Sexual health, sexual rights and sexual pleasure

Author(s): Sofia Gruskin, Vithika Yadav, Antón Castellanos-Usigli, Gvantsa Khizanishvili

and Eszter Kismödi
Source: Sexual and Reproductive Health Matters , December 2019, Vol. 27, No. 1 (December
2019), pp. 29-40
Published by: Taylor & Francis, Ltd.

Stable URL: https://www.jstor.org/stable/10.2307/48617554

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REVIEW ARTICLE

Sexual health, sexual rights and sexual pleasure: meaningfully

engaging the perfect triangle
Sofia Gruskin ,a Vithika Yadav,b Antón Castellanos-Usigli,c Gvantsa Khizanishvili,d
Eszter Kismödie
a Chair of the Global Advisory Board for Sexual Health & Wellbeing; Director of the Institute on Inequalities in Global Health,
Program on Global Health and Human Rights, University of Southern California, Los Angeles, CA, USA. Correspondence:
[email protected]
b Member of the Global Advisory Board for Sexual Health & Wellbeing; Head of Love Matters India, Delhi, India
c Member of the Global Advisory Board for Sexual Health & Wellbeing; Director of Prevention Programs at Wyckoff Heights
Medical Center, Brooklyn, NY, USA
d Member of the Global Advisory Board for Sexual Health & Wellbeing; World Contraception Day Ambassador for Eastern
Europe and Central Asia, Tbilisi, Georgia
e Member of the Global Advisory Board for Sexual Health & Wellbeing; Chief Executive, Sexual and Reproductive Health
Matters, Geneva, Switzerland

Abstract: To improve sexual health, even in this charged political moment, necessitates going beyond
biomedical approaches, and requires meaningfully addressing sexual rights and sexual pleasure. A world
where positive intersections between sexual health, sexual rights and sexual pleasure are reinforced in law, in
programming and in advocacy, can strengthen health, wellbeing and the lived experience of people
everywhere. This requires a clear understanding of what interconnection of these concepts means in practice,
as well as conceptual, personal and systemic approaches that fully recognise and address the harms inflicted
on people’s lives when these interactions are not fully taken into account. Bridging the conceptual and the
pragmatic, this paper reviews current definitions, the influences and intersections of these concepts, and
suggests where comprehensive attention can lead to stronger policy and programming through informed
training and advocacy. DOI: 10.1080/26410397.2019.1593787
Keywords: sexual pleasure, sexual rights, sexual health, human rights, multi-disciplinary perspectives,
advocacy, policy, programming

Introduction for civil society, we move beyond drawing attention

Meaningful concern for sexual health requires atten- only to the negative but set out to highlight positive
tion to political currents, and social movements, examples of how sexual health, sexual rights and sex-
within countries as well as at regional and global ual pleasure have been and can be jointly addressed.
levels, as these influence health, legal and policy stan- It is worth recalling that sexual health has been, and is,
dards, and the impacts these all have on people’s lived for almost all actors in both global and national
experience of their sexuality, sexual health, sexual spaces, a legitimising way to address sexual rights
rights and sexual pleasure. As inadequate support in and sexual pleasure. Sexual health as an entry point
any one area can have negative effects on the others, allows engagement not only with the health sector
this paper takes as its starting premise that all efforts but with programmers and policymakers who might
must be made to support a perfect triangle of sexual not otherwise be immediately sympathetic to the
health, sexual rights and sexual pleasure for all people importance of rights and pleasure.
everywhere in the world. Given the current political
moment with retrenchments occurring everywhere Defining and understanding the context of terms
from the local to the global, increased conservatism The terms “sexual rights,” “sexual health” and “sex-
in all parts of the world, let alone shrinking space ual pleasure” have been used in very different ways

© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group 29
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://
creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.

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S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

