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Evolution of the definition of sexual health

The earliest reference to sexual health was in International Conference on Population and
Development (ICPD) Programme for Action (Cairo, 1994), which stated that reproductive
health, “also includes sexual health, the purpose of which is the enhancement of life and personal
relations, and not merely counselling and care related to reproduction and sexually transmitted
diseases.”1 It further stated that “people are able to have a satisfying and safe sex life and that
they have the capability to reproduce and the freedom to decide if, when and how often to do so.
Implicit in this last condition are the right of men and women to be informed and to have access
to safe, effective, affordable and acceptable methods of family planning of their choice…”

The material determinants of (sexual) health include “access to safe and potable water, adequate
sanitation, adequate food and nutrition, adequate housing, safe and healthy working conditions
and environment, health-related education and information.”

The sexual health outcomes are equally shaped by “social determinants” that refer to social
norms and structures that stigmatise, oppress or marginalise persons on account of their sex,
sexual orientation or gender identity, marital status, age, ability or caste, ethnicity or minority
status. As a result, vulnerabilities and health outcomes of these population groups depends
considerably on legal protection against violence, torture and discrimination. As summed up by
the CESCR in the General Comment no. 22 (2016) the right to sexual and reproductive health is
an integral component of the right to health, and interdependent on fulfillment of all other human
rights.

As sexuality in all its diversity shapes the sexual health outcomes of people, it has a significant
bearing on fulfilment of sexual health. The following working definition of sexuality has been
proposed by the WHO: “…a central aspect of being human throughout life encompasses sex,
gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction.
Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values,
behaviours, practices, roles and relationships. While sexuality can include all of these
dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the
interaction of biological, psychological, social, economic, political, cultural, legal, historical,
religious and spiritual factors.” 6

The realisation of sexual health has been recognised as integral part of the 2030 Sustainable
Development Goals (SDGs) relating to health,10 education,11 and gender equality.12

International law notes the importance of access to age-appropriate comprehensive sexuality

education and information that covers a wide range of issues,13 specifically for women,14
children,15 and disabled persons,16 and sexual minorities17 in enabling self-awareness and
reproductive autonomy, preventing gender-based violence, and promoting responsible sexual
behaviour.

Access to education and information: Make available age-appropriate comprehensive sexuality

education, including accessible and understandable health information, as part of standard school
curriculum, as well as outside of formal school setting, without parental consent and regardless
of marital status, to all population groups. o Ensure full information to adolescents about SRH,
including contraception, family planning, STIs including HIV/ AIDS and dangers of early
pregnancy.

Age appropriate Comprehensive Sexuality Education (CSE) is widely recognised as the way of
enabling children and young persons in schools to become aware about their bodies, personal
hygiene, gender identities as well as safe sex practices. Notably, this helps build capacities to
recognise sexual harm and abuse, enabling young and adults alike to secure help to seek
protection and redress. In adults, scientific, accurate and non-judgmental sexuality information is
foundational to making informed choices, exercise of affirmative consent, safe sex; and for
addressing stigma, prejudice and discrimination on grounds of gender, gender identity, and
sexual orientation. Thus, sexuality education is not about biological reproduction as is commonly
understood through terms like ‘sex education’, but about gender relations, roles, identities, body
and relationship of the self with the body, positive and negative sexual contact, harm and
pleasure, disease prevention, amongst others.

Comprehensive Sexuality Education (CSE) as per international standards has not yet been
implemented anywhere in India yet. Age appropriate sexuality education for adolescents has
often faced considerable resistance in the country, as for instance the backlash against sex
education for being ‘immoral and inappropriate’ by certain sections. However, the Adolescence
Education Programme (AEP) implemented by the National Council of Educational Research and
Training (NCERT) in partnership with UNFPA does address issues around gender and sexuality.
After facing some initial backlash on its content, the NCERT along with the UNFPA revamped
the AEP syllabus in 2010, which is currently implemented in the Kendriya Vidyalayas (1120
schools) and Jawahar Navodaya Vidyalayas.76 This programme contains curriculum for
adolescents from class nine onwards covering changes in the body, gender stereotypes, substance
abuse, recognizing and reporting abuse and HIV/ AIDS.77

