultural factors. In a pilot study, we found that some people who started using IUDs or implants then had an increase in sexual disinhibition—they were more able to “let go” sexually. I remember one participant saying, “Because I use the IUD, I don’t have to listen to that voice inside my head that’s always saying, ‘Could I get pregnant right now? Did I miss my pill this morning?’” That worry about becoming pregnant is diminished when you’re using a foolproof device. And that might improve your sex life.

Lately, I’ve been working with Jessica Sanders and others at the University of Utah on an exciting project. We’re following over 4,000 patients who start a new method of contraception and documenting a variety of sexual outcomes over time. One preliminary finding is that how satisfied you are with your method may have a positive effect on your sex life. Women who consistently say over time that they’re satisfied with their method actually report increased sexual well-being. What a powerful public health message that is: “People who like their method can have really good sex.”

PSRH: Do you think the “pleasure deficit” has lessened in the past decade?

JH: I do, but things are still pretty bleak. We’re not taking an overwhelmingly sex-positive approach to contraception. We still assume that people make decisions about contraception the same way that they make decisions about heart disease medication. And it’s completely different. People don’t fantasize about getting heart disease, whereas they may dream about having a pregnancy someday. And people don’t have to take heart disease medication in the middle of a sexual act. In public health, we’re still stuck in a “rational actor” model, in which we assume that people weigh costs and benefits. If we continue to focus on that model, we’ll continue to view people who have unprotected sex as not knowing better, when we should be saying to ourselves, “It may make sense that people would do this if they can’t find a method that works for them or if their partner can’t keep an erection while using a condom.”

The fact that recently I’ve been funded to do some larger studies of this work may be an indication that the tide is turning. And I can’t tell you how many younger public health practitioners and students I hear from on these issues. The next generation is light-years ahead of my generation. I remain optimistic that our field will take a more sex-positive approach to contraception, which will help us better meet contraceptive users’ needs.

Cover illustrations of Margaret Sanger © Matthew and Eve Levine