Where sexual health meets sexual rights
Radhika Chandiramani
Sexual health is both a state of wellbeing as well as an approach to working on issues of sexuality. While one cannot quarrel with the notion of sexual health as a health goal to be attained, as an approach to working on sexuality more generally it has perhaps got some limitations. What, then, is lacking in a sexual health framework? Put in a nutshell, while claiming that sexual health is not just the absence of disease, sexual health work still limits sexuality to bodies and essentialises sexuality as a biological construct. Because of its focus on health, it does not give sufficient weight to non-biological or non-physical expressions and aspects of sexuality such as desires, fantasies and cravings, as well as the gender and power relations that govern gender and sexual expressions.
In the few cases when sexual health extends its ambit to the provision of education, such as in the form of sexuality education and sex and relationships programmes, the perspective is once again often one of prevention – of HIV, STIs, unplanned pregnancy, sexual abuse, all very worthy causes, deserving of attention. But insufficient attention is often given to more positive goals such as the pursuit of happiness, pleasure or of achieving one’s full (sexual) potential. Because of their normative focus, notions of sexual health also run the risk of setting up standards of what is to be considered ‘sexually healthy’, which can become a trap in itself. For instance, monogamy may be promoted as a standard HIV prevention message. But what if Partying Penis and Vagrant Vulva, users of lubricants and condoms, want to have a good time with as many people as they possibly can? Or, what if someone wants to do something that may not be considered ‘good’ for them, such as participation in sadomasochism or watersports?
These problems and others call for a more expansive framework that recognises that people have different sexual desires, that sex manifests itself and is understood differently in different places and across time (Weeks 1986) and that sexual categories that exist today, such as ‘homosexuality’ were invented in relatively recent times (Katz 1990). As contributions elsewhere in this volume highlight, there is a growing awareness that gender is also not quite as fixed a category as it was thought to be, and the possibility of authentic expression for gender non-conforming people traverses a range of landscapes, from the beautifully vibrant to the agonisingly bleak.
Crucially, sexual health is not about making lifestyle choices. The woman who lives in poverty and does not use contraception is doing so not because she has made a choice. She may do so in order to protect herself from violence from a husband who beats her up if she suggests the use of condoms. She could use a government-supported injectable contraceptive, you might say, to take care of her contraception-related sexual health. Yes, she could, provided it were proved to be safe, which it is not yet, and she was aware of all the risks. The woman who lives in a mansion and is forced to have yet another abortion because the foetus is female, is doing so not because she has made a choice. It is because her husband and her inlaws with whom she lives are forcing her to do so in a society that values sons over daughters. These are real-life examples from our work on the TARSHI sexuality helpline in New Delhi, India.1
For people to achieve sexual health, the material, economic and social conditions affecting their lives need to change. For example, a woman who needs to insert a diaphragm as a method of contraception must have access to clean water in order to wash her hands; an anaemic pregnant woman needs nutritious food; a gender-nonconforming person must be able to find a job and just wages. Callers on the TARSHI helpline reveal their inability to engage in more pleasurable or more frequent sex because of the lack of privacy that results from living in cramped accommodations in which children sleep with their parents. The lack of information in a society where sex is not considered an appropriate topic of education, let alone conversation, and where marriage is arranged for many people, leads to questions on the helpline as well as in sexuality advice columns in newspapers, such as:
I am going to be married soon, to someone my parents have chosen for me. I am 28 years old, a quiet and shy kind of guy. I barely know the woman who will be my wife. She also seems to be quite shy. Must we have sex on the first night itself? What should I do? How do I go about it?
(Chandiramani 2008: 153)
To achieve sexual health, people must also be able to exercise control over their own sexual lives. Sex as practice is relational, even if there is no other person physically present. Even if there are no bodies in contact with each other, as may be in the case of phone sex or cybersex, there are still two or more imaginations at play, each exerting its power over the other. When it comes to actual bodies in contact, power – and the exchange or assertion of it – becomes more readily apparent, whether it be a consensual or non-consensual sexual encounter. To what degrees are people able to make decisions that empower them to exercise control over their own sexual lives? Who gets to make these decisions and who does not? And, why?
For different groups of people, in various parts of the world, the answers will be different. In some places, it will be the case that young girls have no say in having their clitoris removed or their vagina sewn up; in other contexts, rape is used as a weapon of war on both women and men; in some places, sex between consenting heterosexual adults outside marriage is punished while in others it is variously tolerated, expected and approved of. The list goes on. The factors that govern societal responses to these actions have to do with tradition, laws, religious beliefs, commerce and many other influences that have very little to do with health, sexual or otherwise. We need to go beyond notions of health alone in order to address injustices.
