Sexual health, sexual rights and sexual pleasure: meaningfully engaging the perfect triangle.

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.

Introduction

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

Defining and understanding the context of terms

The terms “sexual rights,” “sexual health” and “sexual pleasure” have been used in very different ways by the many technical and political actors engaged in this work. To ensure clarity, each is briefly discussed below, along with proposed definitions (see Box 1) as these will be relevant to the sections on policy, programming and advocacy that follow.

Sexual Health

“ … a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”[1]

Sexuality

“ … 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 .”[1]

Sexual Rights

“The application of existing human rights to sexuality and sexual health constitute sexual rights. Sexual rights protect all people's rights to fulfil and express their sexuality and enjoy sexual health, with due regard for the rights of others and within a framework of protection against discrimination.”[1]

Sexual Pleasure

“Sexual pleasure is the physical and/or psychological satisfaction and enjoyment derived from solitary or shared erotic experiences, including thoughts, dreams and autoeroticism. Self-determination, consent, safety, privacy, confidence and the ability to communicate and negotiate sexual relations are key enabling factors for pleasure to contribute to sexual health and wellbeing. Sexual pleasure should be exercised within the context of sexual rights, particularly the rights to equality and non-discrimination, autonomy and bodily integrity, the right to the highest attainable standard of health and freedom of expression. The experiences of human sexual pleasure are diverse and sexual rights ensure that pleasure is a positive experience for all concerned and not obtained by violating other people’s human rights and wellbeing .”[2]

Sexual health was first defined rather vaguely by the World Health Organization (WHO) in a 1975 Technical Report as: Twenty years later, the Programme of Action of the International Conference on Population and Development[4] included sexual health under the definition of reproductive health, indicating that its purpose is: This definition has since been widely used by global organisations including the World Health Organization (WHO) and non-governmental institutions such as the International Planned Parenthood Federation (IPPF), with important implications also for the approach to sexual health taken by the national level government and civil society actors.

“the integration of the somatic, emotional, intellectual and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication and love.”[ ]

“the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.”[ ]

With respect to sexual rights, arguably to this day no language has been as important as the political articulation in the 1995 Beijing Platform for Action from the Fourth World Conference on Women.[5] Paragraph 96, which sits within the health section of the document, states: Essential in providing for the first time an international mandate to focus on, and invest in, women's reproductive and sexual health beyond the need to control women’s fertility as part of a demographic agenda, and grounded within the internationally agreed legal human rights framework, this remains, despite its obvious limitations, the strongest statement agreed to by the governments of the world.

“The human rights of women include their right to decide freely and responsibly on all matters related to their sexuality, free of coercion, discrimination and violence.”[ ]

Beyond rhetorical articulation of a comprehensive sexual and reproductive health and rights (SRHR) agenda since the Cairo and Beijing articulations, the reality within countries and at the global level has been a siloed approach with reproductive health (and at times reproductive rights) higher on donor and policy maker agendas (whether driven by demographic trends, fertility control, ignorance or discrimination) even when the language is used. The limits to meaningful interaction between work to support sexual rights and reproductive rights is also embedded in movement politics; many movements, including women's health and rights, disability rights and reproductive health and rights movements have tended to neglect issues of sexuality and sexual pleasure.[6] Likewise, those working on sexual rights have more often than not stayed away from reproductive health and rights in their advocacy work[7] for substantive but also political reasons.

The HIV/AIDS movement, and the ways in which it brought focus to the rights of key populations, including their sexual and reproductive rights, has been the most useful in helping to catalyse greater engagement between movements/constituencies and those driving HIV prevention programmes to address sexual health and sexual rights more comprehensively, even as pleasure has rarely been a part of these conversations.[8] In addition, and in parallel, the global women's health and rights movement, LGBTIQ* movements, trans and intersex rights mobilisation, youth mobilising on sexual and reproductive health and rights, advocacy and programmatic work for sex workers’ rights and the disability rights movement – have started to force attention to taboos, stigma, discrimination and human rights violations and led to broader recognition of human rights related to sexuality and sexual health more broadly for all people.[9] The fact that this focus has been on harms, and not pleasure, has in some ways shaped the discourse. Nevertheless, the result has been an increased and comprehensive understanding of sexual rights as human rights relevant to sexuality and sexual health. This growing understanding has been reflected in the work of WHO[10] and other United Nations (UN) agencies, such as the UN Programme on HIV/AIDS (UNAIDS), the UN Population Fund (UNFPA), and the Office of the UN High Commissioner for Human Rights (OHCHR), including in their inter-agency statements (for example, on forced sterilisation,[11] elimination of discrimination in health care settings[12] and elimination of violence and discrimination against LGBTI people,[13]) as well as the work of international non-governmental organisations such as IPPF.[14] The World Association for Sexual Health (WAS), whose work has contributed significantly to the understanding and acknowledgement of sexual rights internationally, issued a revised Declaration of Sexual Rights in 2014,[15] and an accompanying Technical Document[16] taking a comprehensive approach to sexual rights as human rights from a multi-disciplinary perspective and, importantly, with great attention to pleasure as an element of sexual health and sexual rights.[17]