The programme, however, does not comprehensively cover all the sexuality related topics like
gender diversity and same-sex relations. It is also limited by the fact that it does not cover
students below class 9. Experts working with child abuse note that children may have already
gone through abuse by the time they reach puberty as abusers often target younger girls who
have not begun menstruating.78

Approaches outside of formal education, to educate and inform on sexuality and sexual health
concerns are of paramount importance in the context of poverty, low literacy and high dropout
rates. As many children have no access to school education; and also because vulnerable
population groups of adults, are exposed to high risk of abuse and harm, information must be
made available through drop-in centers, peer educators and health workers who work with
communities. Lack of information around sexual health well-being from a young age increases
the vulnerability of adolescents to engage in unsafe sex practices and increases their risk of
contracting Sexually Transmitted Infections (STIs). The official estimates show that 44% of the
reported AIDS cases in India are in the age group 15-29 years.81 A recent study by Lady
Hardinge Medical College reported increase in the rate of STIs amongst adolescents (below the
age of 19) from 1% to 4.9%.82 This was attributed to lack of comprehensive sex education as
well as sexual abuse. Further, according to UNICEF girls are twice at more risk of facing abuse
than boys.83 Research on Gender and HIV has shown that women have less knowledge about
HIV/ AIDS, STIs, modes of transmission and prevention as compared to men.84

Practitioners in the field of HIV prevention are critical of the epidemiological approach of the
HIV prevention programmes, which has serious negative consequences not only for well-being
of those living with HIV, but for sexual health of women and adolescents, who are not typically
deemed as ‘high risk’. Such targeted intervention programming has also resulted in bifurcation of
family planning and STI prevention from HIV related work.

The seeming disconnect between public health programmes on family planning and those on
HIV/ AIDS, are apparent in the focus of family planning on vaginal sex alone, within which
condoms are promoted mainly for avoiding pregnancies, without much mention of their role in
preventing STD/ HIV infections. Added to this is the fact that the primary burden of family
planning falls on women, through sterilisation programmes as well as contraceptive pills. Studies
have shown that women from lower socio-economic background lack access as well as
information on contraceptives, which makes sterilisation camps the most viable option for
them.97

The fact that sexuality manifests during puberty,126 itself necessitates an obligation on the State
and non-State actors like the family and community to contribute towards developing age-
appropriate capacities with respect to sexuality and sexual health.

Ironically, while the capacity of adolescents to engage in sexual relations in not recognised,
juveniles between 16-18 years are deemed to be culpable like adults under the amended Juvenile
Justice Act 2015.132 As such, while the law does not recognise the capacity of adolescents to
consent to sexual intercourse, it recognises the capacity of adolescent boys to be subject to
punishment rather than correction for commission of rape.

Persons with disability Practitioners have noted high levels of sexual harassment and sexual
violence cases against all persons with disability regardless of gender, by the hospital staff. This
includes, but is not limited to sexual assault by inmates and hospital staff and inappropriate
touching during check-ups.152

Poor maternal health continues to be an unjustifiable, but significant problem in India. This is in
spite of the issue garnering significant attention and being the focus of policies and programmes
of the GOI as well as international bodies. Maternal mortality is considered a key indicator of
maternal health. While maternal health is much more than a matter of maternal deaths alone,
maternal mortality is widely accepted as an indicator of a country’s maternal health status.

P27
While economic inequalities have been a key focus of attention, gendered relations of power at
every level have undermined health rights of women, girls and gender diverse individuals.
Sexual and reproductive health and rights (SRHR) have always been sites of power contestations
within families, societies, cultures, and politics; these struggles are exacerbated by economic,
racial, religious, caste, citizenship status, and other social inequities, especially in times of crisis.

