Blurring the Boundaries of Public Health: It’s Time to Make Safer Sex Porn and Erotic Sex Education

Unsafe sex is now the biggest risk factor for the death of young women globally and the second biggest for young men. Alongside this, pornography, which rarely shows safer sex, is one of the key channels for sex education globally. Higher quality research needs to explore the positive and negative impact of porn while the sex education world needs to engage with it to ensure that viewing porn can promote safe sex choices and consent, as well as pleasure. We need unbiased research and innovation into the impact of porn and recognition that can have a positive impact for

1 Foreplay 'Because sex education is rarely sexy and erotica is rarely safe, putting the sexy into safer sex.'The Pleasure Project, 2004.Increasing access to the internet worldwide has ensured that a large amount of sex education or sexual information is received through watching pornography (referred to in this article as 'porn') -material created with the explicit purpose of sexual arousal.In this article, we firstly argue that we need more research to analyse the potential of porn for both positive and negative health impacts, and secondly that porn has the potential to educate about safer sex and can be a source of sex-positive sexuality information.In order to do this we will detail our assessment of research into porn's impact and highlight a small range of alternative ways to deliver sexual health information within this new context; from safer sex porn to sexy sex education.We argue that there needs to be more robust research into the effects of porn as an alternative type of sex education that challenges the harmful norms perpetuated in most porn, while also appealing to audiences that watch porn.This argument and our recommendations for sex education following it are relevant for the public health world now more than ever because, not only do we have the largest population of young people in history, but also the recent Global Burden of Disease Study showed that unsafe sex is now the biggest risk factor for young women's ill health and death, and the second highest for men of the same age (Patton, Murray et al. 2016).
Many argue that porn should be banned or censored; for example, the recent 'ban' in India (Majumder 2015).However, seeking to restrict access to porn when more than 43 per cent of the world population and 37 per cent in low-and middle-income countries currently have access to the internet (World Bank 2016) is, if not impossible, highly challenging and short-sighted.Sex education professionals need to engage and educate to ensure that viewing porn can help promote safe sex choices and consent, as well as pleasure.We believe this can be done to varying degrees by engaging with feminist and alternative porn makers, or making porn that depicts good safe sex.
We argue that there can be an overlap between the pleasure and the public health industries.For example, people who identify themselves as producers of porn can make films with the intention of not only arousing the audience, but also encouraging safe sex behaviours.People who promote safer sex can do so in a way that is erotic.Our central argument is that blurring these boundaries can lead to improved public health and encourage a move within the pleasure industry towards the intentional production of porn that challenges harmful norms such as unsafe sex, women as sexual objects whose pleasure is dependent on men, or violent and non-consensual sex as arousing.We show how a 'harm reduction' approach can be taken to produce sex education that includes discussions of pleasure.Porn is here to stay, and the public health and sexual and reproductive health community needs to wake up to both its existence in hundreds of millions of people's lives, and to its potential as a tool for positively influencing sexual and social wellbeing.

Getting turned on
For the purposes of this article we have defined 'sex education' as information presented with the primary purpose of enhancing understanding of the many elements of sexual health or sexual relationships, while porn is a 'subtype of sexually explicit material' (SEM) produced primarily for generating sexual pleasure or arousal (Watson and Smith 2012).Although commonly understood as explicit material with the intention of increasing sexual pleasure, a quick look through history shows us how wide the definitions of porn actually are: from novels to wall paintings in Pompeii.However, detailing a history of porn is too wide a remit for this article, and indeed today porn comes from a variety of different producers, from that commercially funded by large corporate houses to amateur films and personal home-made mobile phone videos (Forrester 2016).So we recognise the challenges of defining these two forms of communication when many viewers will learn from porn or might get turned on by sex education; it is, however, the primary purpose that is critical in the definition.
Sexual pleasure remains a highly significant, if not primary, motivating factor for sexual behaviour (WAS 2008).It is hard to define, is understood in diverse ways, and arousal often has a culturally distinct basis for each of us; however, it is still often associated with shame, and the pursuit of sexual pleasure is usually positioned as a cause of, or contributor to, disease.Public health and sex education have almost exclusively followed that culture to focus on what not to be or do rather than on what you want to do (Vance 1984;Foucault 1978;Rubin 1984;Knerr and Philpott 2012).It is the authors' position that this has biased the nature of research into sexuality and sexual health, and with this, pre-empted a disease-and risk-focused public health understanding of the role of porn in wellbeing.