by the many technical and political actors engaged Sexual health was first defined rather vaguely by
in this work. To ensure clarity, each is briefly dis- the World Health Organization (WHO) in a 1975
cussed below, along with proposed definitions Technical Report as:
(see Box 1) as these will be relevant to the sections “the integration of the somatic, emotional, intellec-
on policy, programming and advocacy that follow. tual and social aspects of sexual being, in ways
that are positively enriching and that enhance per-
Box 1. Defining terms used in this article sonality, communication and love.”3
Sexual Health Twenty years later, the Programme of Action of the
“ … a state of physical, emotional, mental and social well- International Conference on Population and Devel-
being in relation to sexuality; it is not merely the absence of opment4 included sexual health under the defi-
disease, dysfunction or infirmity. Sexual health requires a nition of reproductive health, indicating that its
positive and respectful approach to sexuality and sexual purpose is:
relationships, as well as the possibility of having pleasurable
“the enhancement of life and personal relations,
and safe sexual experiences, free of coercion, discrimination
and not merely counselling and care related to
and violence. For sexual health to be attained and
reproduction and sexually transmitted diseases.”4
maintained, the sexual rights of all persons must be
respected, protected and fulfilled.”1 This definition has since been widely used by glo-
Sexuality bal organisations including the World Health
Organization (WHO) and non-governmental insti-
“ … a central aspect of being human throughout life
tutions such as the International Planned Parent-
encompasses sex, gender identities and roles, sexual
hood Federation (IPPF), with important
orientation, eroticism, pleasure, intimacy and reproduction.
implications also for the approach to sexual health
Sexuality is experienced and expressed in thoughts, fantasies,
taken by the national level government and civil
desires, beliefs, attitudes, values, behaviours, practices, roles
society actors.
and relationships. While sexuality can include all of these
With respect to sexual rights, arguably to this day
dimensions, not all of them are always experienced or
no language has been as important as the political
expressed. Sexuality is influenced by the interaction of
articulation in the 1995 Beijing Platform for Action
biological, psychological, social, economic, political, cultural,
from the Fourth World Conference on Women.5
legal, historical, religious and spiritual factors.”1
Paragraph 96, which sits within the health section
Sexual Rights of the document, states:
“The application of existing human rights to sexuality and
“The human rights of women include their right to
sexual health constitute sexual rights. Sexual rights protect all
decide freely and responsibly on all matters related
people’s rights to fulfil and express their sexuality and enjoy
to their sexuality, free of coercion, discrimination
sexual health, with due regard for the rights of others and
and violence.”5
within a framework of protection against discrimination.”1
Sexual Pleasure Essential in providing for the first time an inter-
national mandate to focus on, and invest in,
“Sexual pleasure is the physical and/or psychological women’s reproductive and sexual health beyond
satisfaction and enjoyment derived from solitary or the need to control women’s fertility as part of a
shared erotic experiences, including thoughts, dreams demographic agenda, and grounded within the
and autoeroticism. Self-determination, consent, safety, internationally agreed legal human rights frame-
privacy, confidence and the ability to communicate and work, this remains, despite its obvious limitations,
negotiate sexual relations are key enabling factors for the strongest statement agreed to by the govern-
pleasure to contribute to sexual health and wellbeing. ments of the world.
Sexual pleasure should be exercised within the context of Beyond rhetorical articulation of a comprehen-
sexual rights, particularly the rights to equality and non- sive sexual and reproductive health and rights
discrimination, autonomy and bodily integrity, the right (SRHR) agenda since the Cairo and Beijing articula-
to the highest attainable standard of health and freedom tions, the reality within countries and at the global
of expression. The experiences of human sexual pleasure level has been a siloed approach with reproductive
are diverse and sexual rights ensure that pleasure is a health (and at times reproductive rights) higher on
positive experience for all concerned and not obtained by donor and policy maker agendas (whether driven
violating other people’s human rights and wellbeing.”2 by demographic trends, fertility control, ignorance

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 S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