Civil society organisations internationally, regionally, and locally, such as CREA,[18] the Sexual Rights Initiative,[19] and The Egyptian Initiative for Personal Rights,[20] and scholarly initiatives with a strong focus on advocacy, such as Sexuality Policy Watch,[21] have contributed significantly to the advancement of sexual rights in the international, regional, national and local political spheres.

Sexual pleasure is the newest arrival to the sexual health and sexual rights policy landscape, the least developed and potentially the most open to interpretation. Outside the context of sexology, the study of sexual pleasure – when it has occurred – has generally had a narrow heteronormative bias,[22] addressing pleasure through a default focus on adults and within marriage, including in medical text books, sexuality education, etc.[22,23] Sexual pleasure most frequently emerges in policy and programming as a consideration relevant to sexuality or sexual health, rather than as a topic in its own right. Rights-based operational definitions of sexual pleasure in the context of sexual health, and more broadly, have been sorely lacking.

The World Association for Sexual Health (WAS), noted above, has been perhaps the most forward-looking in recognising the linkages between sexual pleasure, rights and health. As a professional association with global relevance, as far back as 2008, it urged all governments, international agencies, private sector, academic institutions and society at large, to recognise sexual pleasure as a component of holistic health and wellbeing[17] and has since urged various actors to recognise the importance of sexual pleasure in research, policy and service delivery, and connected to sexual rights not only from the “free from violence perspective,” but from the perspective of positive sexuality.[15] It has also initiated expert consultations with the WHO and other relevant organisations, to urge them to adopt definitions of sexuality, sexual health and sexual rights, which recognise pleasure as a central element of those definitions. Inspired by the WAS articulation, we adopt the working definition of sexual pleasure put forward by the Global Advisory Board for Sexual Health and Wellbeing[2] for purposes of this article (see Box 1), given its intent to highlight the interconnections with sexuality, sexual health, and sexual rights.

Linkages

The links between sexual pleasure and sexual health have long been understood. Sexual health is now also recognised to be closely associated with the extent to which people’s human rights are protected.[24] To date, however, there has been insufficient attention to the ways in which people’s experience of sexual pleasure is not only tied to their sexual health but dependent on the extent to which their sexual rights are respected, protected and fulfilled.[25] Undue weight seems still to be accorded to the health system and other related institutions as core enablers of individual pleasure. The pathways to how individuals seek and enjoy pleasure are often much more complex and frequently the interface with the health system or facility happens only later, and if there are health consequences (e.g. unintended pregnancy, infections, need for contraception, etc.). The failure to comprehensively approach sexual pleasure from its very roots and intersections with sexuality, sexual health and sexual rights has real implications for people’s lives, including not only limits to the protections from sexual violence, and to the information and health services people can receive, but also from the perspective of how people can relate to their own bodies, establish relationships, and live in the world.

Using the definitions noted above to guide our analysis, below we provide some broad brushstrokes to explore the ways in which the intersections of sexual health, sexual rights and sexual pleasure are currently considered in policy and programming, and suggest some opportunities for advocacy to further strengthen these linkages.

Assessing laws and policies

Laws and policies matter because they set rules and frameworks for people’s conduct in society and for programmatic interventions. They can contribute to or obstruct the development of programmatic and service delivery interventions on sexual health, deter or support people’s experience of sexual pleasure, and enable or disable people to seek and receive the information they require to protect their sexual health and exercise their sexual rights. Legal frameworks can have content that respects and protects human rights, for example those that provide access to comprehensive sexuality education or give equal opportunities in all areas of life for people regardless of sexual orientation, gender identity and expression and age. On the other hand, laws may create limitations to sexual health and pleasure, such as those that do not allow adolescents or unmarried people to access sexual health services without parental or spousal consent.[10] Further, criminalisation of certain behaviours and identities (e.g. LGBT populations) has greatly limited the ways in which sexual pleasure has found expression in policy and programmes. In addition, the emergence of “adolescents” as a category of people requiring intervention has put a focus on the “prevention” of harms in legal frameworks (early marriage, early pregnancy and childbirth, etc.) and largely ignored positive attention to their pleasure, sexuality and sexual rights. The stigma associated with premarital sex and the “moral panic” that accompanies conversations about young people's, particularly young women's, sexuality is profound and deeply ingrained, and “policy” level advancements to address these issues often have to deal with backlash and opposition.