However, while negativity about sex is found in many cultures, people all over the world are pursuing sexual pleasure through watching porn (Pornhub 2016).Public health, including sex education initiatives, on the other hand, focuses on delivering safer sex messaging with an aim to reduce 'risk taking', assuming individuals make 'rational' sexual decisions based only on health considerations.However, there are other factors affecting sexual decision-making, including gender, culture, notions of intimacy and/or authenticity, and desire (Knerr and Philpott 2012).For example, rational choices can be those that make individuals have unsafe sex because they believe it increases intimacy or for economic survival.

The staying power of porn
Porn is one of the most explicit ways that most people encounter sex remotely or in the media.Regardless of the judgements passed on this particular form of media, it is undeniable that porn has an effect on sex lives around the world and is a key source of information on sexuality.While most types of porn are exploitative and perpetuate disempowering visions of gender, race and sexuality, we argue that porn also has the potential to be a medium through which we could promote sexual health, question traditional gender roles, and create empowering social scripts.
By the end of 2015, 3.2 billion people were estimated to be internet users, an eightfold increase on the year 2000 when only 400 million had access (World Bank 2016).While this rate is still disproportionally tilted towards developed countries, 37 per cent of households in the developing world have internet access.These statistics only count households with internet access, and we estimate that, once public venues such as internet cafes, schools and libraries as well as smartphone access are added in, large parts of the population in developing countries are probably connected.The World Bank (2016) estimates that over 50 per cent of the world's population has access to a mobile phone and by 2017 the number of mobile phone users is forecast to reach 4.77 billion.
Porn is often maligned for reinforcing negative, limiting and harmful gender norms.For example, studies in the UK have pointed to the negative impact of porn and the 'pornification' of culture (Smith 2010;Perrin et al. 2008), including the rise in access to internet porn as a cause for the huge increase in numbers of women seeking labiaplasty to try and make their vulvas look more like those they see in porn (Jones and Nurka 2015).
However, porn is a huge and expanding global industry with a growing audience.A simple Google search in June 2016 shows that 'porn' returns 1.8 billion search references, while 'sex education' returns only 13.5 million results.Some research suggests that around 25 per cent of all search engine requests are for porn (Watson and Smith 2012).However, we have been unable to find reliable datasets that disaggregate the search terms for types of sex acts.And what is classified as a search for porn might be for sex education and vice versa.One of the most popular adult sites in the world is LiveJasmin.com, a webcam site that, according to Worthofweb (a site that generates internet statistics), gets almost 300 million visitors a month. 1 According to the study by Ogas and Gaddam (2011), this one site alone is used by 2.5 per cent of internet users each month.The production of porn is from a wide range of producers -from being commercially funded, to people sharing their own home-made porn on their phones, to Snapchat.There are multiple stakeholders and producers.Ogas and Gaddam (2011) point out the exponential jump humans have made in the last decade in terms of access to porn on the internet.They suggest that with huge numbers of people globally using their computers routinely for sexual gratification: [i]t's hard to imagine a more revolutionary development in the history of human sexuality.With a visit to an adult video site like PornHub you can see more naked female bodies in a single minute than the most promiscuous Victorian would have seen in an entire lifetime.But there is an even more dramatic change.We don't have to interact with anyone to obtain erotica.

Getting down to it: what does research into porn tell us?
Despite the increasing access to porn globally, robust research of its impact is rare, moral judgements abound, and public health practitioners shy away from research into porn that uses these channels to also educate about sexual health or healthy sexual relationships.We argue in this article that research has to date been largely biased and focuses on the damage porn can cause -how it can create alternate psychological expectations of sex, reinforce negative gender norms that disempower women, and create an environment in which violent or coercive sex is more acceptable.
In an exploratory literature review we sought to identify research studies on the positive role of porn in sex education, health and wellbeing.