In keeping with this recognition that axes of inequality influence who gets exposed, who gets
sick, and who gets good health care, in this Commentary, we propose the use of an intersectional
lens to explore the impact of the COVID-19 pandemic on the social contract, particularly as
related to SRHR. Developed by African-American legal scholar Kimberle Crenshaw,
‘intersectionality’ is a lens that examines how intersecting identities, such as race, gender, class,
and ability shape people’s experiences with state organs and society at large.

Unsurprisingly, the Lancet-Guttmacher 2018 Report concluded that almost all 4.3 billion people
of reproductive age worldwide would have inadequate sexual and reproductive health services
over the course of their lives.

In addition to these well-documented problems, access has been disrupted to sexual and
reproductive services and commodities provided outside of the health sector, such as through
markets, schools, and drop-in centres. For example, emergency contraception and condoms are
no longer available for adolescents and younger women, as many clinics and school outlets are
shut in SubSharan Africa and Latin America, even though at this time many are exposed to rape
and sexual coercion within homes.

Decades of government failure to adequately regulate these providers has enabled the flourishing
of private systems that offer steeply priced services that evade accountability for the quality of
care they provide. With no other options for crucial SRH services such as emergency obstetric
care, abortions, and long-acting reversible contraceptives, many women and girls utilize
expensive, poor quality services that may push them further into poverty and even cause physical
harm. Their ability to pay has been severely eroded by the economic crisis precipitated by the
pandemic; women working in the informal sector generally have little access to social protection,
health insurance, or other social welfare system.
An intersectional analysis would therefore be not just one that addresses the cumulative
disadvantages and injustices posed by the pandemic for specific social groups, but also the
structural drivers, historical inequalities, and damaged social contract that mediates this
relationship. Intersectional analysis takes on greater importance now than in non-pandemic times
as the state exercises more police and other power: states can deploy myriad ways of ‘othering’
while dodging questions of governance and accountability.

P26

From both the perspective of social determinants of health and the socio anthropological
perspective of health and disease, the fields of public health and collective health have long since
contemplated the social markers of class, gender and race/ethnicity as important references in the
analysis of differentiations in social inequalities.(1,2) More recently, other social markers such as
sexual orientation and generation have been incorporated as important empirical and conceptual
references in studies regarding health inequalities among different social sectors as well as those
focused on sociocultural processes in health, disease, death, and care in specific or minority
social groups.

Intersectionality has recently emerged as an alternative and promising theoretical and

methodological option in analyses that look into the dynamics and complexities of the
interactions of social markers at the individual, institutional and structural levels by taking into
consideration the multiple levels of articulation of social markers in the production of the social
processes of domination and oppression and their impacts in the health-disease process.

In Latin America, given the existence of profound social inequalities, markers of class, gender,
and race have been a part of academic debates and political agendas in the region for over two
decades,(8) especially due to public and political interventions of black women in the feminist
movement. Looking mainly at the experiences of poor, black or Afro-descendant women,
discussions of topics such as the position of women in the labor market, public and private forms
of violence, health issues, and representations of women in the media signal social and health
inequalities and oppressive processes that deepen when analyzed from a racial perspective. The
supposedly universal female gender, installed in society at that time, made invisible the
experiences of oppression of these women. After this universalizing category was rejected by
local black feminists in Brazil, guidelines were established by governmental agencies to generate
actions that could combat social inequalities based on gender and racial disparities.

P35

One reason why providers of SRH services exercise so much power is that their clients often feel
embarrassed, anxious, or socially vulnerable. Just to reach a facility offering contraceptives,
abortion care, or STI treatment, people frequently have had to overcome a number of
psychosocial and financial hurdles. Many people harbour deep-seated fears about the potential
side-effects of contraception or abortion. They may also have heard rumours about or actual
accounts of inconsiderate or humiliating treatment by providers at the facility.