Sexual rights offer such a framework. Sexual rights are based on the core ethical principles of bodily integrity, autonomy, equity and non-discrimination (Corrêa and Petchesky 1994). Sexual rights approach sexuality positively, as a part of life that has the potential to offer excitement, pleasure, comfort, intimacy and all the other joys that sexuality can offer. But sexuality has a dark side as well, and sexual rights seek to prevent and address violence and discrimination that are the reality of many people’s sexual lives, for example people who do not conform to gender and sexual norms, rape survivors, sex workers and many other people. If indeed sexuality is integral to and of value to people’s lives, this aspect of life is also worthy of human rights protections. Just as women’s rights are human rights and reproductive rights are part of human rights, so also sexual rights must be claimed as human rights.
Historically, and as Jane Cottingham’s chapter in this volume explains, reproductive rights predate sexual rights in terms of their formal articulation. However, as a notion, sexual rights subsume many reproductive rights. With the advent of new technologies such as assisted reproductive technologies as well as the increasing popularity of adoption, there are also areas where the two sets of rights, reproductive and sexual, do not meet, because now reproduction is not necessarily dependent on sex. As conditions of life change, so also do the demands for rights.
Corrêa and Petchesky (1994) offer a framework of the evolving articulation of sexual rights that includes: the right to be free from discrimination, coercion and violence and rights based on positive ethical principles such as those of bodily integrity (my body is mine), personhood (right to make one’s own choices), equality (between and among men, women and transgender people) and respect for diversity (in the context of culture, provided the first three principles are not violated).
It is important to note that the articulation of sexual rights is evolving and is a site of contestation among both its detractors as well as its promoters. As in all sites of political struggle, there are opposing camps, as well as factions within camps. Sexual orientation has been a matter of much debate at the international level of the United Nations (Saiz 2004) since at least 1994. It continues to be. On 18 December 2008 Argentina read a statement supported by 66 states that condemned violations based on sexual orientation and gender identity and endorsed a Declaration on Human Rights, Sexual Orientation and Gender Identity at the UN General Assembly (IGLHRC Press Release, 19 December 2008). In response, 57 other states signed an alternative text read by the delegate from Syria and promoted by the Organisation of the Islamic Conference. According to this counter-statement, notions of sexual orientation and gender identity have no legal foundation and should not be linked to international human rights documents (UN Webcast, 18 December 2008).
The struggle for sexual equality and rights continues at local levels as well and is not limited to matters of sexual orientation. One example is provided by the events around Valentine’s Day in India, every year over the last decade, with various rightwing groups threatening and beating up romancing heterosexual couples and the counter-protests by students’ unions and civil society groups claiming the ‘right to live and love in freedom’ (Sharma 2009).
So, how do sexual rights work? Or rather, how might we put them to work? Sexual rights use the principle of consent rather than that of procreation or marriage or the gender of partner to determine what is acceptable sexual behaviour. Consent, in simple terms, means that a person has willingly, of their own free choice, agreed to participate in an activity, with adequate knowledge of its possible consequences. Sexual rights recognise that people bring their own meanings to different sexual acts – that is to say what for one may be highly erotic, for another might be unacceptable (Rubin 1984). This means that a judgmental attitude towards people’s gender and sexual expressions (that are practised consensually) is also a form of violence in and of itself. Because this approach privileges the consent and choice of all people and not just a few, it encourages work with people who have traditionally been neglected (Miller 2000).
For example, once we acknowledge that people with disabilities have sexual feelings, we will include them in sexuality education programmes and reproductive and sexual health and rights interventions. Ann Finger (1992) points to how the sexuality of people with disabilities is ignored, even within the disability rights movement:
Sexuality is often the source of our deepest oppression; it is also often the source of our deepest pain. It’s easier for us to talk about – and formulate strategies for changing – discrimination in employment, education, and housing than to talk about our exclusion from sexuality and reproduction.
(Finger 1992: www.newint.org/issue233/fruit.htm)
We will also recognise that different groups of people negotiate differently for sexual rights. Take the sexual right to decide if, when and how many children to have, as an example. The struggles in most parts of the world have been and continue to be around women’s right to seek an abortion. However, when it comes to women living with a disability or women living with HIV, the struggle is to avoid being coerced into having an abortion, and preceding that, also the struggle to be able to assert their right to engage in sexual activities of their choice. Again, in societies where son-preference exists, the issue is not one of the right to seek an abortion, but of not being forced to abort a female foetus (Visaria 2007).