Social cultural taboos in relation to sexuality are often embedded in laws and policies with negative effects on sexual health and pleasure. For example, laws that penalise and criminalise sexual health related matters, such as same-sex sexual acts and behaviours, transgender expression, sex work, HIV transmission, possession of a condom as evidence of crime, and penalisation of the advertisement of contraception or abortion, codify a restricted approach to morality and reinforce power structures that control the bodies and behaviours of marginalised and discriminated against populations. The burden of unjustified use of criminal and punitive laws is significant: certain population groups, such as gay, lesbian and transgender people, women, adolescents, people engaged in sex work, and those living with HIV, can experience difficulties in accessing relevant services, let alone engaging in positive sexual experiences, with direct impacts on health and pleasure.[26]

Controlling, undermining, restricting and medicalising the sexual needs and desires of certain populations can result in coercive laws, policies and practices. For example, the desires, pleasure and sexual health and rights needs of people living with disability, including with intellectual disabilities, are still often undermined, and controlled through forced sterilisation policies and practices, inaccessibility of sexuality, and sexual health information and services.[9] People with disabilities are often infantilised through laws and policies and held to be asexual[27] (or in some cases, hypersexual), their pleasure irrelevant at best, incapable of reproduction and unfit sexual/marriage partners or parents.[28] For women, disability may mean legal exclusion from a life of partnership and active sexuality, and denial of opportunities for motherhood.[29] These laws, policies and controlling practices undermine the equal rights of people with disabilities, their need for access to information and services, and their desires for pleasure, reproduction and parenting.

While laws and policies should be set in such a way that they respect human rights and acknowledge sexual desire and pleasure as a basic human need, many laws that are set with the intention to protect can end up being discriminatory and coercive by, for example, not recognising non-binary gendered bodies, same-sex sexual practices, or the sexual desires of people under the age of 18 years old. For example, rape laws that do not recognise rape in marriage, or consider any sexual act to be rape if it occurs with a person under the age of 18 years old, or recognise only vaginal penetration by a penis as rape, exclude many people from the spectrum of protection.[16]

Thus, application of the triangle approach to sexual health, rights and pleasure proposed here would require not only careful analysis but also amendment of laws and policies to ensure they do not inadvertently discriminate, and that they respect the rights-based definitions of sexuality, sexual health, and pleasure presented in Box 1. Some positive developments are occurring in this regard at both the international and national levels.

For example, WHO initiated changes to the International Classification of Diseases (ICD10)[30] that is the lead international policy on classification of diseases and health conditions. The ICD greatly influences not only the utilisation of services and insurance codes, but the setting and implementation of national laws, standards of care, services, medical education and research. Accordingly, WHO elaborated a new chapter for ICD 11, called “Conditions related to sexual health,” that brings a more holistic view to sexual health, by connecting the body and mind in relation to sexual functions and dysfunctions; de-psychopathologising gender expression, and eliminating any remaining codes related to sexual orientation.[31] All of these changes are not only justified from the sexology and sexual health perspective but also support sexual rights and different forms of pursuing consensual pleasure.[32]

Human rights bodies, such as the UN Human Rights Committee, the Committee Against Torture, and the European Court of Human Rights, as well as national Constitutional Courts, have increasingly applied human rights standards, such as the rights to non-discrimination, freedom from inhuman and degrading treatment, human dignity, self-determination and bodily integrity, to various sexuality and sexual health related issues with positive implications for both health and pleasure. These linkages are visible in their decisions, though often related to the provision of health services, on such issues as forced sterilisation, involuntary surgeries on intersex and transgender people, mandatory HIV testing, and access to abortion, for example, in cases of rape.[16] These human rights standards, in turn, are increasingly reflected both in public health policies and programmes with positive implications for health, wellbeing and pleasure, with particular attention to the protection of sexuality from the privacy perspective.[16] Within countries, laws and policies that decriminalise consensual sexual behaviours, eliminate mandatory medical interventions, provide people under 18 years old access to the sexual health education, information and services they require, serve as good examples of attention to the kinds of policies needed to ensure health, wellbeing, rights and pleasure for all populations.[10]

