Ezio Di Nucci
Public sexual health: replying to Firth and Neiders on sex doula programs
Public sexual health: replying to Firth and Neiders on sex doula programs

Is there such a thing as sex rights? And if so, are sex rights positive rights, like healthcare rights? Over the last couple of decades, I have discussed these questions at the intersection of philosophy, bioethics, public health, and sexology. Most recently, I have been discussing these questions by proposing the concept of ‘public sexual health’ [1–4]. I am grateful for Firth and Neiders’ continued engagement with my work, despite their critique being often misplaced and sometimes poorly worded (e.g., ‘facile,’ ‘mistake’ [5]). I continue to believe that we are in basic agreement on the big question. That is — whether or not forms of sexual therapies that include sexual services should be included in the basket of welfare provision, especially for disadvantaged groups such as PLWD (people living with disabilities); public sexual health, indeed. Nevertheless, Firth and Neiders’ mistake is the same one from a few years back [6] (that discussion continued on the blog of the Journal of Medical Ethics).1 The problem is insisting that, if sexual rights are like healthcare rights, then my sexual rights puzzle disappears [4]. Because, according to Firth and Neiders, healthcare professionals’ duty to patients is not an individual positive duty but a general positive duty of care by the state, which healthcare professionals choose to individually fulfill (and, even though surprisingly Firth and Neiders fail to mention this, can also opt out through conscientious objection). There are two problems here. First, one cannot assume that sexual rights are like healthcare rights; that is the whole question. So, deploying that as an assumption is question-begging. The whole debate is about the status of sexual rights for the very reason that our society is still struggling to de-moralize and normalize sexuality (which I am sure my opponents will agree with, but if we agree that this has high priority, then do not assume it, please). The second problem is that, even if the analogy between sexual rights and healthcare rights works (it does not have to be an analogy, by the way, it could be that sexual rights are a sub-group of healthcare rights; that is in fact the more plausible option, given ‘public sexual health’ as an aim), the elephant is still there. Namely, is sexuality not only so normal (like health) but also so important, that in cases of emergency, the state will make people care for others, the way in which it would (and has under the COVID-19 pandemic) force medics’ hands (e.g., vaccine mandates)? The two problems are related, because obviously the rights of PLWDs are crucial, but the overarching theoretical question is the place of sexuality in society; and one cannot try to take shortcuts in order to take care of the sexual rights of PLWDs without a full reckoning with the place of sexuality in the modern world. That full reckoning — I am confident we agree here — is a de-moralization process that is much further behind than we sometimes think, since the sexual revolution still sometimes takes more moralizing undertones, as has been the case with the “metoo” movement (but obviously the patriarchy has been hijacking sex for millennia, so the trade-offs here are not so simple). Emancipation cannot be achieved through moralizing, because emancipation is (and has always been since at least the enlightenment) a de-moralizing project [7]. So, the problem that the sexual rights puzzle points to is big, not small (otherwise I would have called it a ‘paradox’); it is the continuing awkward place that sex has in society, globally. The worry here is two-fold. On the one hand, there is the question of whether the ‘healthcare rights’ solution to the sexual rights puzzle side-steps the necessary full reckoning with the place of sex in the modern world, which is a demoralizing project — and clearly health and healthcare themselves are far from having been demoralized (again, just look at the COVID-19 pandemic). The second worry is related: assume that the healthcare rights solution to the ‘sexual rights puzzle’ works; then one might have a theoretical account for a sex doula program like Firth and Neiders want. But here the problem is not just that their solution, as shown above, does not work philosophically. The bigger problem is that such a solution would have a price that society should not be willing to pay, namely the moralization of sex rights as healthcare rights. Demoralizing sex continues to be one of society’s more urgent emancipatory projects. Therefore, the way forward is normalization in the spirit of a new ‘public sexual health,’ whether or not that requires positive sexual rights. Whether comparisons with — and possible inclusions within — healthcare are the way forward for de-moralizing sex, I am skeptical about. However, this short reply does not offer a full argument, just a direction for future work. Let me conclude by touching upon a related issue that — again surprisingly — does not come up in Firth and Neiders’ discussion, namely the question of sexual consent and PLWDs. As I have argued throughout my work [see for example [3]], sexual services for PLWDs are most needed (and theoretically most interesting) when the disabilities in question include cognitive impairments, serious mental health conditions, and neurodegenerative diseases (relatedly, there are independent arguments in favor of deploying more inclusive conceptions of disability). If a sex doula program is restricted to simple consent cases (physical disabilities, for example), it will not do much good. Yet, a much more inclusive sex doula program (or, with my own terminology, ‘public sexual health’) obviously runs serious risks of abuse for two reasons: i) many of the relevant persons might not qualify as consent giving authorities; and ii) differently from more traditional healthcare settings, guardianship might not be an easy solution either when it comes to sexual services for persons with cognitive impairments, serious mental health conditions, and neurodegenerative diseases. Here, again, there is the challenge of what price one is willing to pay in order to de-moralize sexuality. Are we willing, for the sake of emancipation, to push consent boundaries?