1 Introduction

Kenya has a strong record of ratifying major international and regional human rights treaties such as the International Covenant on Economic, Social and Cultural Rights (ICESCR, 1966), Convention on the Elimination of All Forms of Discrimination against Women (CEDAW, 1979) and the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (commonly known as Maputo Protocol, 2003). The Vienna Convention on the Law of Treaties (1969, Art. 2) defines a treaty as “an international agreement concluded between states in written form and governed by international law, whether embodied in a single instrument or in two or more related instruments and whatever its particular designation”. Hamm (2001, p. 1014) points out that the commitment to human rights treaties means that “the realisation of human rights becomes an interest in itself” and that states parties “not only are obliged not to violate human rights but also to contribute to political and socio-economic conditions favourable to respect, protect, and fulfil human rights on the national and international level”. Sexual and reproductive health and rights are essential components of human rights (Freid & Landsberg-Lewis, 2001, p. 109; Leary, 1994, p. 39). Sexual and reproductive health was recognised at the International Conference and Population Development (ICPD) in 1994 and reaffirmed in the Fourth World Conference on Women in 1995 (Oronje, 2013). ICPD (1994, para 7.2) defined reproductive health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, and WHO (2002, p. 5) has provided a definition of sexual health as “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”.

The enforcement of sexual and reproductive health and rights also engages a right to information, a right to life, a right to dignity, a right to privacy, a right to education and a right to non-discrimination (Freid & Landsberg-Lewis, 2001; Gruskin et al., 2010; Tamale, 2008; Durojaye & Ayankogbe, 2005). Violating the right to sexual and reproductive health may impair the enjoyment of other human rights and vice versa (Office of the United Nations High Commissioner for Human Rights and World Health Organisation, 2008). At the domestic level, these rights are embodied in the Constitution of Kenya 2010 and in the Health Act of 2017 to ensure rights-based approach to sexual and reproductive health. In this chapter, I explore four barriers that hinder the enjoyment of sexual and reproductive health and rights. I argue that for women in sex work to enjoy sexual and reproductive health and rights in the country, barriers must be dismantled and the state held accountable (Stefiszyn, 2005) to promote equality and non-discriminatory practices.

2 Methodology

The chapter is based on a qualitative study conducted in 2015 to interrogate whether a human rights-based approach (HRBA) could guarantee sexual and reproductive health of sex workers. It focused on the potential of HRBA laws and policies to improve the right to health leading to greater empowerment of sex workers (Hunt et al., 2015, pp. 2–3). I obtained the data in Kenya between May and July for my PhD research (Lukera, 2019). The research was subject to ethical review process and approved by ethics committee at the University of Sussex. The ethical considerations were subject to the Data Protection Act 1998.

To reach the participants engaged in sex work, I used the Bar Hostess Empowerment and Support Programme (BHESP), a local non-governmental organisation (NGO) working directly with sex workers to recruit them for the study. Given the sensitivity of the topic, which involved discussion of sexual activity and that the interviews, especially with sex workers, could potentially provoke emotional experiences, particularly when sex workers had to relive their difficult experiences (Mitchell & Irvine, 2008, p. 35), I used BHESP, which already had offered counselling services to sex workers, to provide counselling to any of the sex workers who felt distressed, including any delayed reactions of distress (ibid., p. 39), if necessary.

It was important that all the participants in the in-depth interviews and focus group discussion (FGD) give their informed consent. I obtained informed consent by the participants signing the consent forms. To ensure confidentiality in the focus group, the consent form contained information requiring participants to respect the confidentiality of other participants. The participation of participants was voluntary, and I explained to them that they had the right to withdraw at any stage of the interview or focus group without giving reasons. For confidentiality purposes for all the participants including professionals, I used anonymised quotes.

I conducted 1 focus group and 18 key informant interviews. They included ten sex workers, someone from the Division of Reproductive Health in the Ministry of Health, one police officer and four people from NGOs. The selection criteria targeted females 18 years and older and self-identified as sex workers. Purposive sampling was used to select the participants, transcription and thematic analysis conducted. I identified the mobilising organisation together with other key informants through my personal and professional networks (Rapley, 2004, p. 17; Sinha et al., 2007, p. 425; Kristensen & Ravn, 2015, p. 726).