Assessing programming – within and beyond the health sector

Historically, sexual health and rights programmes have tended to focus on preventing negative consequences associated with sexuality, such as: prevention of unintended pregnancies, HIV and sexually transmitted infection (STI) prevention and treatment and addressing sexual dysfunction. The importance of addressing the negative consequences of sexual health behaviours should not be minimised. In many cases, however, this approach has failed to recognise that some of the primary factors behind sexual health risk, and the need for sexual health information and services, are issues that relate to rights, pleasure and sexual desire and not to morbidities and mortalities.[33] The fact that some people don't seek the assistance of sexual health providers until they face a negative consequence related to their sexual activity (such as an STI, erectile dysfunction or contraceptive failure) can reinforce the notion that the health provider’s role is only to resolve these negative issues. The majority of health service providers are not prepared to address the complexity of sexual pleasure (including the dissociation of safety and pleasure) and the diverse ways in which it is experienced at different points of life (adolescence, adulthood and older age) and among different populations (for example, lesbians, gay men and transgender people, as well as people living with HIV, among others).

Sexuality, sexual desire and sexual pleasure remain subjects of shame and stigma in many parts of the world, with sexual health programmes that only focus on the unwanted consequences of sexual behaviours, sexual morbidities and “normalised” heterosexual sexual practices further contribute to stigmatisation. Programmes that promote fear around the negative consequences of sexual activity are based on a risk approach, and leave important conversations about sexual health, sexual rights and sexual pleasure aside. Abstinence-only sexuality education is a particularly vivid example as, amongst other harms, it promotes the belief that premarital sex is “immoral,” and reinforces traditional gender norms, such as the idea that it is unacceptable for women to express sexuality or sexual pleasure.[34] These programmes have had a lot of political support from conservative governments, such as the Trump presidency in the US.

Within the risk-based approach most common to programmatic work in this area, the importance of sexual pleasure to enable sexual health and wellbeing is not well recognised, despite evidence that demonstrates its relevance. For example, promoting pleasure in male and female condom use, alongside safer sex messaging, has been found to increase the consistent use of condoms and the practice of safer sex. This “power of pleasure” approach,[35] has been implemented with great success in several countries, such as Australia, Mozambique and Cambodia, among others. The triangle approach to sexual health programming proposed here, similarly, puts pleasure at the centre, as an element that is intrinsically linked to sexual health and sexual rights, acknowledging and tackling the various risks associated with sexuality, without reinforcing fear or shame.[36] The triangle approach could also be considered a “sex-positive” approach to sexuality and sexual health, constituting an approach that celebrates sexuality as a part of life that can enhance happiness, and not solely focused on preventing negative experiences.

Sexual health programmes, including those that address reproductive health and rights concerns, can cover a wide range of specific thematic areas and goals. They can focus on the provision of sexuality education and/or information (including capacity building programmes for service providers, peer educators or teachers) and the provision of a wide range of sexual health services, including sexuality counselling, HIV and STI prevention, testing and treatment, prevention of unwanted pregnancies, abortion, prevention, testing and treatment for human papillomavirus (HPV) and cervical cancer, prevention and treatment of testicular cancer, addressing sexual dysfunction, providing advice and services on sexuality, and so on.

The education of health providers is crucial for them to be able to deliver quality sexual (and reproductive) health services that incorporate rights and pleasure for all people: adolescents, adults, and the elderly, regardless of sexual identity, social or demographic characteristics. Gender stereotypes often shape health-care providers’ interactions with clients and providers’ response to adolescents seeking sexual health care can be similarly shaped by their own personal views and experiences about young people.[37] For all of these reasons, health-care providers may promote interventions that are more in keeping with their own beliefs than with the needs, rights and desires of their clients.[38] Yet it is worth recognising that some of the reason for this is not stigma but lack of training. Aside from select psychologists, sexologists or sex therapists, health-care providers are often not encouraged or sufficiently trained to feel comfortable providing services which place pleasure or rights at the centre of their engagement with clients.