This was not a systematic review but sought to describe the breadth of scientifically reliable research and in particular to focus on studies that were not designed from the outset to identify harm.The search was primarily conducted using a Medline search with the terms 'porn' or 'sexually explicit media' and 'public health' or 'wellbeing' and 'education'.There was no date limit, but no suitable studies were identified that had been written before 1988.The reference lists of all key studies were also hand checked for relevant research that we may have missed.This process was repeated with Google Scholar, and because of the paucity of peer-reviewed literature a number of non-peer-reviewed studies have been included in our review, one of which is explained individually as evidence of the existence of subtle and hidden forms of bias.
The impact of sexually explicit media (SEM) and porn use is not a new area for public health research.We know of its potential for causing harm, in particular to psychosocial wellbeing, potential for the objectification of women, and for generating harmful negative stereotypes (see e.g.Perrin et al. 2008;Wright and Tokunaga 2016); we also know that it has been found to increase risky sexual behaviour (Jonas et al. 2014;Eaton et al. 2012).Our review brought up many such studies.Notwithstanding the importance of recognising potential for negative outcomes, we believe that this 'harm impact' approach has dominated literature about porn, to the virtual exclusion of a counter perspective, and with this review attempt to correct this bias.
Although the statistics on porn usage might be hard to specify, a large proportion of literature is focused on demonstrating that watching porn can create a culture of unhealthy expectations of violence, sexism and multiple sex partners, and much of this material comes from questionable sources.An example of this is the Covenant Eyes report, Porn Statistics (2015).At first glance this report appears to be produced by a group concerned with 'Internet Accountability and Filtering' and only further investigation into the groups' origin identifies their mission as one of 'fighting internet temptation'.They also generate an app called 'Overcome Porn: The 40 Day Challenge' with the advertising line that 'porn enslaves, it ruins relationships and keeps you from achieving your dreams' (www.covenanteyes.com).The report itself does not divulge this information, and the company was named as one of the 'Best Christian Places to Work' in 2007.Although there is arguably less obvious bias in peer-reviewed publications and papers such as Perrin et al. (2008), many studies take it as a given that 'there is a general consensus that porn endangers the wellbeing of others ' (op. cit.: 11).weak research on whether porn encourages a norm or environment of unsafe sex, and little research on how we might use the communication channel of porn to encourage safer sex, improve self-esteem, enhance body image, challenge gender norms, or empower the viewer (Knerr and Philpott 2012).
Good quality research with a large sample size is rare, and most studies rely on a self-selected or convenience sample with a cross-sectional study design.Furthermore, the research questions being asked focus overwhelmingly on exploring porn's potential for harm, as opposed to potential benefits.A case in point is a study by Traeen et al., which sought to explore the hypothesis that '[t]here is a direct association between consumption of SEM depicting non-condom use and STI [sexually transmitted infection] related sexual risk behaviour among men' (2014: 4).The study was based on a cross-sectional internet-based survey and confirmed this 'negative impact' hypothesis.
It may also be the case that there is a bias towards reporting negative findings.Braun-Courville and Rojas report on a survey of 'Exposure to Sexually Explicit Web Sites and Adolescent Sexual Attitudes and Behaviours' to confirm their hypothesis, 'Adolescents who frequent these web sites are more likely to engage in high risk sexual behaviours ' (2009: 159).While their conclusions mention that SEM serves an 'educational purpose' and plays an important role in 'sexual socialisation', only data that confirm their hypothesis are presented.
The biased and selective methodology of the studies we found leads to the conclusion that porn is predominantly harmful.We would argue that unbiased and inclusive methodology may lead to a different Source Reproduced with kind permission of The Pleasure Project.
Figure 1 The Pleasure Project outcome and could show that porn has both negative and positive impacts.These positive impacts need to be explored and exploited further to increase public health and reduce harm.
Because of inherent partiality or methodological weaknesses that can lead to bias, the fact that evidence of the harmful effects of porn predominates is not equivalent to a conclusion that porn is per se harmful.By far the majority of studies rely on self-reporting, a self-selected or volunteer sample and a study design with a negative hypothesis.Some studies have, to some extent, overcome this by triangulating data from different sources; for example Jonas et al. (2014), who describe an association between viewing risky practices -in this case 'bareback' 2 porn -and safe sex intentions, conducted two separate studies, one online and the other in a sex club, in order to reach their conclusions.However, a recent study by Wright and Tokunaga (2016), published in the wake of a globally prominent case of campus sexual assault, used a 'volunteer' population of university students and an online survey to assess the relationship between 'men's objectifying media consumption' and 'attitudes supportive of violence against women'.Although the paper does not describe how volunteers were recruited, it does make mention of the possibility of reverse causality (i.e. that the supposed effect might also be the cause) due to the crosssectional nature of their study.Both studies were published in the reputable Archives of Sexual Behavior journal.It should also be noted that over-represented in research are studies with men who have sex with men (MSM) and young people, since from a risk perspective these are populations of greater interest.
