A new sexual wellbeing paradigm grounded in capability approach concepts of human flourishing and social justice

Abstract

Over the last twenty years, there has been a growing interest in measuring sexual wellbeing, including by a WHO/UNFPA working group in 2007, which sought clarity on key dimensions and asked for indicators of these to be devised. However, there remains a lack of conceptual clarity surrounding the concept of sexual wellbeing, which may create variation in what is being assessed and to what we are referring. This paper proposes one way in which to achieve conceptual clarity might be through the utilisation of a Capability Approach, thereby posing a new set of normative questions about what sexual wellbeing is. The central argument in this paper is for researchers, theorists and practitioners to focus more fully on a person’s freedom to achieve sexual wellbeing within a particular social and cultural context. We suggest the kinds of data that might need to be captured to operationalise and measure such an understanding. By offering new critical insights, we hope to drive forward empirical and methodological development in the evaluation of sexual wellbeing.

Keywords:

• Sexual wellbeing
• capability approach
• justice
• measurement

Introduction

The normative argument for a right to ‘physical, emotional, mental and social well-being in relation to sexuality’ (WHO (World Health Organization) 2006), or for ‘sexual satisfaction and for choice in matters of reproduction’ (Nussbaum 2000) has seen claims for sexuality to be considered an essential element of one’s overall wellbeing or for human flourishing. General comment No. 22 (2016), on the right to sexual and reproductive health (article 12 of the International Covenant on Economic, Social and Cultural Rights), asserts freedoms and entitlements in relation to sexual health (and reproductive health) and is related to Nussbaum’s articulation of a capability approach (Nussbaum 1997; CESCR 2016).

The World Health Organization’s definition of sexual health is both holistic and affirmative, entering wellbeing territory rather than solely residing in disease prevention (WHO (World Health Organization) 2006). Recently, the World Association for Sexual Health (WAS) declared sexual pleasure to be a human right (World Association for Sexual Health 2021), which builds upon sustained recognition of pleasure as a key aspect of sexuality (Ford et al. 2019). Such directions of travel are important as they influence shifts in research away from sexual health being the province of STIs, HIV and unintended pregnancy towards a more holistic sense of sexual wellbeing. There is a growing interest in measuring sexual wellbeing, including recommendations from a WHO/UNFPA working group in 2007 to ‘explore the various dimensions of ‘sexual well-being’ in order to draw up an appropriate set of indicators’ [World Health Organization (WHO) 2010, 4]. But amidst a burgeoning research base on sexual wellbeing, it is timely to pause to enquire: what exactly is sexual wellbeing?

A recent review of how sexual wellbeing has been defined and measured found few published articles offering a working definition of the concept (Lorimer et al. 2019). As we shall expand upon below, most measurement has narrowly focused on individual-cognitive aspects of sexual wellbeing, with very little attention paid to more distal influences and why these are important to consider. An individual’s freedom to achieve sexual wellbeing may be profoundly shaped in different gendered cultures or social class contexts, yet the dominant approach to assessing sexual wellbeing is by measuring individuals’ sexual function and satisfaction. Now that there is a sizeable evidence-base for such cognitive and affective attributes of the concept of sexual wellbeing, we argue that it is time to develop a more holistic understanding and multidimensional measure of people’s sexual wellbeing.

Many in the field of sexual wellbeing research would likely agree that a multidimensional assessment is required, but we part ways with perhaps the majority of their views both at the ontological and theoretical levels. The central argument in this paper concerns the need for a multidimensional approach to conceptualise and measure sexual wellbeing, that accounts for an individual’s freedom to achieve sexual wellbeing within their socio-cultural context. To achieve this, we engage in foundational theoretical exploration by interrogating the complexity of the concept of sexual wellbeing. Next, we reflect on the evidence-base to date on sexual wellbeing, and touch upon the neighbouring field of wellbeing measurement to illustrate the ways in which multiple dimensions are necessary for wellbeing, or for a good life. We then set-out our case for the relevance of the capability approach to the measurement of sexual wellbeing, and how it can enable us to pose a new set of questions that allow us to define and measure sexual wellbeing.

What is sexual wellbeing?