3 Findings

3.1 The Ambiguous and Confusing Policies

Coherent laws and policies play a significant role in the enjoyment of sexual and reproductive health and rights. The inconsistency of laws and policies in Kenya merits some discussion. In a human rights-based approach, sexual and reproductive health rights-related laws and policies need to be transparent as well as easy to understand and the government has to be accountable in implementation. In situations where the law is not clear, implementation is equally a problem:

I think a good policy is a policy that is responsive to the needs of the people. We have blanket policies. They are too general in the way they have been framed. They are not specific. They do not highlight specific issues they are addressing. They are just blanket policies, in the sense that they are misinterpreted, misused, misapplied and depend on the prevailing environment in terms of application, which is also a danger because it puts a lot of fear in the general population. They [laws] contradict each other. While one will appear to be pro a certain issue there is always another law in place that counters that. So you will find that in terms of actualising these laws and providing services, there is no clear path regarding which direction we are supposed to go, literally, as service providers, programmers or people in the development field. (Representative 1, Family Health Options Kenya, field notes, 23 June 2015)

Participants in this study were concerned with the way reproductive health policies were passed and shelved, and that the public in general, more so women, including the police had very little information regarding, for example, the circumstances under which abortion was allowed in Kenya under the 2010 Constitution.:

The government is just putting them on the shelf … they are not effective … Reproductive Health Policy, Adolescent Health Policy, all those policies are there, but they are not followed… The public is not aware, law enforcers are not aware of the provisions of the Constitution and so … most of the health workers are harassed by police and there is a lot of stigma because of lack of information and misinterpretation of the Constitution because some people feel that provision of abortion services is illegal in Kenya, which is not true. (Healthcare professional, field notes, 25 June 2015)

This does not only suggest that sex workers are in a dilemma with the confusion in implementation of the 2010 Constitution and the reproductive health policies in place, but that the colonial abortion laws as stipulated in the Penal Code (ss. 158–160) have had a significant impact in practice. The healthcare providers’ lives are threatened. They fear police arrests, and, at times, their clinics are vandalised or even burnt down. To deal with the threats, a group of organisations under reproductive health and rights alliance established a legal support network to support providers of reproductive health by, for instance, representing them in court. Citing a 2013–2014 study, the healthcare provider pointed out that approximately 465,000 unsafe abortions occurred in Kenya and that the most affected are poor women who go to quacks, while the rich women can afford good reproductive health services including safe abortion. The Kenya Health Policy (2012–2030) acknowledges unsafe abortion as a major cause of maternal mortality, and at the time of the study some efforts were underway to prevent all these unsafe abortions, as the healthcare provider stated:

We are trying to work on medical abortion whereby women can manage themselves without necessarily going to hospitals. We call it community-based access to misoprostol and there are some organisations which are also training community nurses to distribute misoprostol to women. (Healthcare professional, field notes, 25 June 2015)

This harm reduction model, as the healthcare provider informed this study, discourages women from using sticks or hangers to perform life-threatening abortions because:

They can go buy those medicines in the chemists and they swallow them and then start bleeding. If the pregnancy does not come out they can go to the hospital…We are trying to educate women so that they can do that before nine weeks, that is, one or two months…that is the safest…the bleeding is minimal. (Healthcare Professional, field notes, 25 June 2015)

The Kenyan government has the responsibility to domesticate international and regional human rights commitments into local laws and policies to ensure all women enjoy sexual and reproductive health and rights. The laws need to be clear and transparent even for accountability (Gruskin et al., 2010, p. 139). Where clarity is lacking, there will be confusion and misunderstanding in their interpretation. When this happens, the marginalised groups such as sex workers will suffer the consequences.

