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Understanding Sexual Agency. Implications for Sexual Health Programming

Ine Vanwesenbeeck
Marianne Cense
Miranda van Reeuwijk
1 and
Judith Westeneng
Rutgers, Expert Centre for Sexual and Reproductive Health and Rights, P.O. Box 9022, 3506 GA Utrecht, The Netherlands
Interdisciplinary Social Science (Youth Studies), Utrecht University, Heidelberglaan 8, 3584 CS Utrecht, The Netherlands
Author to whom correspondence should be addressed.
The contribution of Judith Westeneng was supported by NWO-WOTRO under Grant W08.560.004.
Sexes 2021, 2(4), 378-396;
Submission received: 25 June 2021 / Revised: 9 September 2021 / Accepted: 10 September 2021 / Published: 23 September 2021


Debates on human agency, especially female and sexual agency, have permeated the social scientific literature and health educational practice for multiple decades now. This article provides a review of recent agency debates illustrating how criticisms of traditional conceptions of (sexual) agency have led to a notable diversification of the concept. A comprehensive, inclusive description of sexual agency is proposed, focusing on the navigation of goals and desires in the wider structural context, and acknowledging the many forms sexual agency may take. We argue there is no simple relation between sexual agency and sexual health. Next, we describe the implications of such an understanding of sexual agency for Comprehensive Sexuality Education (CSE) and for sexual health and rights (SHR) programming more generally. We put forward validation of agentic variety, gender transformative approaches, meaningful youth participation, and multicomponent strategies as essential in building young peoples’ sexual agency and their role as agents of wider societal change. We also show that these essential conditions, wherever they have been studied, are far from being realized. With this review and connected recommendations, we hope to set the stage for ongoing, well-focused research and development in the area.

1. Introduction

Scientific debates on (sexual) agency (generally understood as “effective human acting”) stretch over more than half a century and have co-evolved with broader societal and scientific developments. Agency has been a subject of interest in a variety of social (sub) disciplines from psychology to sociology, anthropology to philosophy, gender studies, cultural and media studies, youth and health studies, and the international development literature. A view of agency as an individual psychological capacity has been prominent throughout, following an increasing emphasis on individualization and choice in late modernity [1]. However, parallel to the dominant individualistic approach, quite some efforts to conceive of agency in more contextually sensitive ways have also been put forward in an extending body of theory [2]. Evidence from research among “the poor” and other “vulnerable groups”, such as children, has drawn attention to agency’s “boundedness” by contextual opportunities and restrictions. Sociology bears some honorable attempts to bridge the structure–agent divide and understand the interaction between individuals and their (restrictive) environments [1,3,4]. Paradigm wars between voluntarism and determinism, prioritizing either the power of free will or the determination by societal circumstances, have been permeating debates on agency (and other issues in the social sciences).
Interest in female agency specifically has always been key in feminist and gender studies. After all, in order to change the ideological and structural conditions of patriarchy, we have to act [5]. Here as well as in international development studies, the study of female agency is closely linked to the desirability of female empowerment. The interest in female agency has become particularly intense in feminist cultural and media studies concerned with the sexualization of women and girls. Psychological traditions of media effects research came to be criticized for failing to capture the complexity of women’s experiences in dealing with the ever-presence of their objectification and sexualization. This may have caused what has been called a “turn to agency within feminism” [5]. Controversies over women’s objectification versus their subjectivity and agency continue to dominate feminist studies and activism to date. Consideration of female sexual agency specifically has evidently become central to these discussions. Pressing concerns with widespread sexual violence against women and the threat of STI/HIV risk have further strengthened the prime position of female sexual agency on the (feminist) scientific and activist agenda. Likewise, agency has gained a central position in international development cooperation in the areas of gender and sexual and reproductive health and rights (SRHR). Here as well, agency is seen as an essential mode of conduct in the process of empowerment. Empowering young people to make safe and informed choices about their sexual and reproductive health and lives through increasing their (sexual) agency is central to many SRHR programs and donor funding frameworks. Yet, few NGO’s and donors have formulated a good working definition of (sexual) agency that is helpful in guiding Theories of Change, program development, and monitoring progress and program outcomes. Discussions on definitions and connected usefulness of (sexual) agency as a program objective thrive.
This article provides a short history of recent agency debates in the social scientific literature. The literature available is mostly Northern based (i.e., Europe and the USA) but often relates to (young) people in the global South. Below, we will first review developments in relation to human agency in general and next specifically as related to sexual agency. The review will illustrate how criticisms of traditional conceptions of (sexual) agency have led to a notable diversification of the concept. A comprehensive, inclusive description of sexual agency will be proposed next, assumed to be useful for any geographical region. Subsequently, the implications of such an understanding of sexual agency will be considered for Comprehensive Sexuality Education (CSE, understood as an evidence- and curriculum-based process of teaching about the cognitive, emotional, social, interactive, and physical aspects of sexuality) and for sexual and reproductive health and rights (SRHR) programming more generally. Logically, the focus will mostly be on young peoples’ sexual agency here. With some recommendations, amongst others provided by the international literature, we aim to set the stage for ongoing, well-focused research and development in the area.