Of particular interest to the authors of this article is a recent study by Scrimshaw, Antebi-Gruszka and Downing (2016) based on an online self-reported study of MSM and who view SEM, which provides the paradigmatic conclusion that simply viewing porn is not in itself a risk factor for high-risk practices.While viewing a greater proportion of SEM containing condomless sex was a risk factor for more condomless anal sex encounters, the opposite was also true: viewing a greater proportion of SEM where condoms were used was associated with higher condom use, showing that the causal uni-directional links between porn and risky practices cannot be assumed, and that it is viewing risky sex rather than SEM itself that leads to more risky sexual practices.The implications of these findings are that while viewing 'risky practices' in porn can be a risk factor for riskier sexual behaviour, viewing safer sex -for example, SEM where the actors make condoms part of the show -can also promote safer sex practices and increase condom use.(We acknowledge that it cannot be automatically assumed that this pattern might also be true in heterosexual relationships.) We recognise that it is challenging to infer cross-culturally and across hetero-and homosexual sexualities, and that research agendas and resources have been driven by public health notions of risk and humans as vectors of disease; however, a number of studies do cross these lines to explore the impact of condoms in SEM.A small number of studies that set out to define and explore the benefits of viewing porn back up Schrimshaw et al. 's (2016) Wilkerson et al. (2013), who studied the acceptability of HIV prevention messages in SEM viewed by MSM, found that a majority (83 per cent) of participants endorsed the use of porn as a medium for communicating prevention messages.A further review study concerned with SEM and both heterosexual and MSM that 'does affect users' sexual behaviour and pleasure' (Watson and Smith 2012: 123) covers a range of negative, neutral and positive findings and puts forward the concern that 'the anti-porn narrative may create a hostile climate that undermines the value that SEM may have in certain settings' (ibid.).
6 Time to kiss and make up: can porn be education?
Porn is already a primary source of education on sex and sexuality, particularly among young people, and the average age at which a person (in the USA) first sees porn online is estimated to be 11 years (Vogel 2011).This is combined with school-based sex education that is often limited and inadequate, focusing primarily on the biological aspects of sexuality and avoiding information on how to have sex or the pleasurable aspects of sexuality (Watson and Smith 2012;Vogel 2011;Hare et al. 2015).In the USA, the pedagogy of institutionalised sexuality education reportedly leaves young people feeling that 'to have impure thoughts, even touch their own bodies, is a sin' (Kirkham and Skeggs 1996: 9).Some findings in fact refer to an unmet need for realistic and private sources of sex and sexuality information that de-stigmatise and normalise sex and sexuality (Albury 2014;Hare et al. 2015).
It is no surprise then that increasing proportions of young people cite the internet and sexually explicit websites as their main source of information on sexual practices, and refer to the importance of SEM as a guide for knowing what to do sexually.The UK's National Survey on Sexual Attitudes found that 4.1 per cent of 16-24-year-olds consider porn to be their primary source of information about sex (Tanton et al. 2015), and numerous studies emphasise the significant role of porn as a source of sexual socialisation for young people, particularly regarding sexual confidence (Sun et al. 2016;Kimmel 2008;Albury 2014;Tjaden 1988;Watson and Smith 2012).
Porn is often the 'only source of sex education people get' (McKee 2007: 6).In a Population Council Study of 100,000 young people in Andhra Pradesh, India which asked young people where they learnt about sex, 5 per cent of young men said internet porn (Tripathi and Sekher 2013).In China, Li, King and Winter (2009) found that porn was an important source of information about sex for adolescents in Beijing; it ranked as the fourth most mentioned source for boys and the ninth for girls.In Ethiopia, Tadele (2006) found that porn viewed at public cinemas was usually the only source of information about sex for street boys, while a study of porn in Bangladesh found it to be among the top three sources of information mentioned by women (Faiz Rashid and Akram 2014).