3.2 The Criminalised Sex Workers

The right to the highest attainable standard of physical and mental health is often frustrated with the enforcement of criminal law against sex workers. In Kenya, sex workers are criminalised under the Penal Code. The law criminalises living on the earnings of prostitution and distinctively targets women (Penal Code, s. 154). In so doing, their sexual and reproductive health and rights are compromised. They are often arrested by police, and some are arraigned in court, although in some instances police ask them for bribes on the spot or in custody to buy their freedom. The situation is exacerbated when sex workers barely understand the legal status of sex work in their own countries (Overs, 2014). It increases fear, anxiety and uncertainty in the lives of sex workers and inherently affects the enjoyment of sexual and reproductive health and rights. In Ethiopia, for example:

Some suggested that sex work could not be illegal because, if it was, it could not be practised openly without police interference. Some incorrectly thought that conducting another trade alongside sex work, such as waitressing, means that the laws against prostitution do not apply. Others said that they had been told that there are licences that exempt some venues from laws concerning brothel keeping and living off immoral earnings (there are no such licences). However, many participants had an accurate understanding that there are some laws against soliciting and brothel keeping. Most said they were aware that it is illegal for minors to sell sex and for others to exploit children sexually. (Overs, 2014, p. 18)

My research in Kenya supports Overs’ study and clearly demonstrates the need for a better understanding of the law on sex work for greater empowerment of sex workers and to enjoy their sexual and reproductive health and rights. Some sex workers in the focus group suggested that it was the money that they are paid by their clients that make the police “jealous” and hence arrest them. They were convinced with this view for the reasons that they are not arrested because they have been found exchanging money with clients, and also not because they have been caught in the sexual act. The arrest is often when standing at the bus stop, in their neighbourhood or on the streets. The police tend to “judge from dressing” (Sex workers, FGD, field notes, 9 July 2015). Some participants said that “when you walk in town without a man you are [labelled] a prostitute” (ibid.) and that “when a man walks with two women he is asked, which one [of them] is yours? The other one is arrested” (ibid.). Sex workers are harassed for free sex and, in most instances, without a condom. To be released from police custody, “a police officer will want to have sex with you standing in that corner without a condom” (ibid.). Even “when you are found carrying condoms you are [said to be] a prostitute” (ibid.). Sex workers wanted the police to stop arresting them for carrying condoms because “we have a right to protect ourselves because the moment I will go out there and get AIDS, it [would] still [be] the government’s duty to [provide] for me the medication that I would take” (Sex Worker 2, field notes, 15 July 2015). At the time of this research, the sex workers said that the rate of those arrests had gone down but they were still happening.

In Mlolongo, less than 15 miles from Nairobi, the experience of sex workers with the police is different. There are no street-based sex workers over there. There is a sex den. It was described as one building that has 50 rooms typically for sex. Sex workers hire the whole building, and they contribute about 200 Kenya Shillings each (approximately £1.50), and anyone who goes there goes for sex. It is likely that sex workers do not encounter harassment from Mlolongo sites, probably because they do not have street-based sex workers in the area. It is a well-known fact that the police are around the corner from the sex den but they do not go over there to arrest them. According to the representative of the Highway Community Health Resource Centre, an organisation that targets truck drivers but by proxy facilitates healthcare services to sex workers “being a sex worker is not a problem today because even the people who are arresting them are their clients” (Representative, Highway Community Health Resource Centre, field notes, 23 July 2015). The kind of violence and harassment that sex workers encounter on their sites is from clients, particularly those who refuse to wear condoms as discussed below, but not necessarily from the police. When clients fail to use condoms, they expose sex workers to HIV and other sexually transmitted infections that are a threat to their sexual and reproductive health and rights.

When I asked the policymaker why sex workers in Mlolongo operated freely in the sex den even with the police around the corner while those in Nairobi were often arrested, the response showed the lack of legal clarity, discussed above, in even the people who are tasked to make policies in the country:

I am very unclear about the law on sex work. I know when I see the police rounding up the sex workers they make it sound illegal which is also part of the reason that they say they are a vulnerable population. But then a lot of groups promote the health of sex workers, which is … the legal part that I have not really understood. But as health workers we are not there to judge, you know … In terms of legal, I am also just as confused. I am not sure about the legal aspect. I think … a lot of people leave alone the sex workers don’t know their rights. A lot of us even who are educated don’t know our rights. And that’s why I was asking what the legal aspect is because at some point the police will round up the [sex workers]… You know the very people … are violating the rights of the sex workers then we expect that the sex workers will complain about sexual assault? You know those are the things that are such grey areas … One thing we could do and … if we could do it perfectly it would be, advocacy and ensuring information is out there for both the police—the law enforcement, the sex workers and the community. I really feel if we could get that information out and get some interactive forum that to me would be the epitome of achieving a lot of things in Kenya because civic education, understanding of the rights … not just for health almost everything, is still a bit shaky, It’s one of our gaps. I know we have a communication strategy as a government but now we haven’t addressed a lot of things like the legal rights. (Representative, Division of Reproductive Health, Ministry of Health, field notes, 24 June 2015)