2. Recent Agency Debates

Originally, conceptions of agency have heavily drawn on psychological theory, inherently qualifying it as an individual feature and as an intrinsic trait. As such, agency is associated with intentionality, (problem-directed) coping behavior, resilience, competency, assertiveness, mastery, autonomy, and self-efficacy. Additionally, agentic behavior is often supposed to be self-asserting, self-serving, and liberating. It is expected to resist toxic ideologies and circumstances and to transcend harmful domination by others [6]. Sulkunen (2009) [7] qualified the conventional emphasis of agency on self-realization, rationality, and strategic conduct as the “standard view of action”.
Such a construal of agency has met with a number of criticisms. First and foremost, it has been pointed out that contextual factors are connected to agency at many levels in either supportive or restrictive ways. Restriction comes in many shapes and faces, ranging from socioeconomic adversity to normative limitations, from an overall lack of life options to direct social threat, violence, or coercion. Gender inequality and normative, ideological conceptions of agency as inherently masculine form inevitable restrictions on notably women’s agency in many areas. Gender stereotypes work against the display as well as the recognition of female agency. Women suffer backlash for being agentic [8]. Additionally, since stereotypes about competence deficiency are even stronger for Black than for White women, the agentic penalty may be even harsher for them [9]. Clearly, gender and ethnicity as well as other intersecting demographic factors, such as age and class, may be strongly restrictive of agentic opportunities for large groups in any society. The same holds for sex and gender minorities due to social stigmas attached to non-conformative sexual orientations and gender identities (SOGI). People occupying multiple social minority positions, like, for instance, bicultural gay youth whose cultural or religious identities intersect with their sexual identities, may find their agentic options affected in complex ways [10]. Restrictive conditions should clearly not be mistaken for a presumed lack of agency, a deficiency on the part of the actor. Individuals’ agency must be seen as indivisible from the “micro, meso, macro, and chronosystems through which it is constituted, channeled, and disciplined” [11] (p. 468). According to “a capabilities approach” [12], we should not ask what a person should do but what he or she can do. Conversely, put differently: we should understand the choices people have before looking into the choices they make.
Pushing this argument a bit further yet, scholars have criticized considering circumstances and individual action as essentially separate elements. The “selves” that interact with social structures in the exercise of (types of) agency are socially patterned as well [13]. Social influences on identity development and personal experiences color all individual acts to begin with. A “generative concept of agency” [7] further acknowledges that actions also generate structures, which then become the conditions of action while also being its product. Poststructuralist perspectives on agency understand subjectivity and social structures as produced in concert [14]. From this perspective, people are seen to engage ongoingly, habitually, and agentically with their structuring environments while at the same time reinforcing, challenging, or weakening them [15]. The daily enactment of gender roles and the sexual double standard specifically has been cited as “doing gender” [16]. Crucially, agency is thus not necessarily effectively resistant, liberating, or world-changing, nor is it necessarily gender transformative either. Behaviors that are notably conforming, stabilizing, accommodating, or even disempowering still form part of the many modalities that agentic engagement with one’s environment may take.
There is yet another critical angle to the heralding of agency as primarily self-determined, self-serving, and empowering. A view of agency that highlights individual mastery has been considered an exponent of the individualism that characterizes neoliberal ideology, a worldview that sees commercial markets and competition rather than governmental protection as the way to individual freedom. Individual mastery is seen as a neoliberal norm but is principally unattainable for many. The emotional burden it puts on present-day (sexual) actors, notably on girls and women, has therefore been criticized as too high [17,18]. Neoliberal ideology tends to deny structural oppression and inequality, leading Gill and Donaghue [5] to jeer that “the agent is the ideal subject of neoliberalism”. What good at all does the focus on agency do for feminism or for social justice”, these authors wonder. Neoliberalism promotes “free choice”, “being your own (wo)man”, and “putting your mark on the world” but ignores the many limitations to live up to these norms. Critical analyses further show how concepts such as agency, choice, and empowerment may be co-opted, distorted, and abused by omnipresent commercialization, corporate interests, and conservative forces. Agentic behavior is not seldomly promoted, framed, and molded in interests other than those of the agents themselves.

3. Sexual Agency Revisited

To a remarkably large extent, the current agency debates take place in the area of sexuality, notably of young peoples’ and especially girls’ sexuality. In this area as well as in others, agency as a concept has been employed rather self-evidently and unproblematically until recently. In line with “standard views of action”, sexual agency has typically been understood as the ability to initiate sex, make sexual choices, communicate one’s desires, and meet one’s needs [19,20,21]. Definitions often focus on autonomy, on “the rights and ability to define and control your own sexuality, free from coercion and violence” [22]. Operationalizations, such as sexual (refusal) assertiveness, health protective self-efficacy, and sociosexual competence, have been used [23]. Overall, in (sexual) health psychology and programming, sexual agency and related concepts have long predominantly been viewed as intrinsic traits rather than as molded by extrinsic forces and as a quality that needs to be strengthened at the level of the individual.
In more sophisticated models of sexual empowerment and of healthy sexual development [24,25,26], sexual agency is invariably assumed to be of the essence. These models do take available (individual) resources and opportunity structures well into account. Sexual agency is seen as appropriate use of available resources, possibly leading to positive outcomes or achievements. Rather than as a personality trait, sexual agency is thus considered as the use of a set of skills that, (provided they are well-developed) supports, for instance, “voice, choice, and power” [25], freedom of movement, voice, and behavioral control and decision making [27] or “decision-making, collective action, and leadership” [24]. In these models, (sexual) agency is mostly understood as successful navigation of the proverbial winds, waves, streams, and shoals presented in the sex- and gender-related environment, and especially of the many possible contrarieties encountered in them. Navigation is a continuous process of negotiating multiple (possibly opposing) desires, norms, and possibilities. Developing navigation skills is considered a key element of healthy sexual development and an essential element of (sexual) empowerment.
Parallel to a focus on sexual agency as principally a powerful outward performance in the service of self-realization, personal interest, and individual or collective empowerment, we see increasing attention to types of sexual agency that are “different” and may not be recognized as agentic in the first place [11,28,29,30,31,32]. The scientific literature on the matter provides many alternative descriptors for “different” agency. “Bounded” agency is the general term, coined by Evans [29], to indicate that sexual agency is situated “comprising a mix of internalized, personal frames of reference and external, institutional influences” [33] (p. 191). “Bonded” agency is also used to indicate the connection of actors’ selves to cultural sexual systems and, more specifically, to reveal their loyalty to the prescriptions and expectations of family, peers, and intimate partners [34]. It is important to note that sexual agency specifically is, to a substantial extent, principally bonded because much of sexual agency takes place and shape in sexual interaction with another human being in the first place. Likewise, notably in the area of sexuality, young people have dealings with parents or caretakers who, in many cases and certainly when daughters are involved, hold opposing values and want to restrain their children’s sexual behaviors. Gay youth may also have to deal with relatively strong opposition from parents and family. Bell [35] uses the concept “restrained agency” to relate to the interaction of young people with their parents or elders as custodians of social values.
Other concepts used to describe agentic behaviors while taking (restrictive) contexts into account are, for instance, “habituated” (as opposed to “imaginative”) agency [15], “subtle” (as opposed to “public”) agency [35], and “thin” (as opposed to “thick”) agency [36]. Still other suggestions are: “tacit or hidden” [33], “weak” [37], and “symbolic” agency [32]. Mai [30] shows that individuals may be inclined to “act within rather than against” normative options. Crucially, all these studies reveal that sexual agency is comprised of “multiple ways of resisting or inhabiting norms” [38]. Moreover, these studies show that multiple goals and motivations underly the diversity of agentic behaviors. In addition to the aspiration to challenge or change one’s circumstances and act upon the world (as is characteristic of “thick” agency), people may rather (be obliged to) aim for continuity and stability [33], for maintenance of relationships [28,39], for positioning oneself in moral frameworks [34], or for simply “making sense of the world” [40] and of one’s self [34] or merely “getting by” [41]. Bay-Cheng [11] provided some examples of behaviors that may not be considered agentic at first, such as choosing to be in an exploitative sexual relationship to be away from abusive parents or consenting to sex for the sake of much needed relational stability. Cense and Ganzevoort [10] highlighted subtle rather than public agentic strategies among bicultural gay youth in the Netherlands, such as showing respect to parents by adjusting to their sensitivities and avoiding explicit statements about one’s sexual orientation instead of admitting to the Dutch norm of being “out and proud”.
What these examples show, firstly, is that agentic behaviors may be motivated by multiple, contradicting, and competing considerations, which may result in compromising, compliant, and possibly ambivalent agency rather than outright unapologetic, independent, self-serving acting. When sexual agency is employed in service of limited life options, to keep the peace and not stir dissent or to endure and persist in unfavorable conditions, sexual agency may seem to be unhealthy, disempowered, or “thin”. However, “thin” acting often is overly creative, resilient, strategic, and strong, considering the circumstances. Even if it is outright self-defeating, it is still agentic in the sense of navigating one’s options and enacting self and identity. If we only define agency as outward, resisting, and clearly self-serving and healthy acts, we overestimate its potency and underestimate its presence at the same time [11].