or discrimination) even when the language is used. has contributed significantly to the understanding
The limits to meaningful interaction between work and acknowledgement of sexual rights internation-
to support sexual rights and reproductive rights is ally, issued a revised Declaration of Sexual Rights in
also embedded in movement politics; many move- 2014,15 and an accompanying Technical Docu-
ments, including women’s health and rights, dis- ment16 taking a comprehensive approach to sexual
ability rights and reproductive health and rights rights as human rights from a multi-disciplinary
movements have tended to neglect issues of sexu- perspective and, importantly, with great attention
ality and sexual pleasure.6 Likewise, those working to pleasure as an element of sexual health and sex-
on sexual rights have more often than not stayed ual rights.17
away from reproductive health and rights in their Civil society organisations internationally,
advocacy work7 for substantive but also political regionally, and locally, such as CREA,18 the Sexual
reasons. Rights Initiative,19 and The Egyptian Initiative for
The HIV/AIDS movement, and the ways in which Personal Rights,20 and scholarly initiatives with a
it brought focus to the rights of key populations, strong focus on advocacy, such as Sexuality Policy
including their sexual and reproductive rights, Watch,21 have contributed significantly to the
has been the most useful in helping to catalyse advancement of sexual rights in the international,
greater engagement between movements/consti- regional, national and local political spheres.
tuencies and those driving HIV prevention pro- Sexual pleasure is the newest arrival to the sex-
grammes to address sexual health and sexual ual health and sexual rights policy landscape, the
rights more comprehensively, even as pleasure least developed and potentially the most open to
has rarely been a part of these conversations.8 In interpretation. Outside the context of sexology,
addition, and in parallel, the global women’s the study of sexual pleasure – when it has occurred
health and rights movement, LGBTIQ* movements, – has generally had a narrow heteronormative
trans and intersex rights mobilisation, youth mobi- bias,22 addressing pleasure through a default
lising on sexual and reproductive health and focus on adults and within marriage, including in
rights, advocacy and programmatic work for sex medical text books, sexuality education, etc.22,23
workers’ rights and the disability rights movement Sexual pleasure most frequently emerges in policy
– have started to force attention to taboos, stigma, and programming as a consideration relevant to
discrimination and human rights violations and sexuality or sexual health, rather than as a topic
led to broader recognition of human rights related in its own right. Rights-based operational defi-
to sexuality and sexual health more broadly for all nitions of sexual pleasure in the context of sexual
people.9 The fact that this focus has been on health, and more broadly, have been sorely
harms, and not pleasure, has in some ways shaped lacking.
the discourse. Nevertheless, the result has been an The World Association for Sexual Health (WAS),
increased and comprehensive understanding of noted above, has been perhaps the most for-
sexual rights as human rights relevant to sexuality ward-looking in recognising the linkages between
and sexual health. This growing understanding has sexual pleasure, rights and health. As a pro-
been reflected in the work of WHO10 and other fessional association with global relevance, as far
United Nations (UN) agencies, such as the UN Pro- back as 2008, it urged all governments, inter-
gramme on HIV/AIDS (UNAIDS), the UN Population national agencies, private sector, academic insti-
Fund (UNFPA), and the Office of the UN High Com- tutions and society at large, to recognise sexual
missioner for Human Rights (OHCHR), including in pleasure as a component of holistic health and
their inter-agency statements (for example, on wellbeing17 and has since urged various actors to
forced sterilisation,11 elimination of discrimination recognise the importance of sexual pleasure in
in health care settings12 and elimination of vio- research, policy and service delivery, and con-
lence and discrimination against LGBTI people,13) nected to sexual rights not only from the “free
as well as the work of international non-govern- from violence perspective,” but from the perspec-
mental organisations such as IPPF.14 The World tive of positive sexuality.15 It has also initiated
Association for Sexual Health (WAS), whose work expert consultations with the WHO and other rel-
evant organisations, to urge them to adopt defi-
nitions of sexuality, sexual health and sexual
*In this context, LGBTIQ denotes the lesbian, gay, bisexual, rights, which recognise pleasure as a central
transgender, intersex, and queer or questioning movements. element of those definitions. Inspired by the WAS

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S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