Intriguingly, sex workers have a hidden “criminal informant” role. They are treated as criminals as discussed, but they are considered by the police as useful informers of the whereabouts of criminals or thugs in the city. The agenda of having an improved relationship between police and sex workers is different. It is seen as a good “crime-control strategy”. The study found that “when it comes to the police, they [sex workers] can be of great help. These people are friends to the thugs, to criminals, and if you are close with them they will always tell you information about these people [criminals] … and that makes the environment safe” (Inspector of Police, field notes, 10 July 2015). I would argue that care should be taken with such views as they do not serve the interest of sex workers and suggest instead that sex workers are linked to criminals. This has its implications; it makes women in sex work susceptible to further abuse and other negative consequences to sexual and reproductive health.

3.3 Violence Against Sex Workers

Violence against women in sex work remain a barrier to the enjoyment of sexual and reproductive health and rights. Studies have shown that women, especially women doing sex work in Africa and other parts of the world are vulnerable to violence (Fawole & Dagunduro, 2014). The United Nations Declaration on the Elimination of Violence against Women (United Nations, 1988, Art 1) defines violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life”. Most of the violence is experienced from clients and partners of sex workers including pimps. Others include bar managers, DJs, bouncers, taxi drivers, the general public and family members (Representative, BHESP, field notes, 1 July 2015). When asked what violations they encountered from clients, the focus group said:




You find a person refuses to pay you.


Gives you fake money.


Sleeps with you and snatches the money including the one you already had and still beat you.


Another one wants to use all styles on you because he’s paying you.


or maybe you have agreed to use the penis and him he wants your buttocks also breasts.


Another one—I got into his car we talked and we did not agree I just heard loud sound on the automatic car doors. Me I didn’t see him open the door but I just heard a sound ‘gudum’. He just did this [demonstrates the way the car door was opened] and threw me outside the car while it was moving on Peponi Road in Westlands. I was found by police. (Sex Workers, FGD, field notes, 9 July 2015)

Clients assault sex workers when they refuse to engage in sexual activities without condoms. A participant in the focus group narrated how a client once threw her out of a moving car at 2 am on a lonely road because she refused to do a “blow job” for him without a condom. Sex workers said that some clients have big penis and that they would beat them if they refused to have sex. Some clients subjected sex workers to group sex without condoms. They said, “you get into a place [client’s house] and find about fifteen fellow sex workers, what will you do and [yet] you want that money?” “He gets into this one and out” and “ejaculates in the last person” or in the “one he felt was sweeter than the rest” (Sex Workers, FGD, field notes, 9 July 2015). It is important to state that the sex workers noted that some of the violations happened to them before they knew their rights. They referred to these as “those days”. After such experience, sex workers said they would rush for post-exposure prophylaxis treatment at clinics such as the Sex Workers Outreach Programme to prevent HIV infection. Prior to HIV prevention treatment, sex workers said, “we used to buy lemon you squeeze it in water … and you use to wash your vagina. Imagine that lemon is what you want to put inside there to remove the germs” (Sex Workers, FGD, field notes, 9 July 2015).

To avoid getting into the hands of abusive clients and risking their lives, sex workers came up with strategies for their safety. One safety measure was not to go to clients’ houses or hotels or other places the clients chose. Where one ended up in this scenario, they would send a text to a fellow sex worker to notify them of their whereabouts. Another measure is that sex workers pay security guards at different lodges or hotels to ensure that when they go into a room with a client, the client does not walk out alone, or if security guard heard a sex worker scream in the room, the guard would rush to check on her. It was vital to come up with these measures because “our friend was killed and then we saw this is serious and because … the police are not on our side” (Sex Worker 3, field notes, 15 July 2015). Having regular clients is not totally safe either. They may even murder sex workers, especially if they are relied upon for school fees and different bills which make them think they are the only ones in the relationship (Representative, BHESP, field notes, 1 July 2015).