3.1. Sexual Agency as a New Criterion of “Good” Conduct

In addition, it is important to realize that employment of an unnuanced, one-sided reading of agency as clear-cut independent self-realization, works as a key criterion for “good” sexual conduct in neoliberal times, stigmatizing those it supposes not to live up to it. As such, it affects some groups more than it does others. Foremost, is affects women and girls relatively strongly, as heteronormativity is traditionally accompanied by noted ambivalence towards their sexuality. Female sexual strategies may thus be routinely met with ambivalence in the first place. Male agentic strategies may be overvalued as normative, “masculine”, and positive.
Moreover, as Bay-Cheng [17] argued, the unjust casting of certain girls (and boys) as non-agentic, as lacking control and self-determination, or as “falling below the Agency Line” tends to follow common “discursive tracks that degrade and dehumanize particular groups on the basis of class, race, and other marginalized statuses” [17] (p. 286). Negative evaluations are more likely to affect those already suffering disadvantage, stigmatization, and exclusion. Being cast as deficient may also strengthen perceptions of victimhood, particularly in girls, not as the result of violation by another person but as the manifestation of one’s principal weakness and failure and one’s ineptitude as an agent, compelling self-blame. This prescribed normative space may inspire self-interest and control in some but disapproves and largely disempowers many even further, and that reifies racial and socioeconomic inequalities.

3.2. The Victim–Agent Schism

In scholarly work in the area of gender and sexuality, many have pointed to the undesirability of the presumed paradox between women’s vulnerability and women’s agency and personhood [42,43]. It has been stressed that binary thinking and simplistic either-or approaches may confirm rather than undermine gender/sex stereotypes and promote exclusion and stigma and are basically a “parody of agency’s complexity” [2]. Nevertheless, they appear to be highly prevalent in both the scientific literature and sexual health programming.
For instance, Shefer [43] evaluated the dense literature on heterosexuality in the light of HIV/AIDS in the South African context. This literature elaborates on the multiple barriers to women’s access to sexual pleasure and agency in their heterosexual relationships. The dominant picture arising here is a noted “binaristic” one, Shefer found. Heterosex is framed as “a male preserve”, with women’s sexual agency foregrounded as, at best, complicated. In an effort to counter this binarism, some studies then glorify women as agents and as “survivors” of normative gender roles. “The flipside of women being constructed as inevitable victims (or resistant agents) is the reproduction of the stereotype of men as inevitably powerful and controlling in relation to women in heterosexual relationships”, Shefer pointed out [43] (p. 216). It is her primary concern that addressing inequitable heterosexual relationships in a binaristic way may function to reproduce the very discourses that underpin such inequalities in the first place.
It is also worth noting that, even in the case of blatant sexual victimization, victimhood is never complete [44]. The sexual victim is not necessarily (if ever) harmed or helpless all the way down; even the most proverbial victim also displays agency: in defending oneself, in strategizing, and in mitigating negative effects. For these (and other) reasons, many prefer the term “survivor” to “victim”. In hegemonic discourses on victimhood, the all or nothing notion of victimhood is incompatible with agency. The productive way forward is to resist a binaristic picture of women as either victims or agents. We have to carefully articulate a more nuanced understanding of young women’s disputed and complex agency as a multi-layered range of needs, options, goals, perspectives, and types of conduct. Victimhood as well as agency may show not as much in clear blacks and whites but in many shades of grey in overlapping, in-between, mixed, and ambivalent experiences.

3.3. A Continuum of Modalities of Action

Underlying an understanding of sexual agency as entailing multiple modes of action, is the acknowledgement of its multiplicity of purposes in a multiplicity of situations and time frames. Hitlin and Elder [13] distinguished four types of agency, varying by concrete situations, lived experiences, and temporal orientations. According to them, “existential” agency may be enacted in all circumstances and all temporal scopes, basically referring to a fundamental level of human freedom and connected capacity for self-directed action. Even in the most restrictive of contexts, choices are made; one might always have acted otherwise [1]. “Pragmatic” agency is employed in novel situations, in “knives’ edge” moments, and refers to the ability to innovate when routines break down. “Identity” agency, on the other hand, is employed in routine situations and refers to “the capacity to act within socially prescribed role expectations” that, often but not necessarily, lead to the reproduction of structures. Hitlin and Elder stressed that maintaining routine interactions and performing identities do require effort and do define us as agents. We do not passively enact our identities; we exercise agency in the very performance of those identities no matter how conforming or complying they may be.
“Life-course” agency, lastly, is a longer-range version of existential agency. It occurs with a broader sense of our futures involved and comprises actions with long-term implications. Essential to life-course agency are retrospective analyses of decisions made at turning points and transitions as well as a feeling of confidence in one’s ability to make (and stick to) advantageous long-term plans. Clearly, some people have more opportunity to develop a sense of confidence due to experiencing more comfortable life conditions and having made more successful decisions in the past. However one looks at it, agency is always dynamic and evolves according to the situation [30]. Van Reeuwijk [45] applied Hitlin and Elder’s model of temporal ordinations to understand the sexual decision making of children and young adolescents in Tanzania in a context of conflicting sexual norms and expectations set by parents, caretakers, peers, and partners, which inform and compete with individual goals and situational demands. The children she studied used secrecy, lies, silence, exaggerations, deceptions, “skinning” (taking money without giving sex in return), seduction, flirting, and assessing the reputation of potential partners as concrete agentic strategies to benefit from sexual relationships while managing risks to their reputation, education, self-worth, and health.
From this and many other studies, it can be concluded that sexual agency is employed to serve internal as well as external goals: to navigate sexual contexts and expectations, to manage sexual risks, to negotiate desires and preferences, to make sense of experiences, and to maintain relationships. Sexual agency is not only heavily colored by one’s overall life options but also by previous (sexual, relational) experiences. It may vary according to the actor’s short- or long-term perspective or according to situations being novel versus familiar, like in new or casual versus steady, intimate relationships.

