Of the 35 interviews conducted, we have data on where in the interview the questions on understandings of sexual health were asked for 32 participants (interviews for two women were not audio-recorded and the information is not identifiable in the notes on these interviews, and one participant was not asked the question). Of the 32 who were asked about their understandings of sexual health, 27 participants (and all of the women) were asked after seeing all of the images described above; 10 were specifically prompted to consider whether these images were related to sexual health (e.g., ‘Thinking about these images, what does sexual health mean…?).
Given that participants were specifically prompted to consider sexual consent and verbal and physical abuse as dimensions of sexual health, we could have expected participants’ definitions of sexual health to broadly reflect this. Instead, their accounts showed marked differences in the extent to which men’s and women’s understandings of ‘sexual health’ moved beyond narrowly-defined definitions of the prevention of STIs and pregnancy, to those which encompass broader physical, mental and social wellbeing as defined by the WHO [1]. We compare and contrast understandings by gender in relation to these dimensions below.
Sexual health as limited to physical prevention of STIs and pregnancy
Even though most had been shown images designed to facilitate discussion about sexual consent and verbal and physical abuse as described above, when first asked about ‘sexual health’, male participants overwhelmingly equated this term with the avoidance of STIs and pregnancy:
“OK. When I say the phrase sexual health, what pops into your mind?
R: Er, sexual health? Contraception obviously and then hygiene and um, that’s what pops into my mind.
OK so how about things like STIs?
R: Yeah that’s why I say contraception and having that in mind, STDs and HIV and um, the other one.”
(Shane, aged 26–35 years, open relationship)
Shane was asked this question before he was shown the images, but other men offered similar definitions, even after seeing the images:
“I thought it was mainly like about condoms and being careful, no’ catching STIs, that’s just what I thought.” (Daniel, aged 36+ years, single)
Most of the women interviewed also provided similar accounts of their understandings of ‘sexual health’ as being focused on protecting the physical body from STIs and pregnancy:
“Sexual health is taking care of yourself, sexually, all your sexual organs, being checked, going for tests, using protection – not just the pill or, but use condoms.” (Jade, aged 36+ years, single)
Sexual health? Just obviously being aware, you know, if you have unprotected sex, you know, you’re gonna [going to], you could catch something and you know you need to be, you know, look out for yourself, be aware, you know if you have unprotected, you know, you can catch something, and… yeah, and just…(Leanne, aged 18–25 years, single)
Both Jade and Leanne were shown the prompt images before being asked about sexual health, but despite this restricted themselves to narrow discussions of sexual health. However, most female participants, as illustrated below, also offered accounts of sexual health that went beyond this initial focus on the prevention of STIs and pregnancy.
Broader accounts of sexual health
Although the WHO definition of sexual health and wellbeing specifically refers to mental wellbeing, few participants offered unprompted accounts of sexual health that explicitly related to this. Megan was an exception:
“Sexual health means, like, all round. Like, I dunno [don’t know], mental, health around it, physical health. Aye.
So when you say mental health, what sorts of things do you mean?
Well, like, your mental attitude towards sex. So, like, mebbe [maybe] someone will see, think it’s all right to go out, and if a woman says no, d’you know what I mean? That’s still sexual health. Cos sexually, his mind’s no’ healthy. So that’s sexual health as well as physical, whether you’ve got an infection.
You are the first person who’s gone straight out with that. A lot of people go straight for the STIs, despite having discussed all of this. So why d’you think so many people don’t, like, respond like you have? So many people just think STIs rather than –
Because that’s what they get taught, when they hear the word sexual health, it’s about putting a condom on and taking these tablets to get rid of this. Rather than the mental aspect tae [to] sexual health.
(Megan, aged 18–25 years, long term relationship)
More often, it was the relationship context that was raised in the discussion and appeared to be particularly important to the women interviewed:
“…You need to be happy in your relationship. So there is like a psychological side of it as well, as well as your STIs and whatever.” (Kayleigh, aged 18–25 years, Single)
“And just making sure, like, when youse [you] are having sex that... do you know, it's what youse [you] both want an'... is that what you...? Yeah? Yeah, just aboot [about], like, two couples, if that's what they're doing then they talk about it and, you know, there's things in place for them, they're both happy wi' [with] what's going on an' they have a good relationship where they can talk tae [to] one another an' it's all happy.” (Shannon, aged 26–35 years, separated)
Kayleigh and Shannon were specifically prompted to consider whether the images they had been shown were related to sexual health, but the majority of the women we interviewed located their accounts of sexual health within a broader, social account of relationships, without prompting. This social account of relationships was one ideally based on respect and a freedom from violence:
“
So what do you think sexual health means?