The concept of sexual wellbeing is implicit within the WHO definition of sexual health, which enters wellbeing territory through a focus on sexual rights, freedom from violence and coercion and calls for non-discrimination (WHO 2006). Calls for conceptual clarity issued by WHO (WHO 2010), arose in part from a desire to disentangle sexual wellbeing from sexual health, with some motivated to better understand where one ends and the other begins (Lorimer et al. 2019; Mitchell et al. 2021). In addition to calls for conceptual clarity (WHO 2010), attention has also been paid to the ways in which aspects of sexual health (e.g. reproductive choice) relate to social wellbeing, which somewhat muddies the waters (Stephenson et al. 2017). In 2017, the WHO Working Group for Operationalising Sexual Health identified eight intervention areas, placing physical, emotional, mental, and social wellbeing in relation to sexuality at the centre of its framework for sexual health (Stephenson et al. 2017). For this group, sexual health cannot be separated from the concept of wellbeing. Thus, the separation of sexual health and sexual wellbeing remains an ongoing project, and it may be that the two simply cannot be treated as separate concepts if we consider, for example, the impact of lack of abortion care on one’s quality of life. However, recently Mitchell et al. (2021, e610) proposed a seven-domain model of sexual wellbeing (sexual safety and security, sexual respect, sexual self-esteem, resilience in relation to past sexual experiences, forgiveness of past sexual events, self-determination in one’s sex life, and comfort with one’s sexuality), which attempts conceptual clarity from not only sexual health but also from sexual justice and sexual pleasure. In their model, for example, they link the domain of sexual respect to wellbeing through the ways in which sexual respect can mitigate experiences of violence (Mitchell et al. 2021). Thus, attempts to seek clarity are ongoing, although there is still a focus on a particular state of health and not freedom to achieve.

Focusing on sexual wellbeing is important, as there is an emerging evidence base that validates the assessment of sexual wellbeing as being important to one’s overall wellbeing (Hooghe 2012; Rosen and Bachmann 2008; Stephenson and Meston 2015). The relevance of a person’s positive sense of their sexual life and their overall feeling of wellbeing was demonstrated almost three decades ago (Laumann 1994). A useful summary of this evidence by Rosen and Bachmann (2008) conveys the emerging consistency of evidence for a positive view of one’s sexual life impacting positively on one’s overall quality of life. Hooghe (2012) evaluated sexual wellbeing alongside a broader wellbeing evaluation in the ‘Social Cohesion Indicators in the Flemish Region’ survey, and on the basis of their findings argued ‘if one wants to arrive at a full understanding of what well-being actually means for people, the sexual element cannot be overlooked’ (Hooghe 2012, 272). Any individual, organisation or government seeking to expand wellbeing cannot, therefore, neglect the sexual aspect of one’s life; this is not a frivolous consideration. Others have defined sexual pleasure as an integral aspect of sexual wellbeing and linked this to a broader concept of sexual justice (Fava and Fortenberry 2021; Ford et al. 2019). There has also been a shift away from an almost exclusive use of a biomedical lens of disease prevention, to embrace a wider notion of quality of life. Those who seek to attend to issues of equality and justice within the fields of sexual and reproductive health can find purchase in such a holistic conceptualisation. As we noted, terms such as ‘emotional’, ‘mental’ and ‘social’ appear alongside ‘physical’ in the WHO working group’s framework for sexual health, which underscores the importance placed on one’s wider sense of self. Such a framework acknowledges the potential impact of social and structural factors on people and interventions (Stephenson et al. 2017).