4. A New Description of Sexual Agency Proposed

Options, motives, and enactments of sexual agency thus show huge variety both within the individual and between individuals. Under patriarchal, heteronormative rule, differences between women and men or girls and boys are apparent. However, even highly dominant systems like heteronormativity are not homogeneous and do not produce uniform effects for all women and girls [32] or for all men and boys, for that matter. It is well established that sexual choices are influenced by many intersecting factors, such as ethnicity, class, age, and religion. The “marketplace of sexual options” is far from evenly distributed [31]. Nevertheless, agency is everywhere, and all people are agents in their dealing with their identities, their lives, and their sexual options [15]. The full scope of sexual agentic conduct can only be recognized if we accept its full-blown, mutual entanglement with available options and limitations. Likewise, we need to confess to its complexity, situatedness, temporality, and diversity and to its omnipresence and its everyday character as well as to its possible irrationality, ambivalence, and awkwardness.
With the aim to promote a comprehensive, inclusive understanding of sexual agency, we propose the following description:
Sexual agency refers to a continuum of dynamic, every day, situated modalities of action related to sexuality in which agents navigate (contrarieties between) personal goals, desires, and preferences on the one hand and personal living conditions, normative expectations, and the wider structural context on the other hand. A diversity of internal (e.g., self-identification) and/or external goals (e.g., maintain social relationships or challenge the status quo) motivate and direct sexually agentic behavior. Sexual agency may aim for change as well as for endurance, continuity, and stability. It may be overt or tacit. It varies with individual (e.g., temporal orientation) as well as situational variables (e.g., novelty). Sexual agency may reproduce but also resist and renegotiate (aspects of) prevailing norms and the status quo. There is no simple relation between sexual agency and sexual health or well-being. Modalities of action as well as the constructiveness of their (multiple) effects always depend on personal frames of reference as well as on the opportunities and restrictions provided by the (immediate and distant) personal and structural context, including moral and ideological frameworks and dominant sexual stories.

5. Implications for CSE and SRHR Programming

Recently, approaches to Comprehensive Sexuality education (CSE) have gradually evolved from primarily health based to explicitly rights based and from mostly pursuing health goals to strongly favoring empowerment objectives [46]. Although relevant to both approaches, the advancement of young peoples’ and notably girls’ sexual agency has increasingly become one of its central aims. To the extent that agency is traditionally understood as “strong” and as clear-cut, independent self-realization, its relation to empowerment appears to be self-evident. Agency and empowerment have often and long been considered in tandem [47]. However, a changing, diversified, inclusive understanding of sexual agency as sketched above makes the relationship between agency and empowerment less plain. How does “weak” or “thin” agency relate to empowerment? If we accept that “essentially, all individuals and all actions are agentic” [15], the question arises how and when agency indeed supports empowerment. Besides, we may not want to arrive at a point where everything is agency and thereby nothing is or to lose ourselves in conceptual erosion or linguistic confusion.
Actually, developments in the understanding of “agency” and “empowerment” have a great deal in common. Both concepts are discussed widely and are strongly contested. Both have shown to be utterly complex and highly (culturally, geographically, historically) variable. As a matter of fact, the understanding of empowerment has, just like that of agency, gradually shifted from empowerment as an individual state or quality to empowerment as a situated process of personal growth and increasing control over one’s life and circumstances [48]. Both concepts thus put the interaction between individuals and their surroundings at the center. Basically, sexual empowerment and the bolstering or “thickening” [36] of sexual agency both allude to complex, multilayered processes of gradual optimization of the possibilities of individuals to realize their sexual rights and well-being. These processes necessarily take place on the part of the individual as well as of the surrounding context and, notably, at the interface between the two. Certainly, the full acceptance of agency’s complexity begs for delicate balances of all sorts: between determinism and voluntarism, between clashing conceptions of vulnerability and agency [49], and between acknowledgement of structural constraints and appreciation of the choices that women and young people do exercise [2]. All this calls for a reconsideration of how the concept is to be treated in CSE and SRHR programming overall. Below, some (general and more specific) notions considered relevant to that endeavor are highlighted.

5.1. Validation of Agentic Variety

Especially in SRHR promotion, the complexity involved in sexual agency needs to be met by programs that are securely based in the knowledge that all children and young people are sexual agents in their own lives but that there is important contextual diversity among them [35,39,50]. The SRHR justice framework remains applicable unabatedly, as it recognizes intersecting injustices and power structures, centers sexual rights, and unites across identities. However, what is effective for some is not necessarily so for all. In SRHR promotion, there is no one-fits-all solution [51]. Rights-based interventions need to be informed and driven by the differential realities of young peoples’ sexual lives [35]. It is crucial to acknowledge the many ways in which agency may be disciplined, shaped, and bounded. The diversity among students in terms of their bondedness, (religious) morality, identity, feelings, and wishes must be respected. Promotion of coming out as gay as a supposedly agentic ideal may, for instance, result in acceptance and celebration for some youth but in rejection and violence for others depending on the (family) culture and other factors. There is no use pushing towards conduct that a specific context does not allow. In addition, educators need to be careful not to overly burden or frustrate young people. To the contrary, it is crucial to value ambivalence, compromise, and compliance in all sexual strategies, even those that appear self-defeating. Madhok et al. decided in 2013 [52] that “we have not yet arrived at the stage where we can stop stressing the agency of those presumed to lack it”, and this still rings true.
Such is particularly relevant to young people who practice non-normative sexual behaviors or employ non-normative sexual identities. Their agency will be less supported and facilitated and less validated or approved in the social environment. This is true for the agency of supposedly non-agentic girls but likewise for same-sex oriented youth and for non-gender-normative-identifying youth. Girls and women who choose transactional or commercial sex, whether as a strategy of preferred or of last resort, provide another telling example here. Their agency is morally rejected, qualified as “thin”, “weak”, or “unhealthy” or not considered agentic in the first place. As a consequence, they are all too easily stigmatized as victims or deviants and certainly as lacking “proper” agency. There is a pressing need to also recognize their agency as valid and understand (the logic of) their choices [53].
While non-normative agency is socially undervalued, it needs to be relatively “thick” at the same time. Defying structural constraints and moral judgements and pursuing a non-conforming sexual lifestyle, orientation, or identity requires agency that is relatively strong and bold. Non-normative youth may have to put in much more effort to reach equivalent levels of sexual safety and well-being in comparison to others. They may have to employ much more navigational skills than others. Experience learns that many individuals comply with a norm in the first place because “they do not have the wherewithal to challenge it” [54] (p. 11). “People’s ability to not follow a norm, even when they disagree with it, depends on many factors, including their personal agency in connection to the social support system around them and the material resources to withstand possible sanctions” [54] (p. 11). In light of these possible sanctions, non-normative agentic strategies should be applauded for their audacity (provided they fundamentally respect equality and mutual consent, of course) even if they bear a complex relation to one’s social and sexual health and well-being.