I think for me it’s just about being safe.
Safe against STDs and safe in relationships.
So when you say safe in relationships ….?
Safe in relationships with regards to sexual violence. And just because people seem… I think it’s almost ok for younger guys and younger men to treat people, to treat women like they are pieces of meat. But that’s through things like media, things like porn. Things like films, music, anything really.” (Angela, aged 26–35 years, single)
Even though all of the women were asked about sexual health after having seen the prompt images, their reported experiences of domestic violence were almost always more experiential and personal than they were for men. Ten women described experiencing or witnessing gender-based violence of some form, with six of them describing surviving abusive relationships or experiences, including sustained and often coercive and controlling relationships with violence over months or years. Some described these as “hell”, or talked of how this made them reach “rock-bottom” as their self-esteem was undermined.
Women talked of the need not just to have respect from a partner, but also to have respect for themselves. They expressed desires for more positive relationships, based on open communication and trust, choice and freedom from coercion:
“Just think people forcing you tae [to] have sex should be, like, tae [to] force you, in a relationship, if you don’t want tae [to] have sex, you don’t have sex. You don’t get forced.” (Chloe, aged 18–25 years, long-term relationship)
In contrast, just four of the 15 men who were asked about sexual health after being shown the prompt images offered accounts of sexual health that went beyond initial focus on the prevention of STIs and pregnancy:
“Sexual health? Just being safe and being clean, not having STIs, not being, like a lot of these pictures, being bad towards women or forcing yourself upon them or being inappropriate towards them. Yeah, sexual health – that could mean a various number of things, I think, yeah.” (Ryan, aged 36+ years, long-term relationship)
“I don’t think it should be any of that in relationships. I think it should be equal either way, shouldn’t it? Know what I mean? No-one should be – whether it’s her getting hit or him getting hit, or her getting abused, him getting abused. It just shouldn’t happen, should it? Everybody should be equal. I would say, that’s it. Everybody should be equal. Shouldn’t be any of that.” (Scott, aged 36+ years, single)
When explicitly, or further, prompted to consider a broader definition of sexual health by the interviewer, a few men did accept it:
“No, obviously that’s mental health obviously maist [most] of these [referring to images]. Obviously that yin [one], well a’ o [all of] them pretty much so…
Interviewer: So sexual – but you don’t think sexual health can be to do with your mental health at the same time?
Obviously it can mess wi’ [with] your head as well obviously.” (Connor, aged 18–25 years, single)
However, in doing so, a few men still appeared to interpret mental and social wellbeing in terms of the ultimate impact on physical health to some extent:
“[Image D – domestic violence] just… I mean, it’s no’ [not] just aboot [about] sex, is it? It’s just unhealthy relationship, unhealthy lifestyle for that lassie [girl/woman] that’s tae [to] be living you know?
Interviewer: Yeah. But in terms of her sexual health, do you think she has any choice over where she has sex, the type of sex she has?
Nah. Definitely no’. I’m sure her sexual health will be non-existent probably, do you know what I mean? I mean, he’ll be taking what he wants when he wants by the looks o’ [of] that photograph. […] I mean, he could be oot [out] sleeping wi’ [with] other women and passing on all sorts. I don’t’ think the boy’s gonnae be putting condoms on and that, ‘cause I’m sure he’ll be making sure she’s no’ sleeping wi’ anybody else…” (Ally, aged 36+ years, single)
“Do you think any of these relate to sexual health?