Whilst some have sought to disentangle sexual health from sexual wellbeing, many more have pursued the measurement of sexual wellbeing. Despite this, a recent rapid review of how sexual wellbeing has been defined and measured found very few included studies offered a definition of sexual wellbeing (Lorimer et al. 2019). The ten studies in which a definition was offered are detailed in Table 1, and show a focus on a person’s reflection on their sexual self, with one noting that sexual wellbeing is broader than sexual function or sexual satisfaction (Contreras, Lillo, and Vera-Villarroel 2016). Whilst they may appear to capture some elements of social determinants of health, a critique we offer in this paper is that simply attending to what people have and do offers a partial picture; an evaluative space is enlarged by also enquiring as to a person’s capability to achieve. Going beyond definitions, the Lorimer et al. (2019) review also found few studies (n = 10) which explored broader socio-cultural factors impacting on sexual wellbeing, such as gender inequality (Lorimer et al. 2019); this contrasts with the WHO working group framework for sexual health, which places a climate of social-structural factors around the achievement of physical, emotional, mental, and social wellbeing in relation to sexuality (Stephenson et al. 2017). A study of sexual wellness in mid-later life drew attention to cultural influences on sexual wellness, and positioned sexual wellness in relation to quality of life (Syme et al. 2019). Since the WHO/United Nations Population Fund (UNFPA) met to discuss indicators for sexual health, there has been little evidence of sexual wellbeing being measured holistically, despite their call for ‘more research … to explore the various dimensions of ‘sexual well-being’’ (WHO 2010, p. 4) and a call for a new measurement approach (Rosen and Bachmann 2008). However, as we shall elaborate in the next section, simply acknowledging wider socio-structural influences is not the same as capturing them in an evaluative environment. ‘How satisfied are you with your sexual life?’ does not attend to any social determinants of health.

Table 1. Some definitions of sexual wellbeing.

Authors, year of publication	Definition offered by authors
Contreras, Lillo, and Vera-Villarroel (2016)	The term subjective well-being provides a wider and more global assessment of the sexual experience, seeing beyond sexual function and differing from the concept of sexual satisfaction (339)
Crump and Byers (2017)	We conceptualised sexual wellbeing broadly to include behavioural (genital and non-genital sexual frequency, duration of sexual encounters), motivational (sexual desire), and cognitive-affective (sexual satisfaction, anxiety, esteem, negative automatic thoughts) responses. (164)
Foster and Byers (2013)	Sexual well-being refers to an individual’s subjective appraisals of their sexuality, the presence of pleasurable and satisfying experiences, and the absence of sexual problems (149)
Foster and Byers (2016)	We conceptualised sexual well-being as including sexual behavior (sexual frequency), sexual concerns (problem with sexual functioning), and sexual cognitive-affective responses (sexual anxiety, sexual self-schema, sexual esteem, sexual satisfaction) (403)
Frost, McClelland and Dettmann (2017)	We adopt a broad notion of sexual wellbeing in this paper that is inclusive of satisfaction dimensions as well as subjective evaluations of orgasm, and importantly considers the relational contexts in which sexuality occurs (2353)
Kaestle and Evans (2017)	we quantitatively investigate multiple factors that may shape young college women’s sexual well-being, including recent sexual activity, sexual attitudes, sexual agency, and sexual desire (32)
Zimmer-Gembeck and French (2016)	sexual wellbeing was defined as protective sexual behaviours, as well as cognitions and emotions that are associated with sexual behaviour (580)
Muise, Preyde, Maitland and Milhausen (2010)	In the current study, subjective sexual well-being was defined as the cognitive and affective evaluation of oneself as a sexual being (917)
Pearlman-Avnion, Cohen and Eldan (2017)	The term ‘sexual well-being’ refers to an individual’s subjective assessment of a wide range of physical, cognitive, emotional and social aspects of relations with oneself and with others. Sexual well-being includes sexual gratification, sexual knowledge, thoughts, feelings, personal experiences and approach to sexuality (280)
Stephenson and Meston (2015)	We use the term sexual well-being in the present study as an umbrella term encompassing two types of subjective evaluations of one’s sex life: sexual satisfaction and sexual distress (26)