To ensure sexual and reproductive health and rights are respected, protected and fulfilled, the Kenyan government has a duty to ensure women including sex workers are protected against violence from the public or private individuals. These commitments are stipulated in the regional and international human rights treaties earlier mentioned and in the Kenyan Constitution including the law on the protection from domestic violence (Protection Against Domestic Violence, 2015) and the Penal Code.

3.4 Stigma and Discrimination of Sex Workers

The stigma and discrimination surrounding sex workers is well documented (Wong et al., 2011). Studies show that societal discrimination and lack of respect of fundamental human rights directly affect the health status of women (Leary, 1994, p. 38). African women engaged in sex work experience deep societal stigma and discrimination that affect their ability to advocate their own human rights (Mgbako & Smith, 2010, p. 1180) including sexual and reproductive health rights. Sex workers apply what Bandewar and others have referred to as a “clandestine approach” to safeguard their sex work secrets (Bandewar et al., 2010). They suggest that sex workers use this approach to shield their families, more so their children, from stigmatisation as well as embarrassment (ibid.).

3.4.1 Hostile Healthcare Providers

Sex workers are stigmatised and discriminated against even in health facilities. The healthcare providers judge them. Sex workers refer these providers as “hostile healthcare providers”, and they can easily identify them (Representative 2, FHOK, field notes, 23 July 2015). I would refer to them as “blockers of quality health”. The fear of being judged damages the relationship between these two groups: the healthcare providers and sex workers. The elements of mistrust develop. While stigma is associated with public health facilities, the shadow report by sex workers in Kenya to CEDAW reveal that NGO-based clinics are more associated with humane treatment even when they do not always have medication in their facilities as they rely on donor funds (Kenya Sex Worker Alliance and Bar Hostess Empowerment and Support Program, 2017). They listen to the sex workers and their needs over there.

I do not go to the government [hospital] because in the first place they handle us badly. First thing if you go there with STIs [sexually transmitted infections], they will ask [loudly], “where have you gotten these prostitute diseases from?” In the first place if a person talks to you like that you will fear to open your heart and tell them all the problems you have or what you are undergoing. (Sex Worker 2, field notes, 15 July 2015)

But many at times we do not go to those ones of the government because they abuse us and they harass us very much … So now there are our own hospitals [NGO clinics]. Like now Bar Hostess have its own clinic. SWOP has a clinic. So you go to those clinics where you will not be asked questions. You are known as a member and you have a card. So when you go there you won’t be asked questions about who you are… You will just say I met with a client … and we did it without a condom. (Sex worker 3, field notes, 15 July 2015)

Alicia Yamin (2016) cautions focusing on individual health practitioners’ conduct, divorced from context. Doing so gives a rights-based approach a bad name and makes little headway, argues Yamin (2016, p. 136). Nevertheless, Yamin contends that it should not be an excuse to condone negligence and abuse or malfeasance due to the individual actions of healthcare providers (ibid.). Leslie London (2008, p. 68) sets out three ways in which responsibility falling on health professionals may be construed in a rights-based framework. First, according to London, if employed by the government, a health professional may become the instrument through which the government violates the right to health and should therefore guard against involvement in such violations. Second, certain human rights obligations may have horizontal applicability among individuals, for example the obligation not to discriminate against other people. Lastly, human rights may be viewed as an essential part of one’s professional conduct (ibid.). London argues that while the first two carry a possibility of legal sanctions, she notes that professional conduct basically rests almost entirely on professional self-regulation and ethical compliance (ibid.).

It is important to understand how complaints against health professionals are dealt with especially in Kenya. When I asked how the complaints were handled, the policymaker told me that the Ministry of Health received reports against individual health professionals and “a lot of those complaints are directed to specific regulatory bodies—the Kenya Medical Practitioners and Dentist Board or the Nursing Council or the Clinical Officers Council” (Representative, Division of Reproductive Health, Ministry of Health, field notes, 24 July 2015). In addition:

We now take that [complaints] as feedback and try to tailor our training including behavioural change and communication strategy that target care givers … [on] things like post abortion care and sexual and gender-based violence [and] just to address how to interact with patients. We try to instil dignified care in caregivers. (ibid.)