articulation, we adopt the working definition of their sexual health and exercise their sexual rights.
sexual pleasure put forward by the Global Advisory Legal frameworks can have content that respects
Board for Sexual Health and Wellbeing2 for pur- and protects human rights, for example those
poses of this article (see Box 1), given its intent to that provide access to comprehensive sexuality
highlight the interconnections with sexuality, sex- education or give equal opportunities in all areas
ual health, and sexual rights. of life for people regardless of sexual orientation,
gender identity and expression and age. On the
other hand, laws may create limitations to sexual
Linkages health and pleasure, such as those that do not
The links between sexual pleasure and sexual allow adolescents or unmarried people to access
health have long been understood. Sexual health sexual health services without parental or spousal
is now also recognised to be closely associated consent.10 Further, criminalisation of certain beha-
with the extent to which people’s human rights viours and identities (e.g. LGBT populations) has
are protected.24 To date, however, there has greatly limited the ways in which sexual pleasure
been insufficient attention to the ways in which has found expression in policy and programmes.
people’s experience of sexual pleasure is not only In addition, the emergence of “adolescents” as a
tied to their sexual health but dependent on the category of people requiring intervention has put
extent to which their sexual rights are respected, a focus on the “prevention” of harms in legal fra-
protected and fulfilled.25 Undue weight seems meworks (early marriage, early pregnancy and
still to be accorded to the health system and childbirth, etc.) and largely ignored positive atten-
other related institutions as core enablers of indi- tion to their pleasure, sexuality and sexual rights.
vidual pleasure. The pathways to how individuals The stigma associated with premarital sex and
seek and enjoy pleasure are often much more the “moral panic” that accompanies conversations
complex and frequently the interface with the about young people’s, particularly young women’s,
health system or facility happens only later, and sexuality is profound and deeply ingrained, and
if there are health consequences (e.g. unintended “policy” level advancements to address these issues
pregnancy, infections, need for contraception, often have to deal with backlash and opposition.
etc.). The failure to comprehensively approach sex- Social cultural taboos in relation to sexuality are
ual pleasure from its very roots and intersections often embedded in laws and policies with negative
with sexuality, sexual health and sexual rights effects on sexual health and pleasure. For example,
has real implications for people’s lives, including laws that penalise and criminalise sexual health
not only limits to the protections from sexual vio- related matters, such as same-sex sexual acts and
lence, and to the information and health services behaviours, transgender expression, sex work,
people can receive, but also from the perspective HIV transmission, possession of a condom as evi-
of how people can relate to their own bodies, dence of crime, and penalisation of the advertise-
establish relationships, and live in the world. ment of contraception or abortion, codify a
Using the definitions noted above to guide our restricted approach to morality and reinforce
analysis, below we provide some broad brush- power structures that control the bodies and beha-
strokes to explore the ways in which the intersec- viours of marginalised and discriminated against
tions of sexual health, sexual rights and sexual populations. The burden of unjustified use of crim-
pleasure are currently considered in policy and inal and punitive laws is significant: certain popu-
programming, and suggest some opportunities lation groups, such as gay, lesbian and transgender
for advocacy to further strengthen these linkages. people, women, adolescents, people engaged in
sex work, and those living with HIV, can experience
Assessing laws and policies difficulties in accessing relevant services, let alone
Laws and policies matter because they set rules engaging in positive sexual experiences, with direct
and frameworks for people’s conduct in society impacts on health and pleasure.26
and for programmatic interventions. They can con- Controlling, undermining, restricting and medi-
tribute to or obstruct the development of program- calising the sexual needs and desires of certain
matic and service delivery interventions on sexual populations can result in coercive laws, policies
health, deter or support people’s experience of sex- and practices. For example, the desires, pleasure
ual pleasure, and enable or disable people to seek and sexual health and rights needs of people living
and receive the information they require to protect with disability, including with intellectual

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 S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

disabilities, are still often undermined, and con- relation to sexual functions and dysfunctions; de-
trolled through forced sterilisation policies and psychopathologising gender expression, and elimi-
practices, inaccessibility of sexuality, and sexual nating any remaining codes related to sexual
health information and services.9 People with dis- orientation.31 All of these changes are not only jus-
abilities are often infantilised through laws and tified from the sexology and sexual health perspec-
policies and held to be asexual27 (or in some tive but also support sexual rights and different
cases, hypersexual), their pleasure irrelevant at forms of pursuing consensual pleasure.32
best, incapable of reproduction and unfit sexual/ Human rights bodies, such as the UN Human
marriage partners or parents.28 For women, dis- Rights Committee, the Committee Against Torture,
ability may mean legal exclusion from a life of and the European Court of Human Rights, as well
partnership and active sexuality, and denial of as national Constitutional Courts, have increasingly
opportunities for motherhood.29 These laws, pol- applied human rights standards, such as the rights
icies and controlling practices undermine the to non-discrimination, freedom from inhuman
equal rights of people with disabilities, their and degrading treatment, human dignity, self-
need for access to information and services, and determination and bodily integrity, to various
their desires for pleasure, reproduction and sexuality and sexual health related issues with
parenting. positive implications for both health and pleasure.
While laws and policies should be set in such a These linkages are visible in their decisions, though
way that they respect human rights and acknowl- often related to the provision of health services, on
edge sexual desire and pleasure as a basic such issues as forced sterilisation, involuntary sur-
human need, many laws that are set with the geries on intersex and transgender people, manda-
intention to protect can end up being discrimina- tory HIV testing, and access to abortion, for
tory and coercive by, for example, not recognising example, in cases of rape.16 These human rights
non-binary gendered bodies, same-sex sexual prac- standards, in turn, are increasingly reflected both
tices, or the sexual desires of people under the age in public health policies and programmes with
of 18 years old. For example, rape laws that do not positive implications for health, wellbeing and
recognise rape in marriage, or consider any sexual pleasure, with particular attention to the protec-
act to be rape if it occurs with a person under the tion of sexuality from the privacy perspective.16
age of 18 years old, or recognise only vaginal pen- Within countries, laws and policies that decrimina-
etration by a penis as rape, exclude many people lise consensual sexual behaviours, eliminate man-
from the spectrum of protection.16 datory medical interventions, provide people
Thus, application of the triangle approach to under 18 years old access to the sexual health edu-
sexual health, rights and pleasure proposed here cation, information and services they require,
would require not only careful analysis but also serve as good examples of attention to the kinds
amendment of laws and policies to ensure they of policies needed to ensure health, wellbeing,
do not inadvertently discriminate, and that they rights and pleasure for all populations.10
respect the rights-based definitions of sexuality,
sexual health, and pleasure presented in Box 1. Assessing programming – within and beyond
Some positive developments are occurring in this the health sector
regard at both the international and national Historically, sexual health and rights programmes
levels. have tended to focus on preventing negative con-
For example, WHO initiated changes to the sequences associated with sexuality, such as: pre-
International Classification of Diseases (ICD10)30 vention of unintended pregnancies, HIV and
that is the lead international policy on classifi- sexually transmitted infection (STI) prevention
cation of diseases and health conditions. The ICD and treatment and addressing sexual dysfunction.
greatly influences not only the utilisation of ser- The importance of addressing the negative conse-
vices and insurance codes, but the setting and quences of sexual health behaviours should not
implementation of national laws, standards of be minimised. In many cases, however, this
care, services, medical education and research. approach has failed to recognise that some of the
Accordingly, WHO elaborated a new chapter for primary factors behind sexual health risk, and
ICD 11, called “Conditions related to sexual the need for sexual health information and ser-
health,” that brings a more holistic view to sexual vices, are issues that relate to rights, pleasure
health, by connecting the body and mind in and sexual desire and not to morbidities and