There is value in assessing sexual wellbeing in terms of cognitive and affective evaluations of life. For example, such approaches have illuminated the impact of certain health conditions, such as cancer and the effects of treatment, on sexual problems (Bae and Park 2016; Kedde et al. 2013). However, if individual-level changes in health and wellbeing are sought, then efforts are required at the peer- and community-levels, such as have been used to tackle sexual assault (Casey and Lindhorst 2009) or HIV prevention (Herbst and Task Force on Community Preventive Services 2007). There are contexts in which gender norms undermine the health and wellbeing of young people (Bedree et al. 2020), and gender-transformative interventions have been developed (Levy et al. 2020). As such, one’s freedom to achieve sexual wellbeing may be profoundly shaped in different culture or social class contexts. Here we note Alexandrova’s concept of contextualism to draw attention to the possibility of sexual wellbeing being ‘dependent on the context in which [it] is assessed’ (Alexandrova 2017, 23). Conceptualisations of wellbeing often account for subjective physical and mental activities, experiences, and social conditions (Tengland 2016). Indeed, the concept of a ‘wellbeing economy’ has seen this holistic approach taken further to focus on the welfare of a country (Coscieme et al. 2019). In short, wellbeing is about more than health, and it has not been unusual for measures to go beyond health as an outcome, including the social as an important aspect of wellbeing (Mitchell et al. 2017). As such, there is considerable overlap in thinking between the sexual health/wellbeing field and the wider wellbeing research landscape. Our call for a measure of sexual wellbeing to embrace multidimensionality and complexity is, when placed within the broader wellbeing landscape, not unusual. Normative questions and theories on ‘what is a good life’ and ‘what is a good society’ – indeed, ‘what is sexual wellbeing?’ – are important if they are accompanied by a focus on the social conditions which enable an individual to flourish.

An advantage to embracing a more holistic approach to assessing sexual wellbeing is that structural constraints are not treated as psychological conditions. Many living in objective disadvantage may adapt to such circumstances and report being satisfied with life; this is a problem of ‘adaptive preferences’ (Clark 2012; Nussbaum 2000). So, a happiness approach, or one focusing on satisfaction, gives rise to an ‘ontological worry’ about ‘whether this can be captured by mental states only’ (Robeyns 2017, 129). Atkinson (2021), for example, has drawn attention to a remarkable stability in absolute levels of UK population-level subjective wellbeing since 2011, by referring to Office for National Statistics (ONS) data (Atkinson 2021). However, as she also notes, there are data to suggest this is not quite the picture of wellbeing in the UK and argues ‘how we assess subjective wellbeing is toxic, [in] that there seems to be a serious risk that the measurements fail to detect with sufficient sensitivity or speed the very thing they aim to describe’ (Atkinson 2021, 2). We share this concern in relation to sexual wellbeing measurement, as dominant satisfaction-based accounts may lead to policy that is less sensitive to injustices. We suggest a new set of normative questions is required to explore what sexual wellbeing is, which could lead to a new paradigm for how we measure sexual wellbeing in ways that are cognisant of the influence of power, politics, and patriarchy on sexual and reproductive health and rights. Thus far, our critique of how sexual wellbeing has been conceptualised and measured has centred on the narrowness of each. If we are to expand our conceptualisation and our evaluative space, it would help if we had a framework to do so. It is to this that we now turn, to illustrate the utility of the Capability Approach to this field.

The capability approach

The Capability Approach, as articulated by Amartya Sen and Martha Nussbaum, originated from a desire to address the question of how we should assess a person’s wellbeing. Sen’s definition of the approach was ‘an intellectual discipline that gives a central role to the evaluation of a person’s achievements and freedoms in terms of his or her actual ability to do the different things a person has reason to value doing or being’ (Sen 2009a, 16). The framework has a simplicity but also a breadth to it, such that it can be taken up across various disciplines and applied to various policy areas. Alkire notes the approach can be used for evaluation, seeking to understand which capabilities expand and by how much, or have a focus on prospective policy to understand how capabilities expand (Alkire 2008). Regardless, a core contribution of this approach is its emphasis on the multidimensionality of wellbeing. Within this expanded space, the focus is not on how much resource is available to individuals, but how they can take such resources (if at all!) and put them to use. Both Sen and Nussbaum have critiqued utility as a measure of wellbeing (Sen 1980; Nussbaum 2011). Resources are the means to wellbeing achievement rather than the ends, and wellbeing is evaluated in terms of people’s real freedoms and opportunities (Sen 1985). Such an expanded evaluative space is attractive for a holistic understanding of sexual wellbeing, about which we will say more in the next section.

