Sexual and Reproductive Rights: Time to Ring the Bell?

We consider human rights fundamental to our existence. Healthcare delivery has undergone a paradigm shift over recent decades from a categorical and symptom-triggered approach to being dignity and right-centric. However, unlike other dimensions of health, sexual and reproductive rights are often misrepresented, misunderstood, and remain neglected in practice and policy. The domains of sexual and reproductive rights intersect to some extent, especially with regard to contraceptive choices, sexually transmitted diseases, abortion rights, sex education, and so on; however, sexual health spans a much larger domain which includes the concept of wellbeing and freedom. ¹ This not only encompasses prevention and treatment of sexual disorders or dysfunctions but also autonomy, dignity, respect, and pleasure related to sexuality and sexual relationships. ² This discussion assumes a renewed importance during the present troubled times of the Coronavirus Disease 2019 (COVID-19) pandemic as since its onset in early 2020, there has been a growing rise in sexual and intimate partner violence globally.^{3, 4} The United Nations (UN) Women mentions this as a “Shadow Pandemic” calling for worldwide collective efforts to stop it. ⁵ In lieu of the same, on May 27, 2020, the UN Women launched the Shadow Pandemic public awareness campaign in an attempt to battle the gender inequality and ongoing domestic violence during the ongoing global health crisis. As a part of it, a 62nd film was released narrated by the Academy Award-winning actress Kate Winslet, who spoke about the heightened need for awareness about gender-based discrimination as well as one’s sexual and reproductive rights. ⁶

The sexual and reproductive health/rights (SRHR) movement have long been recognized but less frequently implemented. The International Conference on Population and Development (ICPD) held at Cairo, Egypt in 1994 marked the initiation of the SRHR discussion, with a gradual shift from family planning choices and prevention of sexual disorders to rights-based sexuality and gender-equality. ⁷ The ICPD also drafted a Program of Action that highlighted SRHR as a universal human right and was adopted by 179 nations. This draft contained the elements of sexual freedom, reproductive health, women’s empowerment, preventing gender-based violence, and viewed sexual health from an emotional rather than physiological perspective. ⁸ These elements assumed importance in Millennium Development Goals (MDG) 3, 4, and 5 as well as the Sustainable Development Goals, although sexual rights were not explicitly stated.^{7, 9} It has been backed up by various international nongovernmental organizations such as the International Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) Alliance, Center for Health and Gender Equity, International Lesbian and Gay Alliance, World Association for Sexual Health (WAS), and International Planned Parenthood Federation (IPPF).^{10, 11} The WAS founded in 1978 and the subsequent Beijing Conference on Women in 1995 particularly stressed on the sexual rights of women. It was mentioned that “if women have balance in power, the ability to protect themselves from violence will be strengthened.” ¹² This was strongly supported by the UN Commission on Human Rights. ¹² Subsequently, the Valencia Declaration of Sexual Rights issued by the WAS (then known as World Association of Sexology) in the WAS Congress 1997 led to a paradigm shift in sexual rights advocacy. It prompted the UN, World Health Organization (WHO), and IPPF to consider them as integral to fundamental human rights. ¹³ Finally, the Declaration of Sexual Rights was heavily revised by the WAS in 2014 which included 16 SRHR.^{13, 14} These were the principles of equality, security, liberty, autonomy and bodily integrity, freedom from sexual torture, coercion and harassment, privacy, safe sexual experiences, information and sex education, freedom for marriage and relationships, bias-free sexual expressions, and sexual justice (legal protection in case of any sexual right deprivation or dispute). The Valencia Declaration has also influenced the international Yogyakarta Principles, ¹⁵ which are related to gender identity and sexual orientation, sexual identity and integrity, all of which have immense implications for health and wellbeing.

The basis of these rights lies in the WHO’s definition of sexual health, “sexual health is a state of physical, mental and social wellbeing in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having safe and pleasurable sexual experiences, free of coercion, discrimination and violence.” ²

Needless to say, while the first part of this definition aligns with the generation definition of health, the second part of it is often compromised. Gender and sexual orientation-based inequality and stigma, which have widened during the ongoing pandemic, are the recent examples of the same.^{16, 17} In a qualitative exploration with older transgender individuals, the participants revealed “minority stress,” existential crises, neglect, and double jeopardy of “age and gender-based discrimination.” ¹⁸ Several studies have shown the socioeconomic, sexual, and psychosocial plight of the sexual and gender minorities across the world during the COVID outbreak.^{17, 19} These inequalities added with domestic violence (predominantly against women) intersect with other forms of prejudice such as racism, sexism, casteism, and so on in varying degrees of prevalence. Besides, poor sexual health and ignored sexual rights have been shown to result in adverse psychological outcomes.^{2, 7} This discussion is even more relevant this year as the theme for this World Mental Health Day (10 October) as decided by the World Federation for Mental Health (WFMH) is “Mental Health in an Unequal World.” ²⁰ Hence, awareness about the SRHR can be considered to be one of the integral ways to deal with these global mental health inequalities.