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S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

mortalities.33 The fact that some people don’t seek could also be considered a “sex-positive” approach
the assistance of sexual health providers until they to sexuality and sexual health, constituting an
face a negative consequence related to their sexual approach that celebrates sexuality as a part of
activity (such as an STI, erectile dysfunction or con- life that can enhance happiness, and not solely
traceptive failure) can reinforce the notion that the focused on preventing negative experiences.
health provider’s role is only to resolve these nega- Sexual health programmes, including those that
tive issues. The majority of health service providers address reproductive health and rights concerns,
are not prepared to address the complexity of sex- can cover a wide range of specific thematic areas
ual pleasure (including the dissociation of safety and goals. They can focus on the provision of sexu-
and pleasure) and the diverse ways in which it is ality education and/or information (including
experienced at different points of life (adolescence, capacity building programmes for service provi-
adulthood and older age) and among different ders, peer educators or teachers) and the provision
populations (for example, lesbians, gay men and of a wide range of sexual health services, including
transgender people, as well as people living with sexuality counselling, HIV and STI prevention, test-
HIV, among others). ing and treatment, prevention of unwanted preg-
Sexuality, sexual desire and sexual pleasure nancies, abortion, prevention, testing and
remain subjects of shame and stigma in many treatment for human papillomavirus (HPV) and
parts of the world, with sexual health programmes cervical cancer, prevention and treatment of testi-
that only focus on the unwanted consequences of cular cancer, addressing sexual dysfunction, pro-
sexual behaviours, sexual morbidities and “nor- viding advice and services on sexuality, and so on.
malised” heterosexual sexual practices further con- The education of health providers is crucial for
tribute to stigmatisation. Programmes that them to be able to deliver quality sexual (and repro-
promote fear around the negative consequences ductive) health services that incorporate rights and
of sexual activity are based on a risk approach, pleasure for all people: adolescents, adults, and
and leave important conversations about sexual the elderly, regardless of sexual identity, social or
health, sexual rights and sexual pleasure aside. demographic characteristics. Gender stereotypes
Abstinence-only sexuality education is a particu- often shape health-care providers’ interactions
larly vivid example as, amongst other harms, it with clients and providers’ response to adolescents
promotes the belief that premarital sex is seeking sexual health care can be similarly shaped
“immoral,” and reinforces traditional gender by their own personal views and experiences
norms, such as the idea that it is unacceptable about young people.37 For all of these reasons,
for women to express sexuality or sexual plea- health-care providers may promote interventions
sure.34 These programmes have had a lot of politi- that are more in keeping with their own beliefs
cal support from conservative governments, such than with the needs, rights and desires of their cli-
as the Trump presidency in the US. ents.38 Yet it is worth recognising that some of the
Within the risk-based approach most common reason for this is not stigma but lack of training.
to programmatic work in this area, the importance Aside from select psychologists, sexologists or sex
of sexual pleasure to enable sexual health and therapists, health-care providers are often not
wellbeing is not well recognised, despite evidence encouraged or sufficiently trained to feel comforta-
that demonstrates its relevance. For example, pro- ble providing services which place pleasure or rights
moting pleasure in male and female condom use, at the centre of their engagement with clients.
alongside safer sex messaging, has been found to In many countries, both medical students and
increase the consistent use of condoms and the practicing physicians “receive variable, nonstan-
practice of safer sex. This “power of pleasure” dardized, or inadequate training in sexual history
approach,35 has been implemented with great suc- taking and sexual medicine assessment and treat-
cess in several countries, such as Australia, Mozam- ment.”39 For example, Malhotra and colleagues
bique and Cambodia, among others. The triangle conducted a nationwide telephone survey of 500
approach to sexual health programming proposed fourth-year medical students in the US and medi-
here, similarly, puts pleasure at the centre, as an cal school curriculum offices in 2008.40 They
element that is intrinsically linked to sexual health found that 44% of medical schools in the US
and sexual rights, acknowledging and tackling the lacked formal sexual health curricula, that 17.4%
various risks associated with sexuality, without of medical students felt uncomfortable taking sex-
reinforcing fear or shame.36 The triangle approach ual histories from ten to fourteen year-olds and