Sen’s approach considers freedom in ‘positive’ terms: what a person is able to do and be; however, Sen did not discount a ‘negative’ view that could capture what prevents someone from doing something (Sen 1988). Alexander (2008) noted Sen’s use of positive freedom is more than an individual having a choice, but ‘also when other agents, family, community and the state play a crucial role in creating an environment for individual freedom’ (Alexander 2008, 151). Here, we see the approach is not simply about what resources are used but what is going on in a context to enable a resource to be used. Acknowledging contexts should sensitise any use of the capability approach to human diversity and the heterogeneity of freedom and choice. The framework is about what individuals are able to achieve (‘capabilities’), given a combination of personal abilities and the political, social and economic environment (Nussbaum 2011). Here, Nussbaum states it clearly:

‘We might add that … a person with mobility problems, or a missing limb, will require a much larger subvention in order to be mobile than will a person with no such deficiency. If we look further into social context, still more variety appears. Children from minority groups need more money spent on them: we can see this by looking at what they are able to do and to be. All this is one more reason why the Aristotelian wishes to make the central question not, ‘How much do they have?’, but rather, ‘What are they able to do and to be?’ (Nussbaum 1990, 211).

The concept of conversion factors acknowledges that people have different needs to be able to convert resources into capabilities and was developed as a key aspect of Sen’s capability approach. Three conversion factors are commonly discussed: personal, social and environmental (Hvinden and Halvorsen 2018; Robeyns 2017). Personal factors are internal to the individual, social factors are those stemming from society, such as gender norms, and environmental factors stem from the built environment (Robeyns 2017). Attending to conversion factors ‘sensitises us to the empirical variability of constraining and enabling conditions’ (Hvinden and Halvorsen 2018, 6). In a stylised visualisation, Robeyns (2017, 83) illustrates the processes at work in a full capability conceptualisation, with conversion factors occurring between resources and one’s freedom to achieve. The potential functionings a person can choose from is their capability set, but conversion factors influence the size of that capability set. So, as well as shaping the questions we ask, a capability lens influences the data we seek in order to answer such questions.

Flourishing has been conceptualised in positive psychology as referring to high amounts of wellbeing, or high amounts of achieving something (Hone et al. 2014). However, the capability approach allows for an individual to forgo their wellbeing, per se, if it is in pursuit of something they value, such as engaging in public protest despite potential risks to bodily health and freedom. Such a point should alert us to the need to go beyond measuring what people do and have (‘are you satisfied?’, ‘what is your level of function?’), to consider how individuals might be enacting agency goals in relation to their sexual wellbeing when forgoing something for a wider set of values. The need to mentally heal after sexual violence may result in abstaining from sexual relationships and sexual behaviours, yet result in an individual having an expanded capability set (all the functionings a person can choose from). Agency, like wellbeing in the capability approach, has two dimensions: achievements and freedom (Crocker and Robeyns 2009). So, if we fail to attend to agency freedom we risk treating people as ‘living as well-fed, well-clothed, and well-entertained vassals’ (Dreze and Sen 2002, 228). The problem of sexual consent, coercion and gendered expectations influencing these should alert us to the possibility of agency within the power of deciding and not solely in the doing (Lorimer, Knight, and Shoveller 2022). Yet, sexual wellbeing measurement focuses on what people do and have (are you satisfied?), with no cognisance of agency freedom.

