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Translated by Gabrielle Baillargeon-Michaud. 

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To commemorate International Women's Day, Les 3 sex* explores women's health and sexual and reproductive rights (SRHR) worldwide. This article contributes to the discourse on global health, an “area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide to enhance health outcomes and achieve health equity across all populations” (Koplan et al., 2019)​​. It critically examines the binary perspective on gender that is prevalent in global health, focusing on those assigned female at birth while acknowledging the complexities surrounding diverse gender identities and their implications for SRHR. The terms “girls” and “women” used within this text refer to individuals assigned female at birth.

Sexual and reproductive rights are at the forefront of numerous global agendas, spanning both international law and global public health. These rights, which blend health and legal considerations, typically address the specific challenges faced by girls and women.

At the core of sexual and reproductive health rights (SRHR) are persistent inequalities and injustices that disproportionately affect vulnerable groups (Krieger, 2014). Addressing these rights means reflecting on these deep-seated issues of disparity and vulnerability. These concepts are complex and challenging to articulate, particularly from an international viewpoint. Searching for "sexual and reproductive rights" online highlights the complexity of the matter: it uncovers an array of definitions, heated debates, startling statistics, and pervasive narratives and images that often victimize girls and women from low- and middle-income countries.

Contextualizing sexual and reproductive rights is crucial for a genuine understanding of the underlying issues. It is important to consider societal aspects that "structure" the rights of girls and women, including those linked to their sexual and reproductive health. Similarly, society does not randomly distribute vulnerabilities and injustices (Singer et al., 2017). But how can we critically reflect on international sexual and reproductive rights while maintaining an activist stance? How can we contextualize these rights and denounce injustices without victimizing girls and women? Among the frameworks that can foster critical reflections on these questions, the framework of health vulnerabilities and agency is particularly relevant for sexual and reproductive rights (Chung, 2021; Fortin et al., 2023). It is possible to remain critical of injustices, recognize structural vulnerabilities related to sexual and reproductive rights, and value the agency of the girls and women involved.

Sexual and reproductive rights: an overview

Sexual and reproductive rights encompass terms like "women's rights," "gender justice," and "reproductive justice." Navigating these terms, which are often used to define similar activist movements and human rights issues, can be challenging.

Sexual and reproductive rights are widely recognized as fundamental human rights intertwined with sexual and reproductive health (Boyer, 2018). There is now a strong emphasis on the connection between rights and health, with these concepts almost invariably linked. Therefore, when sexual and reproductive rights are respected, protected, and actively upheld, they significantly promote and improve sexual and reproductive health outcomes (World Health Organization, n. d.; Starrs et al., 2018).

Sexual and reproductive rights cover several key areas, including but not limited to:

• Making personal decisions regarding one’s body;
• Living free from violence, discrimination, or stigmatization;
• Preserving one’s physical integrity;
• Accessing sexual and reproductive health services, including contraception;
• Receiving sexual education; and
• Choosing whether to marry or have children, and when.

(Amnesty International, n. d.; Boyer, 2018; Germain et al., 2015)

When these rights are violated, a range of SRHR issues can emerge, such as child marriages and forced marriages, female genital mutilation, unintended pregnancies, and gender-based violence. Many SRHR issues disproportionately affect girls and women because they arise from gender inequalities (Starrs et al., 2018). Thus, it is unsurprising that sexual and reproductive rights are often linked to girls’ and women's health.

It is also important to acknowledge that the framework for sexual and reproductive rights is primarily Western and not universally applicable (Bessa, 2019). Protecting these rights is crucial for continuing progress toward gender equality. The recent rise of political and popular movements against abortion rights highlight the vulnerability of sexual and reproductive rights (Forouzan & Guarnieri, 2023).

However, although these rights are rooted in "universal" human rights, they are not recognized in the same way everywhere (Dale, 2022).

Understanding structural health vulnerabilities can help contextualize sexual and reproductive rights, thereby shaping and adapting more nuanced and appropriate responses to these rights in different contexts.

Structural vulnerabilities of health: barriers to overcome

Vulnerability is defined as the susceptibility to a risk that may result in negative outcomes (Clark & Preto, 2018). Phrases such as "being vulnerable" or "belonging to a vulnerable population" are common in the health sector but can be stigmatizing. By attributing vulnerability to a group, the focus shifts to individuals rather than the systemic issues causing these vulnerabilities, which can be particularly problematic for sexual and reproductive rights.