In a human rights-based approach, privacy and confidentiality in the enjoyment of sexual and reproductive health rights are crucial. Nevertheless, the experience of sex workers in terms of protection of their sexual and reproductive healthcare information is different. Healthcare providers often ignore, while sex workers want to be assured of, their privacy considering the stigma and discrimination they experience. For example, sex worker would explain her health-related issue to the healthcare provider and the provider would then call a colleague to “advertise” the sex worker’s problem. The healthcare providers call them names. In fact, participants in the focus group said that in some public health facilities patients are called out loudly using the names of their diseases. This is problematic and raises fundamental ethical issues. The shaming attitude from the people with responsibility to provide dignified care pushes sex workers further away from the services they so much need.

They [healthcare providers] classify you. People with “kaswende” (sexually transmitted infections) this side and ringworms that side. Even if it is you with that “kaswende”, will you get up and go to that side? …And yet, that is the person who is supposed to examine you and know if you have STI. (Sex Workers, FGD, field notes, 9 July 2015)

Where this happens, “you will get up without treatment and go home” (ibid.). Such encounters were mainly with the female healthcare providers. Expressing their concern, one sex worker remarked, “I never understand if the women in those hospitals were born together. They usually have the same attitude” (ibid.). Stigma impacts on sex workers in several ways. Some brush it off and move on, while others do not. In the focus group, they said it makes “you feel ashamed” and also that “you see yourself as useless” and “not worthy”.

Notably, sex workers in the study pointed out that private clinics were helpful but they were expensive; they, however, reiterated that they could not afford their health services because they are expensive. The clinics run by NGOs are different—they are friendlier to sex workers. When they are sexually assaulted or in need of contraception, sex workers prefer to seek help from NGO clinics because they are treated over there like human beings unlike in the public health facilities.

Me as a sex worker, I can’t go to government clinics. I will have to go to a [private] hospital, I feel it’s friendly. If I go to a place that is private, it is costly, but they will treat me … or I’ll go to these clinics that NGOs have started for us. They are free. They are so much friendlier, and they understand us. They are there for us, us as sex workers. (Sex Worker 2, field notes, 15 July 2015)

Sex workers’ clinics help. They help because when I come here [referring to the BHESP office] everyone knows that I am a prostitute; even if I carry a condom or this whole box [pointing at a condom box], they will not be surprised. [But] when I go to a health centre [at the City Council] and I want even ten condoms they call each other and say this one has taken lots of condoms, looks like she is fucked all the time [laughter] … She is a prostitute. (Sex Workers, FGD, field notes, 9 July 2015)

As a provider of sexual and reproductive health services, Family Health Options Kenya’s (FHOK) representative explained that sex workers go to their facility because they found them “accommodating” (Representative 2, FHOK, field notes, 23 June 2015). Their health providers had created a rapport with sex workers, and this meant that

They can say anything to the healthcare provider attending to them without being judged. They go to specific doctors who may not have necessarily been trained but they have embraced sex workers and other key populations. When the particular doctor is not there, they will not go for treatment. Some doctors are taking the initiative to mentor other doctors to understand the health needs of key populations. (ibid.)

In the community, the situation is not different either. Sex workers are socially excluded. They hide to do sex work. They hide from their neighbours. They leave their houses at night for fear of being seen and operate like “thieves”. This operation makes them question if they have any rights. Churches frown upon them and so do the women in the women groups who are indifferent towards them. Similarly, the children of sex workers are mocked by the neighbours or the neighbours’ children, or at school including by teachers, once information about their sex-worker mothers gets there.

4 Conclusion

The chapter has shown that sexual and reproductive health and rights are essential elements of human rights for women in sex work. They intersect and include a wide spectrum of rights. In Kenya, these rights are embodied in the Constitution of 2010 and in the Health Act of 2017. In spite of these constitutional and legislative changes in the country, the chapter has highlighted the challenges sex workers face. From ambiguous policies to discriminatory treatment in health facilities. The enjoyment of these rights at the domestic level calls upon the government of Kenya to honour its regional and international human rights commitments to advance sex workers’ health leading to their greater empowerment. A rights-based approach creates an enabling environment to deal with human rights challenges. It requires the Kenyan government to provide equal and non-discriminatory sexual and reproductive health services.