Similarly, if we are able to discern the differences between sex work and trafficking for sexual exploitation and believe that sex work is best understood as work, and is not always ‘exploitation’, we will not expend our energies in trying to ‘rescue’ sex workers and ‘rehabilitate’ them in meaningless and frequently demeaning ways, but will instead work towards claiming sex workers’ rights. This is what one sex worker has to say about her being ‘rehabilitated’:
I was also a subject of rehabilitation. They gave me a buffalo. Well, I had this small room [in a house] which I now found myself sharing with the buffalo. You see the buffalo eats a lot, and as I was expected to stop sex work after rehabilitation, there was not much money. I didn’t mind for myself, but I couldn’t bear to see the buffalo wasting before my eyes. So soon I found myself doing twice the sex work to feed the buffalo and me. Well, now the buffalo was in heat, and I had to get her ‘crossed’. I was told that it would cost 100 rupees per attempt. So there I was now being forced to do sex work to pay for the buffalo to have sex! That was enough. I decided I had enough with rehabilitation.
(Revathi 2002: 7)
Sexual rights also push us to look at the question: ‘What is our standard of sexual legitimacy?’ If we make consent rather than gender our bench mark for acceptability, it allows us to work with and for the rights of same-sex desiring people. For instance, in Colombia, because of the work of the LGBT rights group Colombia Diversa, the human rights group Dejusticia and the Group for Public Interest Rights from the Universidad de los Andes, the Colombian Constitutional Court ruled on 28 January 2009 that same-sex couples must be granted the same rights as those in heterosexual common law marriages. The decree (No. 029 of 2009) grants sweeping civil, political, social, economic, immigration and criminal rights to gay and lesbian couples. Until now, these rights had only been reserved for non-married heterosexual couples (Colombia Diversa 2009).
In India, the Supreme Court is expected to pass a judgement on Section 377 of the Indian Penal Code that criminalises ‘carnal intercourse against the order of nature’ and is used by the police to harass and extort money from hijras and men who have sex with men and, in some instances, also beat and torture them. The arguments to remove Section 377 from the statute book are based on consent, privacy, equality, dignity and the right to health. The last argument is made because Section 377 is also used to harass HIV prevention outreach workers who work in areas where men cruise for sex with other men.
Section 377 presents a case of consensual sexual behaviour being penalised, simply because it is interpreted on the basis of gender even though the wording of the law is gender neutral and in its interpretation could be applied also to heterosexual couples who engage ‘in carnal intercourse against the order of nature’, simply by using contraception. Strangely, in the same country, non-consensual sexual behaviour in heterosexual marriage is not penalised. Based on consent as a standard, heterosexual married women who face marital rape should be able to take it on as an issue.
Variables such as gender expression, marital status, sexual preference, age, socio-economic status, race, ethnicity, poverty, caste and religion are some of the axes of privilege or discrimination that intersect not only with one another but also with matters of sexuality. An affirming approach to sexuality must necessarily take into account the fact that people live in multiple dimensions and while they might experience privilege in one of these, they might be disadvantaged in another, or that they might be multiply disadvantaged. For example, a young lesbian from a minority ethnic group may be disadvantaged because of her age, sexual preference, gender, marital status and her ethnicity and may therefore not have the same access to sexual health services that a married woman from a dominant ethnicity may have.
By acknowledging that sexual and gender expression take many different forms, sexual rights offer the possibility of being inclusive of all people. All over the world, there are vibrant and various ways in which people express their gender and sexual identities – ways that defy simple categorisation of people into man–woman or heterosexual–homosexual. For instance, think of the travestis in Latin America, the warias in Indonesia or the hijras in India. Let us look at age as another example. Sexual rights apply to young and old, not just to people who are in the reproductive age range. Given this, sexual health and sex and relationships education programmes need to go beyond the 15–45 age range.
In the area of policy as well, sexual rights can be used towards ensuring there are policies that uphold and do not violate people’s rights. For example, same-sex sexual relations between men are prohibited in more than 80 countries in the world, and in more than half of them this remains as a colonial legacy under which same-sex desiring people are harassed and oppressed (Human Rights Watch 2008). Sexual rights are not just about gay rights or the right to have sex. They engage with people’s fundamental rights to equality and privacy. For example, the Basic Law in Hong Kong states that all residents of Hong Kong shall be treated equally before the law and are entitled to protection under the law without any discrimination. In 2005 a young gay man in Hong Kong, William Leung, then 20 years old, mounted a challenge to the laws which criminalise consensual sex between men aged over 16 years but under 21 years while allowing sex between consenting heterosexuals aged 16 and over. This led to an amendment to the law lowering the age of consent for sex for homosexuals in Hong Kong in August 2006.