In order to understand the role that porn plays in comprehensive sexuality education, we must differentiate between learning about the biological process of reproduction and risks of STIs, and acquiring non-judgemental social knowledge about sex, sexuality and the body that is needed to make informed decisions regarding relationships and sexual behaviour.Porn is an important opportunity to learn -in private -about sex and sexuality that is not taught in a school-based setting (Litras, Latreille and Temple-Smith 2012;Albury 2014).While the forms of sex displayed in SEM may not be representative of real-life experiences, and are often very limited in their portrayal of any types of sexuality beyond a fantasised routine script of hyper-sexed, largely heterosexual, toned bodies, they often provide the only opportunity for young people to see sex performed by real people.Men/boys in particular can suffer from low self-esteem regarding sex when they are inexperienced due to prevalent gender norms that expect boys and men to be more sexual and sexually experienced, and a lack of knowledge and understanding makes them more vulnerable (Litras et al. 2015).
According to Watson and Smith, porn may allow for the creation of social spaces where, 'isolated, socially or sexually anxious or disenfranchised individuals can communicate, find romantic partners, or practice some sexual behaviour in a safe setting ' (2012: 126).It has also been found to function as a source of sex education for young people that can 'provide information about the human body and sexual practices, thus increasing a sense of sexual competence and liberalisation and decreasing sexual shame' (Sun et al. 2016: 991).As one participant in a UK study of young people's views on sex education remarked, 'In class you only get what happens explained to you, whereas in porn you can see exactly what is going on' (Measor 2004: 156).There are of course numerous caveats to this argument -that the information acquired through porn may be culturally inappropriate or that since the sex is dramatised it may be unrepresentative of real-life experiences -in addition to the concern that young people in particular may learn unhealthy practices.Mainstream porn often negates any variety in sexual practice, according to sexual or gender identity, or representation of variations in religion, geography and class beyond stereotypes.The point we wish to make is that, however biased or unhealthy, porn plays a large role in young people's sexuality education and fills a gap in people's knowledge that formal education does not seek to address.
7 Getting to know you better: what else do we need to know to come together for sexy safer sex While internet usage is considerably higher in Western nations, porn is by no means confined to the West, yet research into the relationship between porn and public health is dominated by studies carried out in North America, Australia and Europe.This may be a reflection of the fact that the majority of studies appear to have been financed by individual public health and medicine (academic) departments or institutions in Western countries.Furthermore, the biggest single funding agency is the US National Institute of Health, and understanding the role of porn in sexual health does not appear to have attracted support or interest from international or UN agencies such as the World Health Organization (WHO) or the Joint United Nations Programme on HIV/AIDS (UNAIDS) that hold the global mandate for health or AIDS.Generally, research in this field has followed the 'risk-focused' norm of linking research to biomedical outcomes, with a reluctance and/or lack of funding to address sexuality more broadly.Although the focus on MSM in the context of AIDS has allowed for more productive research into porn's positive impact, it has to some extent excluded those same questions being asked of heterosexual sexualities, which has to a large extent been boxed in with, or problematised, as reproduction-related health.Our concern is that the moral judgement is a very sex-negative one -the public health perspective is to look at human beings as vectors of disease rather than as people having the right to a healthy, satisfying (sexual) life.
We suggest that the heavy weight of evidence in support of a public health case against porn is not a reflection of the immensity of risk and harm, but a reflection of the lack of good research into the non-harmful effects of porn and lack of willingness to challenge the prevailing moral concern and risk-centred focus on sexual health that exist within the global public health community.So, within the caveat that research is limited, we can infer that porn viewers learn about and copy positions, practices and techniques that they watch, and overall research suggests that SEM influences sexual practices and safe sex practices, in both positive and negative ways.We know that porn does sometimes cause harm to some viewers, but there is not enough robust evidence that porn per se leads to violence and no consensus of evidence that it leads to more degrading views of women (McKee 2007).
Ultimately, big chicken and egg questions such as does porn directly contribute to aggression against women, or, on the other hand, do sexually aggressive men gravitate towards porn remain unanswered (Watson and Smith 2012).
The combining of sex industry and public health expertise has huge potential to reach a wider audience in a positive and appealing way.The public health world can detail safer practices or support research on impact -while the pleasure world and porn actors and directors can turn us on.Research into porn's positive impact can underpin how to do this well to maximise safer sex and public health impact.
