A Call for (Renewed) Commitment to Sexual Health, Sexual Rights, and Sexual Pleasure: A Matter of Health and Well-Being

In this charged political moment, and despite all efforts to the contrary, the public health community must take on, and not shy away from, a rights- and pleasure-affirming concern for sexual health and well-being. This is recognizably no small task. Failing to recognize that some of the primary factors behind sexual health risk are in fact issues that relate to sexual rights, desire, and pleasure, the global and national policy and programmatic standards that do exist, as well as the sexual health programs in place in most of the world, still primarily tend to address the negative consequences associated with sexuality, such as the prevention of unintended pregnancies, HIV, and sexually transmitted infections.

POLITICS, EFFECTS, AND PROGRAMMING CONCERNS

Sexual pleasure is a difficult topic for many to address openly, including some within the public health community, even though the links between sexual health and sexual pleasure have long been understood. Around the world, the failure to approach sexual health comprehensively from its very roots and intersections with pleasure, sexuality, and sexual rights has had very real and negative consequences. The pathways to how individuals seek and enjoy sexual pleasure are complex and bring into play larger economic, social, cultural, political, and structural issues that go beyond the typical responsibilities of a health provider. This has implications not only for public health programming and service delivery but also for law and policy and, ultimately, for how people relate to their own bodies, establish relationships, and exist in the world.

In the face of new and reemerging challenges, including ideological attacks against gender equality, sexuality, reproductive freedom, and self-determination, as well as growing nationalism and populism, increased conservatism, and the larger geopolitics around the world, the standards set in 1994 at the International Conference on Population and Development (ICPD) are emerging as a key touchstone for improving (or at least holding the line on) sexual health around the world.¹ At the 1994 International Conference on Population and Development, 179 governments adopted a Programme of Action that recognized the role that reproductive health and gender equality play in the pathway to sustainable development. The adoption of the ICPD Programme of Action was a critical step in moving population concerns away from demographic targets and toward equality and rights-affirming policies and programs, but it was limited in its vision of sexual health, let alone rights and pleasure. Adopting this Programme of Action required political compromises, resulting in sexual health being affirmed within the larger rubric of reproductive health, no mention of pleasure, and the acceptance of the concept and language of reproductive rights rather than sexual rights more generally. A spate of international commitments have followed, more or less based on these initial approaches to sexual health, including the Beijing Fourth World Conference on Women, and today the world is aiming to achieve the United Nations Sustainable Development Goals by 2030, with universal sexual and reproductive health noted as central to much of this agenda.^2–4

Although there is a cursory nod now and again to the role of sexual rights in many international fora, the irony of the current importance of these commitments is that despite evidence of the magnitude of pleasure and rights to sexual health, none has been explicit in addressing pleasure in the context of sexual health or within the broader agenda of health and development. This not only creates “rhetorical problems” but also has had major implications for the targets and indicators set through the Sustainable Development Goals process, the type of data collected by countries in relation to their commitments, and ultimately which programs are funded and in place.

Most lawmakers and policymakers, program managers, and health service providers are not prepared to address the complexity of sexual pleasure or to address the diverse ways in which sexual pleasure is experienced at different points of life (adolescence, adulthood, and older age) or among different populations. The public health community therefore has an important role to play. The World Association for Sexual Health (WAS) has, since 2008, recognized sexual pleasure as a component of holistic health and well-being. After several years of work, the WAS adopted a World Congress of Sexual Health Declaration on Sexual Pleasure in October 2019.⁵ Although the WAS is a professional organization, this declaration, which is circulating widely, may bring a fresh approach to public health spaces and to what governments can be encouraged to understand as their responsibilities for sexual health, despite the larger geopolitical constraints mentioned earlier. Most important, and with concrete examples, the declaration explicitly calls for an intersectional, interdisciplinary, and multisectoral approach to research, programs, service delivery, and advocacy that fully takes into account the links between sexual health and sexual rights and pleasure.

A WAY FORWARD

We need to ensure in our own research, programming, service delivery, and activism in sexual health that we pay attention to pleasure and sexual rights for all people, including adolescents; sex workers; those living with HIV; lesbian, gay, bisexual, transgender, and intersex individuals; refugees or internally displaced persons; persons with disabilities; religious or ethnic minorities; or any combination thereof. A potential first step may be to begin mapping the cases in which sexual health, rights, and pleasure have been successfully brought together conceptually and operationally with documented effects on people’s sexual health in all parts of the world, as well as those cases in which gaps have resulted in limitations on sexual rights and pleasure. Attention needs to be given to the diverse and contextual ways through which individuals exercise choice and privacy; enjoy dignity, nondiscrimination, and safety; receive information; and experience sexual pleasure. An intersectional understanding of sexual health, sexual rights, and sexual pleasure within a broader public health agenda reminds us that we need to pay attention to laws and policies, not just programs and service delivery. The law can be positive and supportive, such as when it makes comprehensive sexuality education available, but it also can be harmful, such as when it does not allow adolescents or married women to access sexual health services without parental or spousal consent, respectively. With respect to service delivery, a great deal of education and other work must be done to move the profession beyond simply addressing the negative consequences of sexual behavior but actually addressing sexual pleasure as an integral part of sexual health.

Focusing on sexual rights and pleasure for all people, beyond simply, of course, the need to engage in good science, is a matter of prudence to all our work. It is not a luxury or a distraction. For the public health community to move the needle on sexual health will require not only moving beyond pathologizing and negative approaches but also bringing explicit, positive, and affirming attention to sexual rights and pleasure.