Consider the example of street harassment, a phenomenon that most women worldwide experience (Fairchild, 2023). Women are often labeled as vulnerable to street harassment, and typically, research and interventions about this topic focus primarily on women. However, centering vulnerability on women leads to victim blaming (Fairchild, 2023). The consequences of this can be severe, potentially leading to sexual violence or child marriages as a means of avoiding slander.

Structural vulnerabilities in health are notably relevant in such a context. Unlike general vulnerability, structural vulnerabilities in health are defined as a heightened risk of harm to certain social groups, directly tied to social inequities (Chung, 2021). Societal structures inequitably distribute these inequalities, resulting in structural vulnerabilities. In the realm of sexual and reproductive rights, political, economic, social, and cultural structures come into play. By examining these structures, we can adopt a more critical perspective on vulnerabilities (Fortin et al., 2023).

Therefore, street harassment is a societal phenomenon perpetuated by unjust structures that foster vulnerabilities. Focusing on structures like social and gender norms helps avoid placing blame on girls and women, or victimizing them. Understanding the structures that allow certain issues, we can better identify ways to strengthen and safeguard sexual and reproductive rights.

Agency: navigating vulnerabilities

In low—and middle-income countries, many women are perceived as vulnerable from a Western viewpoint, yet they often also exercise agency that challenges the structures around them. Agency is the capacity to act within one's capabilities (Morin et al., 2019). There is a dynamic tension between vulnerabilities and agency; no individual is in complete power or is solely vulnerable.

In matters concerning sexual and reproductive rights, identifying agency, particularly in complex situations like child marriage, can be challenging. Right now, approximately 640 million girls and women globally have been married before age 18 (UNICEF, 2023). Various societal structures contribute to this issue, including gender norms, family dynamics, economic opportunities, social status, and taboos surrounding sexuality. These structures disadvantage young girls, making their adolescence particularly vulnerable (Starrs et al., 2018).

It is possible to maintain a nuanced perspective while adopting an activist approach; this would potentially contribute even more to a collective decolonial effort. Grassroots, feminist, and activist movements are crucial in advocating sexual and reproductive rights (Chandra-Mouli et al., 2019).

Recognizing the structural vulnerabilities and agency of young girls enables us to better identify the societal structures on which to act, and to incorporate the agency of those affected into the advocacy efforts.

For instance¹, it is increasingly recognized that young girls develop strategies to combat child marriage (Bessa, 2019; Lokot et al., 2021). Long perceived as powerless, these strategies have been revealed to hold agency, and have a potential to contribute to a broader collective fight. Young girls facing child marriage are best positioned to determine how to advocate for their rights. However, their involvement in this struggle has been limited, as efforts continue to focus on empowering them without acknowledging that they may already possess the capabilities to resist, or that their environments may not permit the exercise of their agency. Instead of viewing local issues through an international lens, we should focus on how affected individuals have developed their agency to navigate oppressive structures in their specific contexts.

To ensure no one is excluded from the fight for sexual and reproductive rights, we must consider societal structures and recognize the agency of those affected within their contexts. If young girls are informed and eager to act, but lack the power to do so, we are faced with "informed powerlessness" (Bessa, 2019). We must explore how their agency can be enacted through societal structures to address complex issues requiring profound structural changes.

How do we advocate for the sexual and reproductive rights of all? The structural vulnerabilities faced by girls and women are embedded within complex community, family, and political contexts. Their agency is limited if the surrounding systems do not allow for structural changes. Therefore, structural interventions can potentially effect transformative changes related to sexual and reproductive rights, particularly concerning gender norms (Kohli et al., 2021).

Sexual and reproductive rights are far from being recognized, protected, and enforced globally. International Women's Day serves as a reminder that the battle for the full protection and enforcement of SRHR continues. However, it is crucial to remember that while sexual and reproductive rights concern everyone, they are not universally defined. By focusing on societal structures, we can deepen our understanding of the underlying dynamics of these rights, the structural vulnerabilities, and the agency of individuals within specific contexts. By engaging with these structures at the local level, we can collectively strengthen the global movement for everyone's rights.

¹ These struggles can manifest in various ways, such as confronting one's family to avoid an arranged marriage, threatening to report a child marriage to authorities, or choosing to marry someone of one's own choice to circumvent an unwanted union (which still constitutes child marriage). However, these acts of defiance are not without repercussions for the young girls involved, who often face both physical and psychological violence from their families and communities when they resist. While these resistance strategies are crucial, they should not be the sole focus; substantial structural changes are necessary to support these efforts and prevent family and community repercussions.