Sexuality, Health, and Human Rights

Over the past 25 years, there has been a veritable explosion of public health research on sexuality. Never have sex and sexual matters been more topical or more worthy of scientific attention.

After a brief interlude of research attention to the subject of sex in the mid-20th century, when the controversial Kinsey studies were published, research focusing on sexuality at the population level languished, and financial support for such work was almost nonexistent. Particularly in the wake of the emerging HIV/AIDS epidemic in the 1980s, the consequences of this long-term neglect of inquiry into sexuality and health became apparent, as did the limitations of existing conceptual frameworks and methodological approaches. The urgent need for more innovative approaches to the study of sexual life became evident.

As public health researchers and practitioners have struggled to address these issues in recent decades, a new wave of research, intervention, and sexual health promotion began to take shape, usually from the ground up, in response to the needs and demands of local communities struggling to respond constructively to a range of sexual health challenges.1

SEXUALITY AND SOCIAL MOVEMENTS

Contrary to what is commonly supposed, the impetus for present-day concern for sexuality and sexual health emerged not from within mainstream biomedicine and public health but from fields peripheral to these—in particular, from the “Cinderella specialties” of genitourinary medicine and reproductive health and from community activism to secure the rights of women, gay men, and other marginalized groups. Indeed, one of the key aspects of research and intervention on sexuality and health that has distinguished this area of work from many others is the extent to which it has been shaped by an evolving set of highly active and engaged social movements.

It is impossible to imagine the recent explosion of work in this area independent of the development of the feminist and women’s health movements. The analysis of gender and gender power differentials as central to any full understanding of sexual relations and interactions has been a crucial contribution of feminist analysis, one that has shaped our understanding of the most pressing research issues and the most difficult barriers to effective interventions for sexual health. But just as the feminist and women’s health movements shaped our understandings of the sexual field, so too have the lesbian, gay, bisexual, transgender, and queer (LGBTQ) movements. Emerging before AIDS in many industrialized countries, and often in the wake of AIDS in many developing nations, LGBTQ scholarship and activism have played a central role in calling attention to sexual diversity. In so doing, LGBTQ scholarship and activism have caused us to rethink our understanding of taken-for-granted categories and classifications—male/female; woman/man; heterosexual/ homosexual; normal/abnormal—that had been used hitherto to map out the sexual field. Like feminism, LGBTQ thinking has drawn attention to the relationship between sexuality and power and has highlighted the need for new conceptual frameworks, novel sampling strategies, and innovative methodological approaches to the study of sexual communities and sexual life.

Finally, perhaps inevitably, drawing strength from the feminist and LGBTQ movements, HIV/AIDS activists—first in the West and more recently in developing countries—have advocated for more effective research and programs on sexuality and health. AIDS activists have been at the forefront in building political alliances around HIV prevention and treatment access—alliances that have remade the design and implementation of public health policy, research agendas, and programs, whether at the level of communities, countries, or international and intergovernmental agencies.

One of the key insights that has emerged from these social movements, and from the work of researchers influenced by them, is the conviction that sexuality cannot be understood apart from social, political, and economic structures or without reference to the cultural and ideological discourses that give sexuality meaning. Sexual health problems are never evenly distributed across all population groups. On the contrary, sexual health problems are systematically shaped by multiple forms of structural violence—institutionalized poverty, racism, ethnic discrimination, gender oppression, sexual stigma and oppression, age differentials, and related forms of social inequality—in ways that typically harm and negatively affect groups and populations already marginalized or oppressed.

We are only beginning to understand the concrete mechanisms through which various forms of structural violence work in synergy to shape key sexual health problems in specific locations and how these problems then reinforce the very forms of oppression that helped to create them, undermining community structures and rolling back development. Nowhere can this cycle be seen more clearly than in HIV-related stigma and the manner in which those most vulnerable are blamed for engaging in behaviors that expose them to infection and being seen as unworthy of public health attention.2

By confronting the challenges to sexual health and well-being, we are forced to move beyond a concept of public health practice as a technical exercise and to rethink moral, ethical, and political dimensions of our work as part of a broader process of social change. Although this idea has long been one of the guiding principles of social medicine and public health, it has become especially relevant in sexuality and health and is crucial in the move from research to practice in sexual health promotion.3

SEXUALITY AND HUMAN RIGHTS

One of the key consequences of the important role played by social movements in relation to sexuality and health has been the calling of attention to the need to speak of research and intervention as extensions of broader struggles for human rights and social justice. Whether the focus is HIV/ AIDS, unwanted pregnancy, sexual abuse and violence, or any other major sexual health issue, sexual health promotion programs around the world have emphasized the profound importance of empowerment, or socially engaged agency, as a precondition for reducing risk and vulnerability.

Human rights approaches offer one of the theoretical and methodological underpinnings of effective sexual health promotion. Sexual rights is still a relatively new area in the human rights discourse—it has been called “the new kid on the block” in international debates4—but it is clear that sexual rights embrace those human rights already recognized in national laws, international human rights documents, and similar consensus documents developed with the United Nations and its various agencies.

Sexual rights include “the right of all persons, free of coercion, discrimination and violence,” to attain the highest possible “standard of sexual health, including access to sexual and reproductive health services”5 Sexual rights also include the right to seek, receive, and pass on information about sexuality and the right to sexuality education. Sexual rights include, above all, the right to have one’s bodily integrity respected and the right to choose—to choose whether or not to be sexually active, to choose one’s sexual partners, to choose to enter into consensual sexual relationships, and to decide whether or not, and when, to have children.

Ultimately, what might be described as true sexual citizenship is possible only when all people have the right to pursue a satisfying, safe, and pleasurable sexual life. But the full realization of sexual citizenship depends on more than state-protected rights. The idea of sexual pleasure, its definitions, its language, and its expression all typically come from the grassroots—from society at its most basic, local level—rather than from government or scientific bodies. Social, cultural, religious, biomedical, scientific, and other nonstate actors are primarily responsible for respecting (or not) the right to sexual pleasure, by abiding (or not) by fundamental principles of equality, freedom, and human dignity.6

Although it is clear that we are still far from fully realizing the potential of sexual rights in any society, it is equally evident that the road to sexual health is underpinned by the struggle for sexual rights. Without being firmly rooted in a conception of and commitment to sexual rights, sexual health promotion can never be effective. Equally important, how the field of public health approaches sexuality shapes society’s ability to realize sexual rights as part of a broader commitment to human dignity and worth. The current wave of public health research and intervention on sexuality and health marks an important step in this direction.

Figure 1.

Three performers dressed with Colombian flag colors dance in Bogota, Colombia, as part of a city project to promote human rights and sexual diversity. Source. Photograph by William Fernando Martinez. Printed with permission of AP Photo.