Maybe... I don't know. Yeah. Maybe [Image A – Rohypnol]. Obviously because if you get spiked wi' [with] rohypnol and you're not in control of what's happening or anything like that so, I mean, you can't turn round and say “Oh, you need tae [to] put a condom on” or, you know, anything like that. So, I mean, [Image A – Rohypnol] would be... again, that's me coming back tae [to] the safe sex type thing.” (Josh, aged 26–35 years, long-term relationship)
And in some cases, it was the potential impact on their own physical sexual health that was of concern:
“Oh wait a minute, what does this say 'I'm not the kind of guy to have sex with a girl when she's too drunk'. Yeah that's related to sexual health as well, that's what I would think you know. If [Image B - Police Scotland campaign on alcohol and consent] like if you're too drunk, I want to think maybe you did this more often. And if you're going to have sex with me when you're in that state then how many guys have you had sex with in that state. So the more likely to have an STI [if] you're the kind of girl who would have sex with me when you are too drunk. So I would worry about my sexual health in that situation.” (Shane, aged 26–35 years, open relationship)
Some men remained actively resistant to broader definitions of sexual health, despite specific prompting:
“Interviewer:
So do you think these images are connected to sexual health and how so?
Sexual health tae [to] me, in probably my ignorance, doesn’t involve domestic violence, physical or mental, to be honest. I think more sexual health as the actual sex and/or the STIs or the physical relationship, I suppose would be the best way for me tae [to] put it, rather than the relationship side of it, if that makes sense? […] I suppose you wouldnae [wouldn’t] want tae [to] have sex wi’ [with] someone that’s slagging you off all the time or beating you up and, obviously, that can have an effect on future partners. But I would still say the definition, tae [to] me, of sexual health is the physical relationship, the sex or the kissing or the oral sex or whatever and the STIs that come from that or… rather than the domestic violence which, tae [to]me, is a separate category.” (Luke, aged 18–25 years, single)
“So what do you think sexual health means?
Well, obviously your sexually transmitted diseases and stuff like that. I don't really know, tae [to] be honest. Obviously your STDs and stuff like that and obviously your transmitted diseases but... other than that... […] Because they're all tae [to] do wi' [with], you know, like people forcing sex on people and... (pause) it's all tae [to] do wi' [with] kind o' relationships and between men and women and... (pause) I mean, tae [to] be honest, I can see the point o' a' [of all] this kind o' [of] stuff being here but I didn't think that there would be anything like that.
You mean [Image D – domestic violence] and [Image E – verbal abuse]?
Yeah, image D and E, yeah. I wouldnae [wouldn’t] really think that they had much tae [to] do wi' [with] sexual health. And you think o' [of] health, you automatically think o' [of] disease, stuff like that. Not these kind o' [of] issues.” (Thomas, aged 26–35 years, long-term relationship)
Furthermore, when presented with the images of domestic violence, a few men talked about women having the ‘choice’ to leave or walk away from situations in which they were threatened with violence, with the onus clearly on the woman to take action:
“So in terms of these relationships, here, the [Image E – verbal abuse] and [Image D – domestic violence], what kind of choices do you think the women in those relationships had in terms of when they had sex and things like that?
I don’t know? They probably don’t have a choice. There’s always a choice to get oot [out] it though.” (Jim, aged 18–25 years, single)
“…they always have sort o’ the option tae [to]… they always have the option tae [to] walk away. I know that sometimes that it’s not gonnae [going to] be as easy as just walking away ‘cause, you know, they might love the person or, you know, they believe that they can change him…” (Josh, aged 26–35 years, long-term relationship)
This was the case even though many men (including Luke and Thomas above) spoke in some way about witnessing or knowing about the experience of domestic abuse. Few men talked about experiencing or perpetrating abuse (and they may have been disinclined to do so to a female interviewer), but eight did talk about witnessing it. For example, Rab recalled a vivid childhood memory of hearing his mother “getting battered off the walls”. He went on to say:
“…sometimes you still get the images and things like that and you just freak oot [out] and you just cannae [cannot] get rid o’ [of] the images and you see what happened to your family, and that’s why I’m against it [violence against women], d’you what I mean? I just don’t trust guys.” (Rab, aged 18-25 years, single).
While this quote suggests that Rab judges such behaviour to be unacceptable or needing to be challenged, this was rare in other men’s accounts, even when discussing rape, as illustrated by an extract from Josh’s interview:
“It might just be that one time when she’s not feeling it [does not want to have sex] and he’s putting more pressure and pressure on her. If anything was tae [to] happen then it would be rape and, again, she can walk away.” (Josh, aged 26–35 years, long-term relationship, emphasis added)
Here, Josh clearly places responsibility for avoiding rape with women rather than suggesting that men should take responsibility for this coercive behaviour.