Across decades of global health work, the question of what counts as a healthy sexual life has largely been answered in distant capitals and by institutions of the wealthier North, and a team of researchers now asks whether that inherited answer has narrowed our sight. The figures they bring to the table are sobering, with hundreds of millions of new infections each year and millions of women unable to secure the contraception they say they want, despite long and costly effort. Their argument, rooted in fieldwork across Africa, Latin America's neighbors in the research record, and Indigenous k
Global Sexual Health Needs Two-Way Knowledge, Not Just Exported Interventions
An estimated 225 million women who wish to avoid pregnancy lack effective contraception, and survivors of peacekeeper sexual abuse in Haiti were left without meaningful justice.
Less teaching the Global South, more learning from it
Mark
Why does a piece about sexual health open with infection and contraception statistics?
Mimi
Because the authors use them as the challenge. After decades of investment, 374 million new infections a year and 225 million women without effective contraception suggest something in the approach may not be working.
Mark
And their answer is that the frameworks themselves are the problem?
Mimi
They ask it as a question first: what if the dominant frameworks aren't as effective or empowering as assumed? Then they argue success has been defined too narrowly, by things like HIV incidence and contraceptive uptake.
Luke
Let me slow that down. Does the piece show that a broader definition would have changed those numbers?
Mimi
No. It argues pleasure-inclusive approaches could make programs more relevant and improve outcomes, but that is stated as a possibility.
Luke
Right, and the evidence it cites is thin. One review of 33 pleasure-inclusive interventions, 25 of them in the United States. That shows a gap, not that these interventions work.
Mark
What about the Haiti example?
Mimi
It's offered as a case where donor and institutional priorities left survivors of peacekeeper abuse without meaningful justice. It illustrates the accountability point.
Luke
It's one example, and the piece doesn't give scale or detail. Also, this is a commentary by researchers arguing a position, not a study testing it.
Mark
So what is the strongest thing here?
Mimi
The call to broaden what counts as evidence, with Māori, Somali and Yoruba traditions as examples, while keeping science. The authors say these complement it rather than replace it.
Il Polso
- Global sexual health priorities have long traveled from North to South, and the commentary argues the direction itself is the problem.
- With more than 374 million new STI cases each year and 225 million women lacking effective contraception, the stakes of getting the framework wrong are measured in lives.
- Survivors of peacekeeper sexual abuse in Haiti still face almost no path to justice, exposing how accountability falls through when power sits far from the people affected.
- The researchers are pushing for locally led care, Global South institutions with real decision-making power, and success measured by joy, safety and autonomy rather than disease counts alone.
- The call lands on funders now: will the money and the authority really move, or will the old hierarchy simply be restated in new language?
Across decades of global health work, the question of what counts as a healthy sexual life has largely been answered in distant capitals and by institutions of the wealthier North, and a team of researchers now asks whether that inherited answer has narrowed our sight. The figures they bring to the table are sobering, with hundreds of millions of new infections each year and millions of women unable to secure the contraception they say they want, despite long and costly effort. Their argument, rooted in fieldwork across Africa, Latin America's neighbors in the research record, and Indigenous knowledge from Aotearoa New Zealand, is that health is more than the absence of disease and that the communities living with these realities should hold the pen. Whether those who fund the work will surrender some of their authority to match that insight remains an open and quietly pressing matter.
The numbers open the commentary, and they are heavy: more than 374 million new cases of four major sexually transmitted infections each year, over a billion people living with such infections, and an estimated 225 million women who want to avoid pregnancy without effective contraception. A team of sexual and reproductive health researchers at Columbia University, drawing on work in Kenya, Mozambique and with the United Nations Population Fund, argues that these outcomes have been pursued through a framework that was largely designed elsewhere.
For decades, the authors write, decisions about contraception, abortion, maternal care, HIV, sexuality education and protection from violence have moved mostly from the Global North to the Global South. Donors and international bodies defined what success looked like, and it was usually measured in infections averted or contraceptive uptake. Pleasure, desire, intimacy and what communities themselves understood as well-being received far less attention. The authors do not dismiss the lives saved, but they note that narrow goals can miss what people actually need, and that in places like Haiti, where women were sexually abused by U.N. peacekeepers and accountability remained weak, local priorities were pushed aside.
The evidence itself reflects the imbalance. Of one review's 33 pleasure-inclusive interventions, 25 were conducted in the United States. The researchers suggest that recognizing why people seek intimacy, not only what risks they want to avoid, could make programs more relevant and more effective.
The commentary then turns to other ways of knowing. Māori scholar Ngāhuia Murphy challenges colonial stories that treat menstruation and women's reproduction as impure, describing them as sacred. Minna Salami calls for sensuous knowledge rooted in the body and relationships. Somali oral poetry and Yoruba traditions of embodied understanding are offered as sources that capture dimensions of experience conventional methods often miss, not as replacements for science.