In many countries, both medical students and practicing physicians “receive variable, nonstandardized, or inadequate training in sexual history taking and sexual medicine assessment and treatment.”[39] For example, Malhotra and colleagues conducted a nationwide telephone survey of 500 fourth-year medical students in the US and medical school curriculum offices in 2008.[40] They found that 44% of medical schools in the US lacked formal sexual health curricula, that 17.4% of medical students felt uncomfortable taking sexual histories from ten to fourteen year-olds and 23.8% from adults aged 75 and over. Also, in 2008, Shindel et al invited 2261 medical students from the US and Canada to participate in an Internet-based survey, in which they found that 53% of respondents “felt they had not received sufficient training in medical school to address sexual concerns clinically.”[41] While a decade old, these studies show that medical education in sexual health in the US and Canada is lacking, with many students and providers reporting feeling unprepared to address sexual health issues with their clients.[42] Data for the rest of the world are sorely lacking.

In its working definition of “sexual pleasure,” the Global Advisory Board for Sexual Health and Wellbeing identified six key factors that represent links between sexual health, sexual rights and sexual pleasure that can be incorporated into programming and the delivery of services: self-determination, consent, safety, privacy, confidence, communication and the ability to negotiate with the partner(s).[2] SRHR programmes that incorporate the links between these three concepts recognise sexuality as a source of pleasure and wellbeing. To date, there are very few documented programmes and technical tools globally that have embraced and have been successful in using pleasure alongside sexual health and sexual rights. Three examples follow:

Example 1:

One such programme is Love Matters, which has created a digital platform on sexuality and pleasure.[43] The project operates at the intersection of media and public health, specialising in media for social change, and talking about sexual pleasure is at the core of their engagement strategy. Rather than using secrecy, silence and shame to try and prevent people from having (risky) sex or focusing only on the negative, they use pleasure as the hook to have difficult conversations with millions of young men and women around the globe. Love Matters is intended as a reality check for these young men and women, offering sexual health and sexual rights information with a positive take on pleasure and relationship satisfaction. The programme demonstrates that the web, mobile and social media platforms give young people the facts they need to have safer, healthier and happier sex, and can deliver science and rights-based sexual health and rights information with a pleasure perspective directly into the hands of young people.

Love Matters worked with the UK-based Institute of Development Studies (IDS) and curated the research bulletin “Digital pathways to sex education,” released in February 2017.[42] It found that across all their sites the “pleasure” pages are more than eight times more popular than the family planning pages, and that the “sexier” content serves as a gateway to other information resources, including risk reduction and disease prevention. This unique demand-led, pleasure-positive approach to sexual health and rights education is reaching people in large numbers. Many sexual and reproductive health organisations are now starting to use the same approach. Love Matters has been a transformative global digital platform that has diversified sources of sexuality information beyond schools and health facilities, and points to the way in which online platforms have created the possibility for people to access diverse information relating to sexuality and pleasure without needing to interface with the health system or with providers.

Example 2:

An example of a technical tool which incorporates the triangle approach linking sexual health, sexual rights and sexual pleasure to inform SRHR programmes is Fulfil! Guidance Document for the Implementation of Young People’s Sexual Rights,[44] published by the International Planned Parenthood Federation (IPPF) and the World Association for Sexual Health (WAS) in 2016. Fulfil! was the result of a multidisciplinary effort, and it responded to the fact that the majority of programmes (and policies) regarding youth’s SRHR frequently emphasised “disease, death, disability and violence associated to sex and sexuality.” In its first section, Fulfil! outlines elements that are fundamental for young people’s sexual rights to be implemented, the first one being “a comprehensive understanding of young people’s sexuality with diversity and sexual wellbeing at the core.” Based on the IPPF and WAS Declarations of Sexual Rights,[14,15] Fulfil! stresses the importance of young people’s experiences of sexual pleasure, as they shape other experiences throughout the lifetime and have a direct impact on their overall health. Apart from providing specific guidance for programmes, laws and policies, Fulfil! also presents a case-by-case decision-making model to support service providers in the implementation of young people’s sexual rights, in which ethical, practical and legal factors need to be balanced.

Example 3:

With respect to training and capacity building, the Global Advisory Board for Sexual Health and Wellbeing (GAB) has developed a training toolkit[45] for future health professionals to deliver services with the triangle approach. The training aims to create an understanding of the links between sexual health, sexual right and sexual pleasure, and to raise awareness on the importance of delivering services with a rights and pleasure approach. It also includes the Pleasuremeter,[43] which is a tool based on the GAB’s working definition of sexual pleasure and motivational interviewing techniques (such as asking open-ended questions and using scales to address behavioural stages of change) to address the links between sexual health, sexual rights and sexual pleasure in the taking of sexual histories. This training was piloted in May 2017 at the World Congress for Sexual Health in Prague, Czech Republic, has been further refined, sent for peer review, finalised and is now freely downloadable.