Sexual rights also require us to analyse the underlying motives with which funding support is given. The US President’s Emergency Plan for AIDS Relief (PEPFAR) has until recently endorsed the ABC approach (Abstain, Be faithful, use Condoms) and mandated that 33 per cent of the HIV prevention funds be used for abstinence-untilmarriage programmes. This was changed in 2008 to requiring organisations that spent less than 50 per cent of their funds on abstinence-only programmes to explain why they did so (obviously pressurising them to spend more) (PlusNews, 21 January 2009). Given the circumstances and realities of many people’s lives, this is an entirely inappropriate proposition. For instance, how many women, especially in regions like Asia and Africa, have the power to insist on their male partners being ‘faithful’, let alone use condoms or be abstinent? Joke van Kampen from Malawi offers a searing critique of how the ABC approach is leading to a D – D for disaster – in Africa. Her arguments are valid in other parts of the world as well, as she notes how unrealistic the approach is and points out the gender double standards that it perpetuates as well as the inaccurate connections that it creates. She says:
In a sort of strange side effect of the abstinence mantra, manuals on sex education linger on virginity for pages. While virginity might seem a desirable state of being to some people, it is as useful in HIV/AIDS prevention as advising people to stay inside in order to reduce traffic accidents. Full blown double standards go unchallenged in the virginity discourse, since virgins are, we all know this, female.
The same double standards are resulting in hilarious communication hazards. One of the many NGOs here that were circulating messages on the occasion of World AIDS Day published two posters here: one portraying women in a village, pouring maize, the other portraying men drinking beer and playing trick track (ok, let’s not split hairs here). The theme of World AIDS Day being Keeping the Promise, the women on the poster say: ‘I promise to be mutually faithful’, the men promise ‘to reduce the number of my sexual partners’. Apart from the fact that it is hard to imagine how an individual can promise to be mutual, note that these promises, when kept, will lead to infection indeed.
(Kampen 2006: www.comminit.com/drum_beat_345.html)
In addition to this disastrous intervention, recent US law has also required organisations receiving US global HIV/AIDS and anti-trafficking funds to adopt the antiprostitution oath. This means that organisations cannot in any way be seen to support prostitution. Therefore, organisations that work to support sex workers’ rights to health, clean water, food, health services, education for their children and other meaningful forms of employment are thwarted in their aims, and are also not able to use the skills that sex workers have to train others including rural youth on safer sex practices. PEPFAR Watch has evidence that these restrictions are already undermining promising interventions. As Meena Seshu, who works with people in prostitution, says:
Many of the women I work with are what are known as devadasis, called temple prostitutes in some parts of India. For them, prostitution is a way of life. The fact is some of the women are strong fighters, who negotiate with the police, who negotiate with health systems and doctors all the time, and come out with flying colors. And they’re the best educators of their male clients I have seen. These women are able to talk to them straight. All of the truths we’d assumed were challenged by them. There are women here. They’re saying something. Isn’t it right that we listen?
(Kaplan 2006: www.alternet.org/rights/33284?page=2)
And, of course, as Françoise Girard has pointed out:
These are only some of the sexuality-related policies of the Bush Administration. They nevertheless give an idea of the Administration and their allies in Congress in their drive to remake America and the world in line with their moral and religious values. Sexuality is not an afterthought, but a center piece of their thinking. Large sums of money are being spent to make this vision of a mythical, heterosexual, conjugal sexual past, a reality.
(Girard 2004: 30)
Fortunately, with a recent change of administration in the USA there are some signs of improvement. It has been announced, for example, that the ‘Mexico City Policy’ has been revoked (ABC News, 23 January, 2009). This regulation, also called the ‘global gag rule’ by abortion rights activists, prohibited the use of Federal funds by international family planning groups to promote or perform abortions, even if the funding for these activities came from other sources. This resulted in a lack of sexual and reproductive health services for countless women and was a serious violation of their sexual and reproductive rights.
That is why we need to get beyond bodies and health to see how we can build on and promote sexual rights for all – for young people who may be vulnerable and marginalised, for lesbians and gays and other same-sex desiring people who may not yet have a name for themselves, for indigenous as well as rural women, for people with disabilities and also for heterosexuals who, because of their very ‘ordinariness’, may be neglected, apart from being ‘targeted’ by HIV prevention interventions that do not take pleasurable sexuality into account. Sexual rights are for all, not just the chosen few.
1 The TARSHI helpline has been operating for 13 years and has responded to more than 60,000 calls from people between the ages of 10 and 70+ years. For more information, see www.tarshi.net
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