5.2. Centring Young People

The modern literature on sexual agency reads as a general appeal to thoroughly take account of young people’s perspectives and to acknowledge their everyday agency rather than having an overriding concern with correcting “deviant” agency [33,42,55]. Agency is embedded in everyday life, such as in young people’s experiences and practices at school and at home or in interactions with relatives, friends and, notably, romantic partners. Social interventions must embrace “everyday agency” and start with children and young people’s own perspectives, Payne [55] asserted.
With a shift in focus on CSE as empowerment rather than health focused, teaching methods have become an important object of scrutiny. There is wide agreement that a participatory, learner-centered approach is crucial to adequate CSE delivery. Empowering methods need to put young people at the center and be sensitive to (the heterogeneity of) their concerns, realities, suggestions, interests, and resistance [46]. Active participation of students is key. Teachers are supposed to facilitate the empowerment process rather than teach content, improve knowledge, or regulate behaviors.
Theory, development, and research on youth participation in the area of SRHR is beginning to take shape. Villa-Torres and Svanemyr [56] and Evelia et al. [57] provided overviews of conceptual frameworks to better understand youth participation. Definitions of youth participation vary but invariably stress the need of youth engagement to take place “on equal terms” and “in all stages or program development and implementation” for it to be truly meaningful. All frameworks have the intention to establish and adopt “processes for shared decision making and power between the holder of the adult role and the young person, through the recognition of young people’s contributions, individually and/or collectively” [56] (p. S53).
In the context of CSE, peer education (defined as “a form of teaching and/or sharing information, values, and behaviors by members of similar age and/or status groups”) is a relatively frequently implemented and evaluated form of youth participation. Peer education, when used as stand-alone, still seems to have modest effects in promoting health behaviors of beneficiaries other than of the peer educators themselves (as recipients of training and supervision) [58]. But peer education supports broader empowerment goals for young people. Peer educators may offer a unique value as a source of sensitization and as a referral point to experts and services [59]. Outcomes other than health behaviors have hardly been studied in peer education scholarship. More research is needed to identify and realize the best conditions and procedures for various forms of youth participation to be employed in the classroom and beyond. After all, youth participation is no luxury but a basic, principal requirement and a (political, social) human right. Children’s and adolescents’ right to participation in all matters related to their own lives has been recognized in the Convention on the Rights of the Child [56]. Step one in strengthening young people’s sexual agency is indeed involving them as agents and putting their (diverse) perspectives and everyday sexual agency at the center of any SRHR intervention.

5.3. Gender Transformative Approaches

Another general principle now widely promoted for addressing agency in CSE and wider SRHR programming is its focus on gender transformation. There is mounting evidence that gender norms, sexual double standards, and heteronormativity are extremely harmful in relation to sexual agency, rights, and well-being. Overall, a gender transformative approach (GTA) actively aims to examine, question, and change rigid gender norms and imbalances of power [60]. It does so by purposefully raising the subject; by addressing heteronormativity and its consequences for girls, boys, and sexual and gender minority youth; and by fostering personal reflection and critical thinking about how gender norms manifest and operate, especially in relation to agency. Gender Transformative Approaches also include interventions that aim to structurally change harmful power imbalances, for instance, at the institutional level. Zimmerman et al. [27] explicitly called for integrated approaches concomitantly addressing gender inequities and agency in the promotion of adolescent health and wellbeing.
Evidence of GTA effectiveness is starting to become available. Based on her comprehensive review of evaluation studies, Haberland [61] concluded that education programs that address gender or power are five times more likely to be effective in terms of reduced rates of pregnancy or STIs as those that do not. Levy et al. [62] conducted a systematic review of evaluations of 59 programs that aimed to transform gendered social norms and found that three quarters of them measured significant improvements in health-related and gender-related indicators. Limitations in program focus (often on improving the individual power of the beneficiaries) as well as in study designs and measurements have not granted us decent evidence for outcome measures other than individual health behaviors, even less so for specific (sex or gender minority) groups. However, a central belief is that programs that uncritically build on gendered assumptions and the sexual double standard lead to distorted understandings of (particularly) girls’ sexual agency, subjectivity, and autonomy. Calls to include gender in CSE are thus first and foremost advocated to serve the empowerment and agency of girls. However, when absent, all young people’s understandings of sexual agency, rights, consent, sexualized harassment, and violence are affected [63].
As such, the benefits of addressing gender for boys and young men are also paramount in CSE as elsewhere [64]. Double standards place a heavy mandate on boys: a pressure to develop nothing less than highly agentic, “real” heterosexual masculinity. This mandate may be less ambivalent and critical than that for girls, but it also sets requirements that cannot easily be met. In their research among youth in Kinshasa, Zimmerman et al. [65] found that young adolescent boys may have as many difficulties with agentic behaviors, such as exhibiting voice and decision making, as girls have at that age. Boys may thus profit from enhancement of their navigational competencies as much as girls. Moreover, the norm of masculinity limits the development of emotionality, openness, responsiveness, and connectedness. This draws not only on romantic partnerships but on all social relationships. In addition, the sexual double standard that strongly influences the power dynamics within heterosexual relationships is, in fact, the recipe for fundamental inequality. For agency to serve the development of equal, healthy, and satisfying relationships characterized by mutuality, openness and shared responsibility, and interactional skills should break free from rigid norms of masculinity. This is particularly true to the extent that masculinity may become “toxic” and associated with homonegativity and homophobia as well as with sexual aggression and risky behavior. Sexual agency in the service of “toxic masculinity” stands at odds with sexual agency in the service of sexual health and sexual rights for all. Insight into these mechanisms is well promoted by gender transformative approaches.
However, it also needs to be acknowledged that the thematizing of gender and agency in sexuality education is not without pitfalls. Teachers and educators, even if they are aware of the importance, struggle with the treatment of gender [66,67]. Gender sensitivity too often translates into a confirmation of alleged gender differences rather than into an undermining of gender stereotypes or binary thinking [68]. In addition, as is the case in “toxic masculinity”, certain forms of agency do not align well with notions of overall empowerment and gender equity. In their study of gender norms and agency among girls and boys in Kinshasa, Zimmerman et al. [65] found unexpected relations between adherence of gender norms and aspects of agency, such as voice and decision making. As also noted above, conforming to gender norms may facilitate certain forms of agency and power, at least for some, under certain circumstances. Zimmerman et al. [65] concluded that the relationships between gender norms, agency, and empowerment are complex and deserving of critical reflection by researchers and programmers.