Further, the WHO has also laid down the basis for reproductive rights. They are defined as:

“Reproductive rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. They also include the right to make all these decisions free from discrimination, violence and coercion.” ² National legislations, sociocultural norms, media, misinformation, social stigma, socioeconomic contexts, and literacy, all of these influence the understanding and implementation of SRHR.^{1, 2, 7} Of particular importance are the vulnerable groups such as age and gender minorities, adolescents, individuals with intellectual disability, homeless and socio-economically impoverished, and finally individuals living with mental illness. Institutional sexual abuse has also been on the rise and its vital for stakeholders at all levels to ensure effective and appropriate measures to hold it off. Sensitivity to these rights and their implementation in daily practice is of paramount importance. Interventions among individuals with intellectual disability have shown to improve self-stigma and encourage constructive dialogue about sexual rights. ²¹ A recent review by McGranahan et al ²² on rights-based approaches to sexual and reproductive health in low- and middle-income countries concluded that though some interventions were useful, most evidence was of poor quality. ²² Though condom use, HIV and STD testing and rights-awareness improved after such interventions, there was not much mention about women empowerment, gender equality, prevention of sexual violence, and sexual freedom from coercion. Unfortunately, these constructs are often subjective and abstract and thus may not be gauged through quantitative studies. Lived experiences, phenomenological exploration, and interpretative analysis may lend more understanding into this dimension of SRHR that stresses on sexual expressions free of stigma and discrimination. This will involve an older adult speaking freely of his/her sexual needs, bias-free same-sex relationships, freedom of sexual expression across ages, strict “no” to gender-based violence, and free decisions about childbirth and contraception. Only then, can the basis of SRHR inclusive society be laid.

Shepard mentioned that political will and national awareness are imperative to establish sexual rights in a nation. ²³ It is indeed so. Sexuality is “socio-culturally constructed” by intersections with conduct, social structures, belief systems, and reproductive practices. ¹ Based on the UN Convention for Human Rights, the concepts of dignity, autonomy, respect, and equality are applicable even to sexual practices which encompass sexual orientation, expressions, partner selection, safe abortion, and reproductive choices. ² At a systemic level, the SRHR goals are “universal access to reproductive healthcare, sexual health and family planning”. ²⁴ Social concerns such as female infanticide, sexual violence, gender-based discrimination, sexism, child marriage, and HIV stigmatization need to be dealt with at both community and administrative levels. ²⁵ The right to comprehensive sex education as declared by the Commission on Population and Development is fundamental which improves knowledge-attitude-practice related to healthy sexuality and reproductive practices. ²⁶ Finally, health professionals dealing with sexual health should be sensitive about understanding cultural facets of sexuality and gender roles-balance-power for designing implementations.

India is a signatory to the International Conference on Human Rights Declaration (1968), the International Conference on Population and Development (1964), the International Covenant on Economic, Social and Cultural Rights (1996), and the Convention on the Elimination of All Forms of Discrimination against Women (1979). Reproductive rights are well-recognized in all these conventions and hence it’s the national obligation to implement the principles into laws and policies.^{27, 28} Even though well-intentioned steps have been taken in this regard, the conversion from paper to reality is still laden with huge gaps. The recent country assessment undertaken in India for the National Human Rights Commission (NHRC) by Partners for Law in Development (PLD) and SAMA Resource Group for Women and Health in 2018 is the first national enquiry of its kind. ²⁹ It stresses, “International human rights standards demand that SRHR services should be available, accessible, acceptable and of good quality.” Acknowledging the need for integration of these rights into the public health infrastructure and national health programs, the NHRC calls for prevention of stigma surrounding adolescent sexual expression, same-sex relations, sex workers, and sexual minorities. ²⁹ This will help preventing abuse, violence, and discrimination against them as well as keep them integrated into the health services. It is imperative that there cannot be sound health without sexual wellbeing. Research into sexuality need to move beyond management of sexual dysfunctions to exploration, assessment, and implementation of sexual rights. Inclusion of the voices of service users is vital for rights-based service care provisions. Also, we suggest that any proposed convention or policy on human rights need to have SRHR integrated in their framework. As we practice medicine, irrespective of the specialty, it’s a collective responsibility to move beyond the disorder-based thinking of sexual health and the moralistic understanding of “good versus bad” sex. It is time that we appreciate and promote rights, justice, and equality-based inclusive environment and service delivery so that every individual understands and enjoys the sexual and reproductive rights that they fundamentally deserve.