Relevance of the capability approach to sexual wellbeing

We have noted three ways in which the Capability Approach holds relevance for any conceptualisation or evaluation of sexual wellbeing. Firstly, the focus on people’s freedoms to achieve expands our evaluative space. Secondly, conversion factors focus attention towards the different needs people will have to be able to convert a resource to a capability. We gave an example of the third – forgoing something to boost another aspect of one’s wellbeing, so here we elaborate on the first two. Starting with wellbeing being both about one’s achievement but also one’s freedom to achieve, a recent review of conceptualisation and measurement of sexual wellbeing found a dominant focus on sexual functioning and/or satisfaction (Lorimer et al. 2019). Why should we go beyond these to take heed of the focus of the capability framework? Studies have revealed the wider social-structural contexts in which such individual-level factors manifest. For example, there can often be lasting trauma from sexual violence that impacts sexual wellbeing, such as negatively affecting relationship quality (Parish et al. 2007) and sexual difficulties (Lacelle et al. 2012; Luo, Parish, and Laumann 2008). Female genital mutilation/cutting (FGM/C) impacts negatively on sexual satisfaction (Berg and Denison 2012), with female empowerment strategies having the potential to reduce the prevalence of FGM/C (Salam et al. 2016). Gilmore and Khosla (2020) remind us of the influence of power, politics and patriarchy on sexual and reproductive health and rights (Gilmore and Khosla 2020). Material circumstances can also affect self-reflection of one’s sexuality (Bay-Cheng 2017). More recently, the COVID-19 pandemic has shown an impact on people’s sexual relationships and behaviours (Li et al. 2020; Jacob et al. 2020). Many working in the sexual health and wellbeing field may find little to disagree with here. So, perhaps the question is not why conceptualise sexual wellbeing holistically and create your evaluative space accordingly, but how does a capability lens enable the evaluation of wellbeing in such a broad manner?

Over the past decade, capability-based measures have gained considerable support in public health and medicine (Brazier et al. 2019). This may, in part, have been driven by the growing complexity of health interventions and policies, which are often cross-sectoral and require going beyond standard health outcomes. Rich theories of health capability and capability measures have been developed by health researchers and provide a more detailed account (Ruger 2009; Venkatapuram 2013; Greco, Skordis-Worrall, and Mills 2018). The ICECAP-A, ICECAP-O and ICECAP-SCM for example focus on the wellbeing of adults, older people and those at the end of life, respectively.¹ The capability approach was operationalised as an outcome measure for the evaluation of complex public health interventions (OCAP-18) (Lorgelly et al. 2015). The Women’s Capabilities Index sought to assess the quality of life of women of child-bearing age in Malawi and Uganda (Greco, Skordis-Worrall, and Mills 2018). A review of empirical applications of the capability approach within health research, found a ‘lack of reliance on health status as the sole measure of capability’ (Mitchell et al. 2017, 354). The ICECAP-A, for example, identified five attributes of capability wellbeing, including stability, attachment, achievement, autonomy and enjoyment (Al-Janabi, Flynn, and Coast 2012). In treating health as an influence over broader attributes of wellbeing, such capability-based research has been able to capture the multidimensionality of wellbeing.

A second way in which the capability approach holds relevance for conceptualising or evaluating of sexual wellbeing, is through the core idea of people having different abilities to convert resources into functionings (Robeyns 2017). Consider for example a bag in which we have all our potential functionings; such a bag is our capability set. Two women in abusive relationships may have different capability sets, or a different amount of potential functionings they can select from their bag if, for example, one lives in an area where public services are available to support her, financially, legally and emotionally to leave the abusive relationship whereas the other does not. Although both appear to be in a similar situation, they in fact have different sets of potential functionings and one has a much larger bag. The structural elements of gender, race and class inequalities will influence an individuals’ set of conversion factors, such that any account of how able a person is to achieve sexual wellbeing will require attention to these broader constraints, or enablers. Some have cautioned against an over-focus on constraints, to also seek enablers or facilitators to wellbeing (Hvinden and Halvorsen 2018). If we speak to people in a more holistic way about their sexual wellbeing, we should enquire about not just their personal characteristics, but also their social arrangements and note their environmental structures (all treated as conversion factors) that are hindering or enabling them. An example of a holistic sexual health project, in which people were asked about the everyday texture of their lives is the DeMaSH (Deprivation, Masculinities and Sexual Health) study (Lorimer et al. 2018). That which reproduces a hierarchy can be so mundane to be obscured as experienced or as part of a struggle (Bottero 2004), so it is important to consider how to capture such information. Perhaps a useful route into such an expanded terrain is via emotions, as how we feel has social significance in terms of agency freedom. Fear of violence can lead to taking refuge in a narrow form of femininity (Lorimer et al. 2018).