5.4. Building Navigational Competencies

Therefore, it is of critical importance to carefully consider which specific navigational competencies in support of young people’s sexual agency should be addressed in CSE. In their model of general healthy sexual development and sexual well-being, Kagesten and van Reeuwijk [25] identified six key domains of competencies: sexual literacy, gender equitable attitudes, respect for human rights and understanding of consent, critical reflection skills, coping skills and stress management, and interpersonal relationship skills. Interpersonal relationship skills include, for example, the ability to communicate and negotiate, express affection, listen to others, ask for, give, and refuse consent. Critical reflection skills refer to insights in how one’s own feelings, behavior, and experiences are shaped by social structures. These skills help young people understand multiple and conflicting messages about what type of feelings and behavior is acceptable and for whom and under what circumstances. While the competencies include a basic understanding of sexual and reproductive health, they are fundamentally about having positive attitudes that support and respect gender equality, human rights, and diversities; being able to apply a critical lens towards social and cultural norms and messages; the capacity to cope with stressful events; as well as being able to communicate and negotiate in interpersonal relationships. Taken together, they form the foundation for how adolescents navigate and explore sexuality both in relation to themselves and others. As such, they form the foundation for young people’s agency. Kågesten and van Reeuwijk [25] viewed agency as the link that “mediates” what an individual wants or desires and the actual achievement of this goal while drawing on social and material resources at multiple levels.
In line with Kågesten and van Reeuwijk, strengthening young people’s capacity for critical reflection is widely endorsed as well as a precondition for successful navigation of their normative contexts. Related goals are the cultivation of “sex cultural intelligence” [69], of “media-literacy” (the skills to critically use, evaluate, and create media content), of help-seeking and advocacy skills, and of young people’s capacities for sexual citizenship [70]. Cense [39] proposed to always stimulate critical reflection by explicitly opposing different sexual cultures, norms, and stories; to not mask conflict and difficulty in making sexual choices; and to counterbalance the (neoliberal) pressure to make the right choice by reframing “mistakes” as “learning experiences”.
While taking young people’s boundedness to their environments into account, acknowledging that any sexual decision making is a “bumpy road” [39] may provide vital support. Rather than focusing on teaching students to “make the right decision”, CSE could strengthen students’ skills to navigate their (practical, ideological, social) realities and prepare them to be ready for that bumpiness ahead. A discussion about situations that make it difficult to use a condom is more helpful and “empowering” than preaching that condoms must be used to prevent pregnancy and diseases. While acknowledging the reality of transactional sex, allowing space to build negotiation skills is more effective than only depicting the narrative of abstinence. Even in the context of restrictive structures that limit choices and options, strengthening sexual literacy can increase a sense of normality and body pride and reduce shame and anxiety. Strengthening navigation skills can help young people to consider and weigh the options and scenarios that are available to them, even if they are few.
Additionally suggested in the literature is the need for the creation of personal narratives, as they are necessarily “the site where agency emerges” [71]. Koenig et al. [72] found the extent to which young adolescents have communicated about sex-related issues (relationships, pregnancy, and contraception) to be positively related to aspects of agency, such as voice and decision making (although not consistently across all contexts). Munford and Sanders [40] also recommended the articulation of needs and feelings and giving young people a voice. In addition, these authors stressed the power of small, positive events and seeing possibilities in “try-out” agency.
Creation of personal narratives or listening to stories of other people are one way to learn how to navigate, but a more effective way is learning by doing. For this aim, “serious games” are a promising venue. Rutgers and STI Netherlands developed the serious game in which young people practice setting sexual boundaries and communicating about sexuality in a safe setting through computer based observational learning. In “Can you fix it?”, players determine the storyline of a video by intervening in a sexually charged situation that becomes problematic for the characters involved, for instance, because their boundaries are crossed, or their feelings are hurt. The videos deal with situations, such as sexting, exposing, dating, sexual boundaries when in a relationship, contraception, unintended pregnancy, sexual harassment, and violence and expressing LGBT identities. Players are challenged to “fix” the outcome of the story by choosing an alternative storyline. Through this interaction, socio-sexual relational competencies are practiced and strengthened. With the present technological developments, educational methodologies are multiplying and will change the face of many an educational endeavor, among which is most certainly the area of SRHR. Digital components to CSE may deliver challenging content that teachers may be grappling with in the classroom and can help connect young people to support systems, for example, to sexual minority support groups, online counselling and advice, or other professionals in social work and health care. Digital extension of CSE may also increase reach, especially for out-of-school youth.
Educators’ support to young people’s agency may extend far beyond the classroom situation. Principally, CSE could be a critical moment in young people’s sexual development and transition experiences and help them to take important life decisions. Sex educators could also function as key adults and help young people to develop additional support systems. Sex educators could, for example, play a crucial role in providing support of (homo) sexual relationships in contexts where these are forbidden for young people as well as in dealing with the disempowering consequences and stigma when they become public knowledge [28]. Throughout contexts, sex educators and other professionals in social work and health care may be vital in staying alongside youth as they negotiate their sexual worlds, continuing to support them when they falter and make mistakes, and also celebrating their achievements [40]. There is no overrating the importance of key adults in assisting young people in their navigating their complex, multifaceted sexual environments. Much future innovation and research in the area of applicable methodology is needed for the optimization of this role.