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 S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

23.8% from adults aged 75 and over. Also, in Love Matters worked with the UK-based Institute
2008, Shindel et al invited 2261 medical students of Development Studies (IDS) and curated the
from the US and Canada to participate in an Inter- research bulletin “Digital pathways to sex edu-
net-based survey, in which they found that 53% of cation,” released in February 2017.42 It found
respondents “felt they had not received sufficient that across all their sites the “pleasure” pages are
training in medical school to address sexual con- more than eight times more popular than the
cerns clinically.”41 While a decade old, these family planning pages, and that the “sexier” con-
studies show that medical education in sexual tent serves as a gateway to other information
health in the US and Canada is lacking, with resources, including risk reduction and disease
many students and providers reporting feeling prevention. This unique demand-led, pleasure-
unprepared to address sexual health issues with positive approach to sexual health and rights edu-
their clients.42 Data for the rest of the world are cation is reaching people in large numbers. Many
sorely lacking. sexual and reproductive health organisations are
In its working definition of “sexual pleasure,” now starting to use the same approach. Love Mat-
the Global Advisory Board for Sexual Health and ters has been a transformative global digital plat-
Wellbeing identified six key factors that represent form that has diversified sources of sexuality
links between sexual health, sexual rights and sex- information beyond schools and health facilities,
ual pleasure that can be incorporated into pro- and points to the way in which online platforms
gramming and the delivery of services: self- have created the possibility for people to access
determination, consent, safety, privacy, confi- diverse information relating to sexuality and plea-
dence, communication and the ability to negotiate sure without needing to interface with the health
with the partner(s).2 SRHR programmes that incor- system or with providers.
porate the links between these three concepts
recognise sexuality as a source of pleasure and Example 2:
wellbeing. To date, there are very few documented An example of a technical tool which incorporates
programmes and technical tools globally that have the triangle approach linking sexual health, sexual
embraced and have been successful in using plea- rights and sexual pleasure to inform SRHR pro-
sure alongside sexual health and sexual rights. grammes is Fulfil! Guidance Document for the
Three examples follow: Implementation of Young People’s Sexual Rights, 44
published by the International Planned Parent-
hood Federation (IPPF) and the World Association
Example 1: for Sexual Health (WAS) in 2016. Fulfil! was the
One such programme is Love Matters, which has cre- result of a multidisciplinary effort, and it
ated a digital platform on sexuality and pleasure.43 responded to the fact that the majority of pro-
The project operates at the intersection of media grammes (and policies) regarding youth’s SRHR fre-
and public health, specialising in media for social quently emphasised “disease, death, disability and
change, and talking about sexual pleasure is at violence associated to sex and sexuality.” In its first
the core of their engagement strategy. Rather than section, Fulfil! outlines elements that are funda-
using secrecy, silence and shame to try and prevent mental for young people’s sexual rights to be
people from having (risky) sex or focusing only on implemented, the first one being “a comprehen-
the negative, they use pleasure as the hook to sive understanding of young people’s sexuality
have difficult conversations with millions of young with diversity and sexual wellbeing at the core.”
men and women around the globe. Love Matters Based on the IPPF and WAS Declarations of Sexual
is intended as a reality check for these young men Rights,14,15 Fulfil! stresses the importance of young
and women, offering sexual health and sexual rights people’s experiences of sexual pleasure, as they
information with a positive take on pleasure and shape other experiences throughout the lifetime
relationship satisfaction. The programme demon- and have a direct impact on their overall health.
strates that the web, mobile and social media plat- Apart from providing specific guidance for pro-
forms give young people the facts they need to have grammes, laws and policies, Fulfil! also presents a
safer, healthier and happier sex, and can deliver case-by-case decision-making model to support
science and rights-based sexual health and rights service providers in the implementation of young
information with a pleasure perspective directly people’s sexual rights, in which ethical, practical
into the hands of young people. and legal factors need to be balanced.