The Capability Approach centres the idea of a flourishing life, particularly Nussbaum’s articulation with its roots in Aristotle’s ideas of what was required for a human to lead a flourishing life (Nussbaum 2011). Central to Sen’s capability approach is public debate and dialogue, as it is through this that social justice can be fostered (Sen 2009b). The next section outlines our idea for how to turn from these ideas towards something that can actually be measured or explored empirically.

Time to measure sexual wellbeing multidimensionally?

We now turn from theory to methodological concerns. Setting out to measure sexual wellbeing from a capability perspective requires the translation of philosophical and abstract concepts into empirical variables. However, given the small number of studies on sexual wellbeing that give an explicit definition of the concept (Lorimer et al. 2019), our measurement starting point is ontological uncertainty: what is sexual wellbeing? As such, we would propose returning to first principles to theoretically interrogate the complex concept of sexual wellbeing. However, when we look to the capability measurement field, we can see that existing capability lists have been derived in a variety of ways, including practical reasoning and participatory approaches. Perhaps the most well-known version of a list derived from practical reasoning is Nussbaum’s ten central capabilities (Nussbaum 2000). However, participatory approaches are more democratic ways to engage in a process of deriving a list and ‘give legitimacy to the outcome that simply copying Nussbaum’s list will lack’ (Robeyns 2003, 69). There is no single recipe, and operationalisation often depends on the context and the type of available data (Comim 2008; Robeyns 2005). We have set out the gaps in knowledge in relation to understanding sexual wellbeing holistically, and here we also draw attention to some key missing voices including young LGBTQ people as noted in the review of sexual wellbeing conceptualisation and measurement (Lorimer et al. 2019). As such, we would recommend a participatory process to explore the concept of sexual wellbeing with a diverse group of people. This is an approach that has been used by some in the field of health research, such as to develop the ICE-CAP suite of measures (Al-Janabi, Flynn, and Coast 2012; Grewal et al. 2006; Coast et al. 2021). Engaging with people in this way is in keeping with Sen’s view of ensuring capabilities are rooted in the local context and the experiences of those whom the list concerns. How public debate offer possibilities to transform inequalities is a point taken up by others, such as in relation to gender inequalities and education (DeJaeghere 2012). Unterhalter (2007), writing about gender inequality and education, argues for public debate as a way to foster social change by being able to account for multiple sites of injustice and the various forms it takes (Unterhalter 2007). A top-down discussion of rights would obscure the lived reality for people in relation to their ability to achieve sexual wellbeing and, as such it could be an approach that obscures injustice.

So, a first step in creating a capability-based measure of sexual wellbeing would be to engage with people to explore their experiences of sexual wellbeing. Existing qualitative studies on sexual wellbeing offer some useful data to begin to unpack the ontological uncertainty and could direct the focus of further qualitative work. For example, studies have explored norms related to femininities and masculinities (Menger et al. 2015; Phong 2008) and the social construction of marriage and divorce for how this affects sexual wellbeing (Zarei et al. 2013; Domic and Philaretou 2007). Findings such as these can alert us to the importance of teasing out conversion factors. We could also map existing evidence and people’s views to existing capability lists, for example the Women’s Capabilities Index derived the list of capabilities from a series of participatory exercises with women (Greco et al. 2015). The suite of ICECAP measures also embraced a qualitative approach to develop conceptual attributes (Sutton and Coast 2014; Al-Janabi, Flynn, and Coast 2012). Table 2 shows some examples of existing capability lists, and we note the commonality of relational items (affiliation, attachment, social relations) (Nussbaum 2000; Robeyns 2003; Al-Janabi, Flynn, and Coast 2012; Greco et al. 2015).

Table 2. Four example lists of capabilities.