Rethinking advocacy

Achieving a world where intersections between sexual health, sexual rights and sexual pleasure are reinforced and positively influence people’s lives will require not only strong policy and programming, but also comprehensive and linked global, national and local grassroots advocacy. Advocacy is needed to: support policy and legal change; demand equal opportunities, rights and conditions for all; promote investment in local and national rights-based sexual health services that address pleasure; demand quality of care and comprehensive sexuality education; and hold relevant stakeholders accountable. This is not the concern of just one group. If pleasure is to be understood and addressed in the context of sexual health and sexual rights, advocates must include civil society organisations, researchers and research institutions, service providers, and both the public and private sectors. Most importantly, it will also require solidarity and harmonisation of efforts.

Efforts are being made daily to weaken global solidarity and global principles and institutions, and this is a concern for all engaged in sexual health and rights work. Silo-isation and conflicting approaches to using rights discourse, even amongst movements that ought to be aligned, occur as a matter of course, with profound effects on sexual rights and pleasure. One example is the conflation of sex work with trafficking by various women’s rights groups and feminist organisations.[46]

Efforts must be made towards cross-movement alliance building efforts that can enable/foster local-global connections, including with respect to differing perceptions of sexuality, pleasure, and rights: for example, finding common ground amongst those concerned with trafficking and those advocating for sex workers’ rights, in working towards the elimination of all kinds of violence and exploitation.

Equality, non-discrimination and universalism are key to all social movements and engaging these principles will help to build bridges across movements. For the triangle to take hold in these complicated times, there is a need to form and maintain broad coalitions – ones aimed at preserving our web of local and international partnerships, 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 solidarity. For those engaged with the intersection of sexual health, rights and pleasure as individuals, and as a collective group of human beings, we need to figure out how and when to act. This means that across the range of topics we work on we have to work together more actively to support people to achieve sexual pleasure and to be able to claim their rights, and to protect people who advocate in this area.

Understanding where progress has been made, and where backlash has occurred, is relevant to determining where and how sexual pleasure can best be brought into these efforts. For those of us engaged in advocacy to advance sexual rights and sexual pleasure will need to take into account current North/South, North/North and South/South politics at a governmental level, as well as what is happening with those opposed to sexual rights, let alone sexual pleasure, in all forums.

Conclusions

There is increased recognition and support for sexual health and rights, even as current policy, programming and advocacy efforts and discourse around sexuality have yet to engage fully with the interconnections between sexual rights, sexual health and sexual pleasure. Implementation of the “triangle approach” to sexual health and rights is more important now than ever with the current political climate, for every individual and especially for those who are most marginalised.[47]

There is a need to learn from and move beyond conversations about pleasure, focused only on certain populations, whether with young people, women, and/or other marginalized populations, or specifically focused on sexual orientation, gender, gender expression, or sex characteristics, and support the relevance of sexual health, sexual rights and pleasure as a universal demand for all people.

An intersectional, inter-disciplinary and multi-sectorial implementation is critical to ensure that programmes are endorsed, implemented, funded and maintained, locally and globally. A potential first step may be to begin mapping, in order to make explicit, cases in which sexual health, rights and pleasure have successfully been brought together conceptually and operationally, as well as those cases where gaps in relation to the needs and rights of certain populations are identified. Such a mapping would make it easier to analyse where it would help to work with partners to ensure consistency, and where it might be strategic to begin this work at a very basic conceptual level. Where these concepts have been brought together in operational terms, there is a clear need to document programming efforts, and most importantly the difference this has made to people's lives. Rigorous evaluation of what has been put in place can effectively be used to frame arguments that are more likely to be accepted by states and institutions of power globally and within countries, and in ways that can facilitate access to resources which can then further support direct impacts on people’s lives. It is important to acknowledge, however, that recognition of the importance of sexual pleasure – when it does occur – still remains very much embedded within the public health realm. For this work to take root will need attention to the diverse and contextual ways through which individuals exercise choice, receive information and enjoy sexual pleasure, as well as more “eco system” work within institutions, communities, families, and so on, to create the enabling environment necessary for everyone to enjoy sexual rights and pleasure. Who is vulnerable or disadvantaged clearly will vary between countries and within countries, and so we need vigilance to ensure that a focus now and in the future results in better laws, policies and programmes to support sexual health, sexual rights and sexual pleasure for all people, and without distinction.