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S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

Example 3: matter of course, with profound effects on sexual

With respect to training and capacity building, the rights and pleasure. One example is the conflation
Global Advisory Board for Sexual Health and Well- of sex work with trafficking by various women’s
being (GAB) has developed a training toolkit45 for rights groups and feminist organisations.46
future health professionals to deliver services with Efforts must be made towards cross-movement
the triangle approach. The training aims to create alliance building efforts that can enable/foster
an understanding of the links between sexual health, local-global connections, including with respect
sexual right and sexual pleasure, and to raise aware- to differing perceptions of sexuality, pleasure,
ness on the importance of delivering services with a and rights: for example, finding common ground
rights and pleasure approach. It also includes the amongst those concerned with trafficking and
Pleasuremeter,43 which is a tool based on the GAB’s those advocating for sex workers’ rights, in working
working definition of sexual pleasure and motiva- towards the elimination of all kinds of violence and
tional interviewing techniques (such as asking exploitation.
open-ended questions and using scales to address Equality, non-discrimination and universalism
behavioural stages of change) to address the links are key to all social movements and engaging
between sexual health, sexual rights and sexual plea- these principles will help to build bridges across
sure in the taking of sexual histories. This training movements. For the triangle to take hold in these
was piloted in May 2017 at the World Congress for complicated times, there is a need to form and
Sexual Health in Prague, Czech Republic, has been maintain broad coalitions – ones aimed at preser-
further refined, sent for peer review, finalised and ving our web of local and international partner-
is now freely downloadable.† ships, from the people we work with and the ways
we work together, to how we understand the work
we do within a framework of international solidar-
Rethinking advocacy ity. For those engaged with the intersection of sex-
Achieving a world where intersections between sex- ual health, rights and pleasure as individuals, and
ual health, sexual rights and sexual pleasure are as a collective group of human beings, we need to
reinforced and positively influence people’s lives figure out how and when to act. This means that
will require not only strong policy and program- across the range of topics we work on we have to
ming, but also comprehensive and linked global, work together more actively to support people to
national and local grassroots advocacy. Advocacy achieve sexual pleasure and to be able to claim
is needed to: support policy and legal change; their rights, and to protect people who advocate
demand equal opportunities, rights and conditions in this area.
for all; promote investment in local and national Understanding where progress has been made,
rights-based sexual health services that address and where backlash has occurred, is relevant to
pleasure; demand quality of care and comprehen- determining where and how sexual pleasure can
sive sexuality education; and hold relevant stake- best be brought into these efforts. For those of us
holders accountable. This is not the concern of engaged in advocacy to advance sexual rights
just one group. If pleasure is to be understood and sexual pleasure will need to take into account
and addressed in the context of sexual health and current North/South, North/North and South/
sexual rights, advocates must include civil society South politics at a governmental level, as well as
organisations, researchers and research insti- what is happening with those opposed to sexual
tutions, service providers, and both the public and rights, let alone sexual pleasure, in all forums.
private sectors. Most importantly, it will also require
solidarity and harmonisation of efforts.
Efforts are being made daily to weaken global Conclusions
solidarity and global principles and institutions, There is increased recognition and support for sex-
and this is a concern for all engaged in sexual health ual health and rights, even as current policy, pro-
and rights work. Silo-isation and conflicting gramming and advocacy efforts and discourse
approaches to using rights discourse, even amongst around sexuality have yet to engage fully with
movements that ought to be aligned, occur as a the interconnections between sexual rights, sexual
health and sexual pleasure. Implementation of the
†
The GAB’s toolkit is available for free download at the follow- “triangle approach” to sexual health and rights is
ing link: http://www.gab-shw.org/resources/training-toolkit/. more important now than ever with the current