Porn can also be made in different ways and with different intentions from how it is now; there are emerging examples of new ways to make porn, from feminist to queer independent porn, and of course the mobile phone video function allows for home-made porn to be uploaded direct, such as on YouPorn.In fact, all but one of the examples we provide later in this article are women-led, i.e. porn made by women, sexual health interventions run by women and sex workers, etc.Thus, we are highlighting the alternative methods of information exchange and production when it comes to SEM.While porn is usually produced for the male gaze, women do watch porn as well; however, we cannot say how it affects women's understanding or expression of their own sexuality since there is not enough evidence around this.Typically, the dynamics of heterosexual porn production follow global patriarchal norms.However, we believe that an alternative form of SEM could be one that highlights more gender equitable porn, a wider range of sexuality and sexual identities, and love and romance.
This section includes examples of how this can be done by blurring the boundaries to create safer sex porn or sexy sex education as very short case studies.They draw out key themes and lessons in terms of engaging with film-makers or erotica to show that we might be able to challenge the norms of porn, what moral decisions need to be made and the barriers that could be faced.This range of examples is drawn from The Global Mapping of Pleasure (Knerr and Philpott 2008). 3  Source Reproduced with kind permission of The Pleasure Project.
Figure 2 The Pleasure Project l Modern Loving: The Ultimate Guide to Sexy Pleasure is a 100 per cent safer sex erotic film that was made in the UK aimed to created kinky, fun, pleasurable sex with real couples.It also showed how to use condoms in a sexy way.The Pleasure Project was the 'condom consultant' on the film set and worked to find creative ways to include condoms and safer sex in the film scenes, while also building the actors' confidence in using condoms during shooting.The film was conceptualised, produced and scripted by women with the intent to create an alternative type of content.The actors also discussed how they found using male and female condoms, and there were many scenes to show the wide range of safer sex practices that are possible. 4 l Selina Fire is a sex blogger and writer with a difference -she writes to make safer sex hot without it being a big deal.Her sex blog, Sex in the City -The Real Version, includes lots of pornographic and arousing descriptions of safer sex.She also writes a column for Penthouse Forum magazine and dedicated a whole column (April 2007) to ideas for kinkier safer sex, including mutual masturbation, tit sex, fisting, getting her partner to come on her face, and exhibitionism.Selina writes about safer sex with the intention to arouse.
l The Kama Sutra for Sexy Safe Sex: Durbar Mahila Samanwaya Committee, Sonagachi, in West Bengal, India is a sex workers' co-operative which takes a pioneering sex-positive approach to sex workers' rights and health, and has had success in lowering rates of HIV among its workers.Among their many ground-breaking projects and achievements is that they have used the Kama Sutra to teach sex workers how to give clients a high degree of sexual pleasure with less penetrative sex.They have also shared information in workshops about sexy safer sex techniques and tips.
Source Reproduced with kind permission of The Pleasure Project.
Figure 3 The Pleasure Project l Safe Sex is Hot Sex Porn: Chi Chi LaRue is an erotic film director, drag queen and performer in the USA.She is considered one of the gay adult industry's most successful directors and also directs straight and bisexual erotic films.A long-time advocate for condom use in gay porn, LaRue announced she would no longer produce films for Vivid Video in 2006 because they adopted a condom-optional policy.LaRue set up the production company Channel 1 Releasing, which requires actors to use condoms in all of its films.In response to recent reports of a rise in HIV among gay men and an increase in 'bareback' porn, LaRue created a four-minute public service video explaining the risks of barebacking, and the responsibility of porn consumers to avoid anal sex without using a condom, in order to protect the health and lives of porn actors.The video had the message to 'wrap it up' because 'safe sex is hot sex', while gay porn video clips run in the background.
l The Pleasure Project is an international education and advocacy organisation working to eroticise safer sex.It builds bridges between the health sector and the sex world, and helps to develop the evidence base for a sex-positive approach to safer sex.It promotes sexual health and prevention of STIs, including HIV, by encouraging sex education with an emphasis on 'good sex', and by focusing on one of the primary reasons people have sex -the pursuit of pleasure.Since 2004, The Pleasure Project has had a wide range of media coverage and is widely credited as leading advocacy in the public health world to 'put the sexy into safer sex' (Figures 1, 2 and 3).It has provided condom consultancy for erotic films, and has mastered the art of erotic condom demonstration. 5 There are other examples of how to create safer sex porn or break down the safe sex education/porn binary to reach audiences with sexual health information in an arousing way.The Make Love not Porn website 6 allows people to upload films of their own sex life.The Berlin Porn Festival, hosted annually, showcases independent porn and creates a space for discussion on financing, feminist porn and safer sex, and issues awards for the 'best independent porn'.