5.5. Young People as Agents of Change

In addition to ways of building individual competencies, the profound connectedness between individual agency and the individual’s context calls for focusing on the wider context, on group and school norms and processes, and on participation in communities and societies at large. Ninsiima [31], for example, highlighted investment in appropriate resources and inclusive access to sexual and reproductive justice. Bay-Cheng [17] suggested stopping the scrutiny and surveillance of girls themselves and examining the circumstances of girls’ lives and sexualities instead.
Importantly and suggested by many, young people could be stimulated to take an active role in social change and advocacy and in “opening up landscapes for more generative agency” [40,51]. Strengthening of their advocacy skills is crucial to the overall agency-related agenda but could be particularly useful for groups and contexts where unlawfulness, stigma, and discrimination demand a high toll on young people’s sexual lives. Indeed, involving and supporting young people as agents of change seems to be logical, desirable, and beneficial in multiple ways. Principally, they already engage with their structuring environments on a daily basis, accommodating, reinforcing, and/or challenging their conditions continually. A great many agentic strategies may contribute to social change. They do not always need to be overly public or stir up widescale rebellion; more subtle forms of agency provide a significant form of agentic power as well and are as important in relation to bringing about social change [10]. The validation of agentic variety should most certainly extend to a validation of its differentiated effectiveness.
Purposefully supporting young people as agents of change may kill the proverbial multiple birds with one stone: it may benefit their personal agency as well as, ultimately, may help change the societal conditions that shape their sexual rights, well-being, and agency in the first place. In addition, it would signify significant progress in meaningful youth participation. However, the participation of young people as agents of change may also be accompanied by disappointments, backlash, and further repression. There are many barriers and pitfalls to acting as agents of change. Clearly, this burden cannot be put on young people’s shoulders alone. Multiple support systems will have to be put in place. The literature on Meaningful Youth Participation (MYP) provides some illustration in this.

5.6. Overcoming Barriers to Meaningful Youth Participation (MYP)

A plea to concede to young people’s agentic realities, center youth perspectives, and realize meaningful ways of youth participation in CSE and SRHR programming has permeated (this article and) recent CSE literature. However, evidence shows that progress in this area is uneven, to say the least. As “having a youth program or youth project within an organization does not necessarily guarantee youth participation”, Villa-Torres and Svenamyr learned from their review of the available evidence [56] (p. S54). Research in South Africa [73] and Kenya [57] showed that, despite clear aspirations among certain groups of young people to be active agents of change and overall positive attitudes towards the principle of youth participation among CSE and SRHR stakeholders, the implementation of true and really meaningful forms of youth integration and participation suffers serious headwinds.
Among the barriers identified in the literature are a lack of innovative practices and research; a lack of knowledge and skills; and a lack of organizational readiness, guidelines, structures, and, especially, finances. In addition, educational systems in the countries investigated are such that creative critical thinking is often not stimulated or even allowed. Young people’s sexuality or addressing SRHR in general are all too often still considered taboo in the first place. Adults may consider young people’s aims a threat to existing norms and the status quo, be unwilling to see young people as equals, and/or reluctant to recognize young people’s potential value. Evelia et al. [57] cited Ahmed [74], who described that Kenyan society is characterized by deeply ingrained principles of respect for elders, expectations of strict obedience and discipline, and young people occupying an inferior position to adults. De Haas [75] demonstrated that the professional norms educators in Uganda are instructed with require a form of authority that is strongly at odds with participatory teaching methods. Additionally, Campbell et al. [73] recognized that where South African adults themselves are marginalized in society, their power over youth may be one of few spaces where they can show authority.
Adults’ (conscious or unconscious) position that young people must be disciplined and controlled is an exponent of what has been called “adultism”, defined as “behavior and attitudes based on the assumption that adults are better than young people and entitled to act upon young people without agreement” [28] (p. 1). The term has come to be used to describe and explain “not only children’s disadvantaged position within social life but also their positioning within adult-centric and paternalistic practice generated by the field of mainstream psychology” [76]. Adultism relates to status differentials and power imbalances in adult–child relations, to adult authoritarianism, and adult-centric perspectives. Adultism underscores deeply held beliefs of children as incompetent and vulnerable and of young people as inferior and as being primarily future adults, overlooking them as complex people in the present [76]. These deeply embedded social norms are at right angles with the requisite youth-centeredness of CSE and overall meaningful youth participation in SRHR programming. It is obvious that changing these norms and building on the proper conditions for MYP is an extremely challenging process. A helpful suggestion is to view youth as a cultural group rather than as an age group: A cultural group with their own valuable perspectives, competencies, and contributions [77].
From the above, it clearly follows that there is a need to also work with adults in building on young people’s agency, roles as agents of change, and MYP, notably with parents, teachers, and other professionals in the SRHR field. Adult groups will have to learn to take young people more seriously, be willing to genuinely listen to what young people have to share, and to employ true “youth-friendliness”. The professional training and coaching of teachers and other educators will have to better tune into these needs. Organizations will have to build on structures, guidelines, opportunities, proper support of young people, and funding of MYP. SRHR programmers have to also be aware that increasing a group’s agency can generate unintended effects. As people increase their voice and choice, they may make decisions that do not align with program goals. Young people increasing their (public) sexual agency may experience direct conflict or resistance in their family or community. As adolescent girls increase their capacity and ability to voice their opinion, they may begin to refuse their parents’ requests, even when those requests are protective [40]. Parenting programs are indispensable in SRHR programming and have indeed already been shown to be able to positively impact SRHR outcomes [78]. These programs enhanced parents’ own knowledge and self-confidence to discuss SRH issues with their children—an important building block for subsequent communication and support, which in turn is an important building block for young people’s creation of personal narratives related to their sexuality as a crucial site for their sexual agency [72].

