Global sexual health: why communal knowledge about pleasure and wellbeing matters

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For decades, discussions and decisions about access to contraception, abortion, maternal healthcare, HIV prevention and treatment, comprehensive sexuality education, gender equity, and protection from sexual violence have largely flowed in one direction. From the global north to the global south.

Researchers, donors and international organisations have exported programmes, defined success, and determined which questions matter most. How can HIV be prevented? How can contraceptive uptake be increased? How can maternal deaths be reduced? Far less attention has been paid to questions about pleasure, desire, or what communities themselves define as sexual wellbeing.

And despite decades of investment, many of the world's biggest sexual health challenges remain. Every year there are more than 374 million new cases of four major sexually transmitted infections. More than one billion people are living with sexually transmitted infections worldwide. Furthermore, an estimated 225 million women who wish to avoid pregnancy are still not using effective contraception.

These numbers should prompt an uncomfortable question. What if the dominant frameworks guiding global sexual health are not as effective or as empowering as many researchers, donors and policymakers assume?

That question also emerges from our own experiences as sexual and reproductive health researchers at Columbia University. Our work has taken us across diverse global settings, including substantial engagement in Africa: from research on HPV vaccine implementation in Kenya and HIV prevention in Mozambique, to work with the United Nations Population Fund and academic, governmental and nongovernmental partners on sexual rights, sexual pleasure and sexual health. Our team also brings Indigenous health and policy expertise from Aotearoa New Zealand, including research grounded in Hauora Māori approaches to sexual and reproductive health.

These experiences helped motivate our recent commentary, in which we examine how colonial histories, unequal funding structures and global research hierarchies shape where knowledge is produced and whose knowledge is considered legitimate. We argue that global south communities are treated as places where interventions are delivered rather than where new ideas emerge.

We draw on examples from Māori communities, Somalia and west Africa. We show how global south and indigenous traditions offer ways of understanding bodies, sexuality, wellbeing and knowledge that differ from – and can expand – current approaches.

We recommend that global sexual health should move beyond simply exporting interventions. Instead, researchers, practitioners and funders should work alongside communities to co-create new approaches. These must value local knowledge, cultural traditions, pleasure and wellbeing as essential components of sexual health.

When expertise flows in only one direction

In modern global health, expertise has often been assumed to flow from wealthy countries to everyone else. As reflected in the recent Porto Proclamation on Sexual Health, Rights and Justice, there is growing recognition that global sexual health requires more equitable collaboration and shared leadership. Yet this imbalance continues to shape donor priorities, funding and international policy. It often leaves communities with little authority to define success on their own terms.

Global efforts to reduce HIV, expand access to contraception and improve sexual and reproductive health have saved countless lives. But when interventions are designed primarily around externally defined priorities, they can miss what people actually need. Success is measured only through HIV incidence or contraceptive uptake. It overlooks pleasure, intimacy, bodily autonomy, reproductive choice and wellbeing.

In some settings, this narrow focus has overlooked sexual violence and sidelined local priorities in favour of donor agendas. In Haiti, for example, sexual exploitation and abuse of women by UN peacekeepers persisted amid major gaps in accountability and legal recourse, leaving many survivors without meaningful avenues for justice.

There is an effort to build more collaboratively with target populations and create new indicators of success. Yet the evidence base itself reflects the geographic imbalances we describe. In one systematic review of 33 pleasure-inclusive interventions, 25 were conducted in the United States. Very few were conducted in global south settings.

By acknowledging why people have sex – not simply the risks they hope to avoid – interventions could become more relevant while improving health outcomes.

There is growing recognition that effective sexual health programmes cannot simply be exported. Programmes are being developed in partnership with the communities most affected.

What would it look like to redefine global sexual health?

Modern public health relies on surveys, clinical trials and epidemiological data. These approaches remain indispensable, but they are not the only ways of understanding sexuality, bodies and wellbeing.

Researcher Ngāhuia Murphy draws on Māori cosmologies to challenge colonial narratives that portray menstruation and women's reproduction as shameful or impure. She instead describes it as sacred and life-giving.

Feminist researcher and author Minna Salami argues for “sensuous knowledge”. She contrasts dominant European traditions of “hard” knowledge with ways of knowing grounded in relationships, lived experience and the body. This embodied knowledge encompasses intuitive sensations, movement, emotion, ritual, and socially learned practices.

In Somalia, oral literary traditions have long served as a way of sharing knowledge and resisting colonial power. As scholars of Somali oral poetry have argued, poetry can serve as a source of knowledge about health, bodies and wellbeing. This is not because it replaces scientific evidence, but because it captures dimensions of human experience that conventional public health methods often miss.

Likewise, Nigeria's Yoruba knowledge traditions understand knowledge as something experienced through the senses as well as reason.

These traditions complement science by helping researchers ask better questions and design more responsive programmes.

What would it take to decolonise sexual health?

Put global south communities at the centre of sexual health decision-making. Support community-led understandings of pleasure, wellbeing and sexuality. Success must be measured beyond disease prevention to include joy, safety, intimacy, autonomy and belonging. Actors must embed anti-racist, feminist, LGBTQ+ and indigenous perspectives.

There must be greater support for locally designed models of care. For example, community-led services in which local organisations help determine what services are provided, how they are delivered, and how success is defined. This must go hand in hand with shifting funding and decision-making power towards global south institutions. Researchers and funders must also critically examine how their own positions, assumptions and institutional power shape efforts.

Importantly, there must be a recognition of global south communities as architects of innovation.

None of this means abandoning science. It means broadening what counts as evidence and who gets to produce it. Bringing together rigorous research with indigenous knowledge, lived experience and community leadership can build sexual health programmes that are more equitable and more effective.

The future of global sexual health must depend less on teaching the global south and more on learning from it.

Madison Moore, MPH, a graduate of Columbia University Mailman School of Public Health, served as the first author of the original published paper and played a leading role in its conceptualisation, writing, and editing.

Jessie V Ford does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

By Jessie V Ford, Assistant Professor, Sociomedical Sciences, Columbia University