Conclusion: coming together at last
With unsafe sex being the biggest risk factor for premature death and illnesses for young women globally and the second biggest for young men, and HIV being the single most common cause of death of adolescent girls in Africa, the public health world does not have time or the moral 'luxury' to shun working with the porn industry, either directly or recognising its influence.Porn is one of the key channels, if not the key channel for sex education globally.The public health world, those responsible for sex education, academia and the porn industry need to start to understand and then respect the advantages they bring to the others' work.There is also a need for sex education organisations and academics to engage in research that is open to the hypothesis that porn can cause both negative and positive impacts on Based on our literature review, we propose a new research agenda in porn research.We believe that there needs to be more research on, and knowledge of, the porn industry by sex education organisations and academics, rather than assumptions about how it operates or who works in it.In order to harness the huge audiences that porn has been able to capture, public health needs to research the following: l How sex education and porn access is changing in low-income countries in Asia and Africa with increased access to mobile phones and the internet.
l The incentives and structural drivers that could increase safer sex, challenge normative depictions of gender and encourage fair working practices and conditions within different parts of the porn industry.
l What impact would different types of sex education/porn that aim to increase safer sex and condom use have, and to what degree?
l What type of safer sex in porn would have the biggest behaviour change impact?For whom? Whether porn with love and romance has the potential to make sex better and safer.
l How do we make porn safe and still reach the right audience to have impact?
l How can we disentangle the influence of porn from wider social roles of men and women and their unequal power relationships?Do men and women get influenced by porn in different ways?
l It is largely men who make and watch porn; would alternative means of production and makers of films make a difference in terms of their messages or impact?Would films made by those usually objectified, such as women, trans people or sex workers create safer spaces for behaviour change?
l What could incentivise alternative and safer porn?For example, whether de-criminalisation in countries where making porn is illegal would help actors ask for protection under labour or health legislation, or whether unionisation of pleasure industry staff enables them to demand improved health and safety standards and other labour rights.
l Given the increasing consumption of porn, to what extent have agencies with the expressed mandate for young people's health or HIV prevention or sex education (for example, WHO, UNAIDS, UNESCO) addressed the need to discuss and tackle its impact?public health.The research we found was limited, assumed a negative impact of porn viewing and has been methodologically flawed.This bias limits the ability of the public health and sex education world to know how to use this media channel to ensure positive behaviour change.In addition, international agencies with a mandate for sexual and reproductive health need to engage with porn; a future paper will address to what extent they actually do.In conclusion, we call for more unbiased research and programme innovation into the impact of porn, and its potential positive impact, and a recognition that SEM can have a positive impact for public health.
Notes 1 LiveJasmin.com is a webcam site where viewers can choose their model, select women using a variety of identifiers including hair colour, ethnicity, body type, use of toys, cigarettes, etc. Viewers pay to access the webcam of their preferred woman.The site also offers TV channels.The site does not appear to offer porn that is outside the stereotypical norm and there is no reference to an option for 'feminist porn' in the search choices.We cannot verify the reliability of Worthofweb or their statistics.2 Anal sex without a condom.3 Pleasure Map at www.thepleasureproject.org/pleasuremap.4 www.amazon.co.uk/Modern-Loving-Ultimate-Sexual-Pleasure/dp/B0002YCYEY. 5 www.thepleasureproject.org.6 http://makelovenotporn.com.
conclusions that viewing more condomed sex in SEM can increase condom use.A research synthesis of the effectiveness of sexual risk reduction interventions that integrated a safer sex eroticisation component, which included interventions with heterosexuals and MSM, found an overall improvement in condom use, HIV-related knowledge, communication with sexual partners and other positive behaviours (Scott-Sheldon and Johnson 2006).

Box 1
When will I see you again: a future research agenda?