5.7. Multicomponent Approaches

With this, we have totally entered the realm of multicomponent approaches in SRHR programming. Multicomponent approaches aim bringing together actions to improve individual empowerment, strengthen the health system, and create a more SRHR-supportive environment [79]. They link agency to structure. These approaches have been strongly promoted since the response to HIV shifted from an emergency to a longer-term response and since it became apparent that a more comprehensive strategy modifying social conditions rather than individual behaviors was central to success in tackling the epidemic. A social/structural approach addresses the key drivers of HIV vulnerability that affect the ability of individuals to protect themselves and others against HIV. In development work, notably in (women’s) empowerment programs, there is already a substantial tradition to focus on multicomponent strategies at different levels, such as addressing social norms, advocating for legal reforms, expanding women’s economic opportunities, safeguarding social protection, and enhancing education [80].
The call for ecological, multicomponent strategies is permeating the SRHR literature nowadays, and the notion that young people’s sexual agency and sexual citizenship cannot be achieved by CSE alone is firmly taking hold [46,81]. A 20-year ICPD progress report by Chandra-Mouli et al. [58] showed that sexuality education is most impactful when school-based programs are complemented by community elements, including condom distribution, building awareness and support, and increasing demand for SRH education and services among youth. Additionally, addressing gender inequalities; providing training for health providers; and involving parents, teachers, and other community gatekeepers, such as religious leaders, may be beneficial. The authors argue for “SRH intervention packages” to improve CSE’s effectiveness. The school as a socializing institution with solidified, school-based sex education will, however, ideally always form a firm foundation for young people’s sexual well-being. The school context has an enormous potential in terms of reach and scale. It can reach young people over multiple years with a multiplicity of educational methods. However, a variety of additional methods and strategies, especially outreach to notably vulnerable groups, will also be indispensable to extend school-based education into a solid basis for SRHR for all.
Specifically in the area of adolescent SRHR (ASRHR), Igras et al. [82] mentioned four interlinking cornerstones of their Multi-Component Systems Approach (MCSA): Strengthening sexuality information and education, strengthening youth-friendly services, amplifying community and societal support for ASRHR, and amplifying government support for ASRHR. They presented evidence showing impressive results measured by gains in adolescent knowledge, agency, and use of ASRH services and increases in community and governmental attitudes supportive of young people’s right to ASRHR. The evidence shows that in reinforcing sexuality education and ASRH services while concurrently amplifying governmental and societal support for young people, explicitly linking actions that work across components, the MCSA fosters systems inter-relatedness and reinforcement of actions across health and education sectors and government and civil society, which leads to normalization of ASRHR across the social and systems ecology.
This does not refrain from the fact that normalization of ASRHR and changing related social norms is a delicate and complex process. Prerequisite for the effectiveness of social-norms-shifting interventions is careful assessment of the (local) context, meticulously mapping support and resistance among stakeholders, and developing a detailed Theory of Change [54]. IRH [54] stresses that, notably when empowerment and strengthening agency are involved in norm-changing programs, it is extremely important to carefully consider how to build agency within the community and the cultural context of a program. Externally defined agency can generate pushback, increase risk for harm, and poorly reflect the values or vision of a community. A systematic review of evaluations of gender transformative programs has also shown the importance of cultural sensitivity and community involvement, inclusion of multiple stakeholders and sectors, and the implementation of diversified strategies as notable preconditions to touch upon broader systems of inequality and accomplish broader norm change (beyond effects on individual health and gender-related indicators) [62].

6. Conclusions

This article has reviewed relevant literature and scholarly debates on young people’s sexual agency and their implications for CSE and SRHR programming. We endorsed the many criticisms on traditional (individualistic, simplistic, one-dimensional) understandings of (sexual) agency. Sexual agency is a complex, multi-layered, utterly context-related, and variable phenomenon (also see Box 1). Its complexity and volatility undeniably pose difficulties for research, education, and overall SRHR programming. It has these difficulties in common with the concept of empowerment [83]. Both sexual agency and sexual empowerment relate to complex, multifarious processes of gradual optimization of the possibilities of individuals to realize their sexual rights and well-being. These processes necessarily take place on the part of the individual as well as of the surrounding context and, notably, at the interface between the two. There is no going around addressing young people’s sexual agency nor empowerment. They are central to any progress in the area. We have put forward validation of agentic variety, gender transformative approaches, meaningful youth participation, and multicomponent strategies as essential in building young people’s sexual agency and their role as agents of wider societal change. We also showed that these conditions, wherever they have been studied, are far from being realized. We identified “adultism” as an important barrier and a deeply embedded social norm in need of adjustment. Research methods in the area also need to adapt to the growing insights into the complexity of youth sexual agency. Therefore, we urge those working in the field to continue to study, comprehend, and tackle sexual agency. We press for all scholars and practitioners to keep innovating their methods and approaches and share their experiences. For it is not until all young people’s sexual agency is recognized, supported, and validated at the multiple societal levels involved that SRHR for all becomes a feasible goal.
Box 1. Key take aways.
Sexual agency is a complex, multi-layered, utterly context-related, and variable phenomenon. It relates to individual-level behavior, the opportunity structure (e.g., what choices do people have), and the interaction between them. Agentic behavior is not one-directional towards healthy outcomes but includes navigating—sometimes contradicting or opposing—options, desires, and considerations. Strengthening young people’s agency by SRHR programming is therefore challenging and should consider the following main lessons:
There is no one-size fits all: individual-level situations and realities must be taken into account;
Center young people to ensure programs address their concerns, interests, realities, and suggestions. Active participation is key, and involved professionals (e.g., teachers) should facilitate the empowerment process rather than teach content or regulate behavior;
Importance of navigation skills: rather than teaching students to “take the right decision”, programs could strengthen young people’s skills to navigate their realities and prepare them for a “bumpy road”. Critical reflection, sexual literacy and negotiation skills are among the core competencies to be strengthened;
Gender transformative approach is essential to address harmful gender norms, sexual double standards, and heteronormativity that impede sexual agency, rights, and wellbeing;
Involve and support young people as agents of change;
Work with adults to create a more enabling environment for young people’s sexual agency and to enable young people to participate meaningfully and act as agents of change; and Focus on multi-component system approaches to address the systemic barriers for individual-level agency.

Author Contributions

Conceptualization, methodology and investigation, all authors; writing-original draft preparation, I.V.; writing-review and editing, M.C., M.v.R., and J.W.; All authors have read and agreed to the published version of the manuscript.


The contribution of Judith Westeneng was supported by NWO-WOTRO under Grant W08.560.004. The research received no other external funding.

Conflicts of Interest

The authors declare no conflict of interest.


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Vanwesenbeeck, I.; Cense, M.; van Reeuwijk, M.; Westeneng, J. Understanding Sexual Agency. Implications for Sexual Health Programming. Sexes 2021, 2, 378-396.

AMA Style

Vanwesenbeeck I, Cense M, van Reeuwijk M, Westeneng J. Understanding Sexual Agency. Implications for Sexual Health Programming. Sexes. 2021; 2(4):378-396.

Chicago/Turabian Style

Vanwesenbeeck, Ine, Marianne Cense, Miranda van Reeuwijk, and Judith Westeneng. 2021. "Understanding Sexual Agency. Implications for Sexual Health Programming" Sexes 2, no. 4: 378-396.

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