36

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 S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

political climate, for every individual and pleasure – when it does occur – still remains very
especially for those who are most marginalised.47 much embedded within the public health realm.
There is a need to learn from and move beyond For this work to take root will need attention to
conversations about pleasure, focused only on cer- the diverse and contextual ways through which
tain populations, whether with young people, individuals exercise choice, receive information
women, and/or other marginalized populations, and enjoy sexual pleasure, as well as more “eco sys-
or specifically focused on sexual orientation, gen- tem” work within institutions, communities,
der, gender expression, or sex characteristics, and families, and so on, to create the enabling environ-
support the relevance of sexual health, sexual rights ment necessary for everyone to enjoy sexual rights
and pleasure as a universal demand for all people. and pleasure. Who is vulnerable or disadvantaged
An intersectional, inter-disciplinary and multi- clearly will vary between countries and within
sectorial implementation is critical to ensure that countries, and so we need vigilance to ensure
programmes are endorsed, implemented, funded that a focus now and in the future results in better
and maintained, locally and globally. A potential laws, policies and programmes to support sexual
first step may be to begin mapping, in order to health, sexual rights and sexual pleasure for all
make explicit, cases in which sexual health, rights people, and without distinction.
and pleasure have successfully been brought
together conceptually and operationally, as well Acknowledgements
as those cases where gaps in relation to the The authors wish to gratefully acknowledge the
needs and rights of certain populations are ident- other members of the Global Advisory Board for Sex-
ified. Such a mapping would make it easier to ana- ual Health and Wellbeing including Doortje Brae-
lyse where it would help to work with partners to ken, Jian Chen, Lyubov Erofeeva, Faysal El Kak,
ensure consistency, and where it might be strategic Tlaleng Mofokeng, Pauline Oosterhoff, and, in par-
to begin this work at a very basic conceptual level. ticular, Caryn Gooi and Volker Sydow for their vision
Where these concepts have been brought together and support in bringing us together. The Global
in operational terms, there is a clear need to docu- Advisory Board for Sexual Health and Wellbeing
ment programming efforts, and most importantly was convened by RB. The views expressed in the
the difference this has made to people’s lives. Rig- materials are those of the authors and not of RB.
orous evaluation of what has been put in place can
effectively be used to frame arguments that are Disclosure statement
more likely to be accepted by states and insti- No potential conflict of interest was reported by the
tutions of power globally and within countries, authors.
and in ways that can facilitate access to resources
which can then further support direct impacts on ORCID
people’s lives. It is important to acknowledge, how- Sofia Gruskin http://orcid.org/0000-0002-2418-
ever, that recognition of the importance of sexual 011X

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Résumé Resumen
Pour améliorer la santé sexuelle, même dans ce Para mejorar la salud sexual, en estos tiempos
moment politique tendu, il faut dépasser les polarizados políticamente, se necesita ir más allá
approches biomédicales et aborder efficacement de los enfoques biomédicos y abordar de manera
les droits sexuels et le plaisir sexuel. Un monde où significativa los derechos sexuales y el placer sex-
les intersections positives entre la santé sexuelle, ual. Un mundo donde intersecciones positivas
les droits sexuels et le plaisir sexuel sont renforcées entre salud sexual, derechos sexuales y placer sex-
dans la loi, dans la programmation et dans le plai- ual son reafirmados en la ley, en programas y en
doyer peut consolider la santé, le bien-être et l’ex- actividades de promoción y defensa, puede fortale-
périence vécue de personnes dans tous les pays cer la salud, el bienestar y las vivencias de las per-
du monde. Il faut pour cela comprendre clairement sonas en todos los países del mundo. Para ello, se
la signification de l’interconnexion de ces concepts necesita una buena comprensión de qué significa
dans la pratique, et disposer d’approches concep- en la práctica la interconexión de estos conceptos,
tuelles, personnelles et systémiques qui donnent así como enfoques conceptuales, personales y sis-
acte des dommages infligés à la vie des personnes témicos que reconocen y abordan plenamente
quand ces interactions ne sont pas totalement los daños infligidos en la vida de las personas
prises en compte et qui s’y attaquent. Faisant le cuando estas interacciones no son consideradas

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S. Gruskin et al. Sexual and Reproductive Health Matters 2019;27(1):29–40

lien entre le domaine conceptuel et les approches en su totalidad. Salvando las brechas entre lo con-
pragmatiques, cet article examine les définitions ceptual y lo pragmático, este artículo revisa las
actuelles, les influences et les intersections de ces definiciones actuales, las influencias y las intersec-
concepts, et il indique comment une attention glo- ciones de estos conceptos, y sugiere dónde la aten-
bale peut mener à une programmation et des poli- ción integral puede producir mejores políticas y
tiques plus fortes par des activités éclairées de programas por medio de capacitación y promoción
formation et de plaidoyer. y defensa informadas.

40

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