The World Health Organisation (WHO) frames sexual health as “a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” [
1]. The principles of this broadly accepted definition are reflected in the Department of Health’s Framework for Sexual Health Promotion in England and the Scottish Government’s Sexual Health and Blood Borne Virus Framework (2015–2020), which both aim to deliver on positive sexual health at the individual and societal level [
2,
3]. For example, the outcome-based Scottish Government’s Sexual Health and Blood Borne Virus Framework contains an outcome that ‘sexual relationships are free from coercion and harm’, as well as one that sets out to achieve ‘fewer newly acquired blood borne virus and sexually transmitted infections’.
There is growing evidence of the need for a ‘holistic’ approach to sexual health, but less evidence of how to deliver this [
4]. Sexual violence is associated with HIV, sexually transmitted infections (STIs) and unplanned pregnancy and non-volitional sex and sexual dysfunction are known to have negative effects on mental health [
4]. This highlights the importance of extending our understanding of sexual health beyond the traditional biomedical outcomes of STIs and unplanned pregnancy and the individual risk behaviours, such as the non-use of condoms. Yet, very few studies have explored how health improvement efforts can capitalise on or seek to improve positive sexual health [
5]. In turn, there are multiple risk factors for sexual violence, many of which derive from the community and societal levels, and there is evidence that peer norms can support such violence [
6]. Again, there is limited evidence of effective strategies for the prevention of sexual violence, and despite recognition of the need to intervene at the community and societal level, very few studies have addressed risk factors beyond the individual level [
7]. Furthermore, the challenges of enacting a ‘holistic’ approach to sexual health in the ‘real world’ may be much harder in some communities than others.
As noted above peer norms can negatively influence attitudes and behaviour [
6]. The social construction of masculinity in our society – the attitudes, behaviours and characteristics that are associated with being male – impact on men’s (and women’s) relationships and health [
8‐
13]. Dominant forms of masculinity are associated with toughness, aggression and excessive risk-taking, plentiful sexual encounters, and sexual risk-taking behaviour (for example, the non-use of condoms) [
9‐
14]. Evidence focussed on men from areas of high deprivation is limited, but relationships between ‘masculinity’ and ‘health’ are mediated through other aspects of identity and status, such as social class and ethnicity [
15,
16]. Previous research has demonstrated conventional beliefs about masculinity among older adolescent and young adult males are associated with poor sexual health [
17,
18]. However, the relationship between masculinities and deprivation is complicated [
8,
11,
18,
19]. For example, in inner-city areas of deprivation in the North of England, some young men did engage in narratives of respecting their female sexual partners, [
20] and protective contraceptive practices were evident among incarcerated men (aged 16–20) interviewed within Scottish prisons, despite many displaying dominant masculine attitudes [
21]. Clear trends exist in relation to associations between low socio-economic status (SES) and poor sexual health, [
22,
23] but further work is required to explore how masculinity is associated with these in adulthood. Locally, two Scottish Government-commissioned research projects noted associations between socio-economic deprivation and high risk sexual behaviours, despite no knowledge gaps in sexual health, [
24] as well as negative attitudes towards women (such as their views about women who carried or used condoms) among men from lower socio-economic groups [
25]. While policy efforts seek to impact on such inequalities, [
2,
3] our review of literature on masculinities, sexual health, gender and risk taking found only one study focused on the sexual health of adult heterosexual men [
26]. Its focus on HIV prevention in African American men limited its generalisability or transferability to the UK context [
26]. This, combined with the limited evidence on interventions to improve positive sexual health and sexual violence more broadly discussed above suggests a significant knowledge gap [
6,
7].
The Deprivation, Masculinities and Sexual Health (DeMaSH) study aimed to address this knowledge gap and explore sexual health understandings using a masculinities framework to inform intervention development [
27]. We sought to bring together three key areas of research: masculinities, to be cognisant of the social context in which sexual relationships are enacted; deprivation, recognising the existing associations between low socio-economic status and negative sexual health experiences; and social and gender relations, given the interplay between women’s and men’s experiences. The findings presented below demonstrate narrow understandings of sexual health among our participants and highlight the scale of the challenge to improving sexual health in its broadest sense in these communities.