Martha Nussbaum (used for the OCAP-18)	ICECAP-A	Ingrid Robeyns’ (gender equality)	Women’s Capabilities Index
Derived from reasoning	Derived empirically	Derived from brainstorming and participatory process with experts	Derived from bottom-up, participatory process
Life	Stability	Life and physical health	Physical strength
Bodily health	Attachment	Mental well-being	Inner wellbeing
Bodily integrity	Achievement	Bodily integrity and safety	Family wellbeing
Senses, imagination & thought	Autonomy	Social relations	Community relations
Emotions	Enjoyment	Political empowerment	Economic security
Practical reason		Education and knowledge
Affiliation		Domestic work and nonmarket care
Other species		Paid work and other projects
Play		Shelter and environment
Control over one’s environment		Mobility
		Leisure activities
		Time-autonomy
		Respect
		Religion

We would also argue that there are decades of social theory and epistemological insights that have not yet been capitalised upon in order to bring greater integration between social theory and qualitative approaches to operationalising the capability approach (Zimmerman 2006; Gangas 2016; Joas 1996). Here we agree with Atkinson (2021), who calls for ‘the social as central’ in our accounts of wellbeing, as social conditions hinder or enable a person to flourish (Veenhoven 2008). By drawing on social theory and integrating this with qualitative approaches we could open a new path for handling structure and agency – placing people in contexts – and interrogate the concept of agency freedom for new epistemological insights (Crocker and Robeyns 2009). Sen’s own conceptualisation of agency has evolved over time, as was described by Crocker and Robeyns (2009), and the wider capability field has engaged with the concept of agency in various ways. Indeed, the concept of agency is one that is understood and applied in various ways, depending on discipline and topic, often relating to a power to but others have suggested non-performative and reflexive conceptualisations are important in relation to young people (Lorimer, Knight, and Shoveller 2022).

Should any of the above be carried out, various stakeholders should also be involved as they may be a vital voice in establishing acceptability of a capability-based measure of sexual wellbeing. Engaging them would allow for exploration of the acceptability of the new ‘grammar’ of human flourishing and justice (with a focus on what people are able to do and be, not simply what one has, and shifts the language towards structural influences). Sen’s view of reasoned debate encourages different voices so as to allow the inclusion of different values (Sen 2009b). Promotion of more inclusive societies is, for example, a key part of Scotland’s public health framework, and inclusivity and reducing inequalities is rooted in the sexual health and blood borne virus framework (The Scottish Government 2015); but would policymakers embrace a new tool for capturing how well we are doing as a society in relation to people’s sexual wellbeing? Is there interest in capturing how well a policy is working to advance an individual’s freedom to function? We would also encourage engagement with the concept of epistemic justice – who can speak, who is heard, and how they are heard - not just ideas of freedoms to flourish and achieve sexual wellbeing (Fricker 2007). As the rapid review by Lorimer et al. (2019) noted, certain voices remain conspicuously absent from the evidence base on sexual wellbeing, which is a route to injustice. Further work would then be required to ensure such a capability list was made practical for use across various contexts, such as being added to existing large-scale population surveys. Lorgelly et al. (2015) provide an example of the use of mixed methods to reduce and refine a capability-based list (Lorgelly et al. 2015) and guidelines were recently published on the reporting of qualitative research in relation to quantitative health preference studies (Hollin et al. 2020).

Conclusions

Sexual wellbeing is important in its own right, and for its relationship to one’s overall wellbeing (Hooghe 2012; Rosen and Bachmann 2008; Stephenson and Meston 2015). How sexual wellbeing is measured influences how it is understood, how it is analysed and how policies are designed to influence it. The dominance of narrow assessments is of limited use to policymakers who cannot meet the challenge of designing policies to alleviate poor sexual wellbeing without a prior conceptual discussion of what sexual wellbeing is. If you do not fully know what something is, how can you change it? Our ideas are timely in asking how we ensure sexual wellbeing is an integral consideration of wellbeing and a flourishing human life. We have argued for an expanded evaluative space that accounts for one’s freedom to flourish. Our emphasis is on not treating people as a set of conditions or as free-floating vessels with affective states, but as whole humans who exist in relation to context and social structure.

Acknowledgements

We acknowledge, and thank, the anonymous reviewers of this paper, who helped us to refine our ideas for this community of researchers and practitioners.

Disclosure statement

The authors do not have any conflicts of interest to declare.

Additional information

Funding

The rapid review referred to was funded by a grant from Chief Scientist Office, Scottish Government (CGA/17/33).

Notes

1 See https://www.bristol.ac.uk/population-health-sciences/centres/healthecon/research-programmes/economics-of-health-and-care-across-the-life-course/capability-across-the-life-course/ for more information.