From this come the recommendations: place Global South communities at the center of decisions, measure success to include joy, safety and belonging, support community-run services that define their own goals, and shift funding and authority toward Southern institutions. Researchers and funders, the authors add, should examine how their own positions shape the work. The closing claim is simple: the future of this field should rest less on teaching the Global South and more on learning from it. Whether donors will act on that is the question the piece leaves hanging.
The numbers come first, and they are not small. Every year there are more than 374 million new cases of four major sexually transmitted infections, and more than 1 billion people worldwide are living with such infections. An estimated 225 million women who want to avoid pregnancy still are not using effective contraception. These figures, cited by a team of sexual and reproductive health researchers at Columbia University, sit at the center of a commentary that asks whether decades of investment have been built on the wrong framework.
The authors' argument is about direction of travel. For decades, they write, decisions about contraception, abortion, maternal health care, HIV prevention and treatment, comprehensive sexuality education, gender equity and protection from sexual violence have flowed mostly from the Global North to the Global South. Researchers, donors and international organizations have exported programs, defined success and decided which questions matter: how to prevent HIV, how to raise contraceptive uptake, how to reduce maternal deaths. Far less attention has gone to pleasure, desire, or what communities themselves understand as sexual well-being.
The researchers say their view comes from their own fieldwork. Their experience includes HPV vaccine implementation research in Kenya, HIV prevention work in Mozambique, and work with the United Nations Population Fund and academic, governmental and nongovernmental partners on sexual rights, pleasure and health. The team also includes Indigenous health and policy expertise from Aotearoa New Zealand, including research grounded in Hauora Māori approaches. Their commentary traces how colonial histories, unequal funding structures and global research hierarchies shape where knowledge is produced and whose counts as legitimate. In their telling, Global South communities are treated as places where interventions are delivered, not where ideas originate.
They do not dismiss what has been achieved. Global efforts on HIV, contraception and sexual and reproductive health have saved countless lives. But when programs are designed around externally set priorities, the authors argue, they can miss what people need. Success gets measured by HIV incidence or contraceptive uptake, which leaves out pleasure, intimacy, bodily autonomy, reproductive choice and well-being. In some places the narrow focus has overlooked sexual violence and pushed local priorities aside for donor agendas. They point to Haiti, where sexual exploitation and abuse of women by U.N. peacekeepers persisted amid major gaps in accountability and legal recourse, leaving many survivors without meaningful avenues to justice.
The evidence base, they note, carries the same imbalance. One systematic review of 33 pleasure-inclusive interventions found that 25 were conducted in the United States, and very few in Global South settings. The authors argue that acknowledging why people have sex, and not only the risks they want to avoid, could make interventions more relevant and improve health outcomes. They cite the recent Porto Proclamation on Sexual Health, Rights and Justice as a sign of growing recognition that the field needs more equitable collaboration and shared leadership.
The commentary then turns to other ways of knowing. Researcher Ngāhuia Murphy draws on Māori cosmologies to challenge colonial narratives that cast menstruation and women's reproduction as shameful or impure, describing them instead as sacred and life-giving. Feminist author Minna Salami advocates what she calls sensuous knowledge, grounded in relationships, lived experience and the body, as opposed to dominant European traditions of hard knowledge. In Somalia, oral poetry has long carried knowledge and resisted colonial power, and scholars argue it can inform understanding of health and bodies, not by replacing scientific evidence but by capturing dimensions of experience that conventional methods miss. Nigeria's Yoruba traditions likewise treat knowledge as something experienced through the senses as well as reason.
From this the authors draw a set of recommendations. Put Global South communities at the center of decision-making. Measure success beyond disease prevention to include joy, safety, intimacy, autonomy and belonging. Embed antiracist, feminist, LGBTQ+ and Indigenous perspectives. Support locally designed models of care, such as community-led services where local organizations decide what is offered, how it is delivered and how success is defined. Shift funding and decision-making power toward Global South institutions, and have researchers and funders examine how their own positions and institutional power shape their work.
None of this, they stress, means abandoning science. It means widening what counts as evidence and who produces it. Their closing line states the thesis plainly: the future of global sexual health should depend less on teaching the Global South and more on learning from it. Whether donors will move money and authority accordingly is the question the commentary leaves open.
Citazioni salienti
Global sexual health should move beyond exporting interventions and co-create approaches with communities that value local knowledge, pleasure and well-being.— Columbia University sexual and reproductive health researchers, commentary
The future of global sexual health must depend less on teaching the Global South and more on learning from it.— Commentary authors
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