Hence, while a potential client may be exhibiting resilience and courage by seeking SRH
services, she or he may still experience considerable apprehension which could be exacerbated or
ameliorated by providers. If providers do not respect clients’ privacy or confidentiality, clients
could be ridiculed, beaten, or even ostracized. Those who are more socially marginalized, such
as the unmarried or poor or those with disabilities, are even more susceptible to whatever might
transpire at a clinic.7-10

One common reason that providers deny women contraceptives is their adherence to outdated
national policies. For instance, many providers require proof that a woman is not pregnant prior
to prescribing birth control methods other than the condom.51

Comprehensive counselling tailored to the needs and educational level of clients seems to have a
positive effect on their use of family planning.11 In Niger and Gambia, researchers found that
only 14%-19% of clients who reported that they were adequately counselled on side effects
discontinued contraceptive use, as compared to a 37%–51% discontinuation rate among clients
who did not feel they had been sufficiently counselled.79 In rural Bangladesh, visiting family-
health workers who gave empathetic and “high-quality” counselling appeared to increase
contraceptive use by 21% and continuation rates by 72%.30.

In Ghana, for example, the private sector supplied 54% of the couple-years of protection (CYPs)
in 2003. From DHS data we know that the majority of public sector CYPs come from urban
hospitals and clinics providing IUDs, sterilizations, injections, and implants. Pharmacies and
chemical sellers are the largest source within Ghana’s private sector and the last reported source
of family planning for 39% of all contraceptive users, supplying mostly pills and condoms.
Public financing for SRH services in this instance has limited benefits for the poor, because it is
directed primarily at services (e.g. sterilization, IUD) that are only delivered by providers in
urban settings serving a higher-income clientele. Intentionally or not, the central decisions on
what services would be financed by the national family planning programme effectively defined
where services would be provided. Equity of SRH service delivery is often (as in the example
from Ghana cited above) partially determined by what services are financed or subsidized. For
family planning, it is often the case that long-term methods, being more cost effective at
reducing fertility, are given priority among government-supported initiatives, to the detriment of
the poor – who often live in areas where such services are of low quality or unavailable.

P36

Viewing this relationship through the lens of human rights reveals a close and multifaceted

connection between reproductive health and human rights. Yet the recognition of reproductive
health as a human right under international human rights law has been sporadic, piecemeal, and
indirect. International human rights conventions do not explicitly establish a discrete human right
to reproductive health, but they often recognize specific aspects of this right.5

The human right to reproductive health exists at the intersection of discourses about reproductive
rights and the right to health.8

The practice of female genital mutilation (FGM)-the ritualistic cutting and scarring of the
genitals of women and young girlsremains a widespread practice in some parts of Africa and the
Middle East.36 An estimated 100 to 140 million girls and women are affected worldwide, and
three million girls in Africa are subjected to different variations of this procedure each year.37
FGM has potentially serious reproductive health consequences for girls and women, including
more frequent infections of the reproductive tract, infertility, and prolonged or obstructed
childbirth.38 This practice violates a number of human rights in addition to the right to
reproductive health, including the rights to avoid inhuman and degrading treatment and
discrimination.39
Reproductive rights have developed over many years due to the impassioned advocacy and
incremental legal advancements of two interrelated movements: national and transnational
women's rights movements and the international human rights movement.

Motherhood and childhood are entitled to special care and assistance. All children, whether born
in or out of wedlock, 98 shall enjoy the same social protection.98

The second integral concept for understanding reproductive health rights under the right to health
model involves recognizing that the underlying determinants of health play a vital role in
achieving good health outcomes. Underlying determinants, such as "food and nutrition, housing,
access to safe and potable water and adequate sanitation, safe and healthy working conditions,
and a healthy environment"' 19 can have an important effect on reproductive health. In settings
where these determinants are not safeguarded, their absence can destabilize political, social, and
economic conditions and undermine reproductive health rights.

The models outlined above demonstrate that the content and focus of reproductive health rights can
differ depending on the perspectives and priorities advanced by governments, advocates, scholars, and
individuals, as well as the jurisprudential development of rights within court systems.