The Sustainable Development Goals (SDGs) and the proclaimed vision of leaving no one behind have been lauded for their transformative potential in redressing inequalities. Yet, there exist too few interrogations of the root causes and underpinning structures that keep uneven development in place. This paper reflects on this omission in relation to sexual and reproductive health and rights (SRHR) drawing on over three decades of professional experience advancing SRHR and by the relevant literature. Engaging with the theme of a recent conference – Leave NO ONE Behind! Justice in Sexual and Reproductive Health – it asks what it would take to realise the pledge of universal access to sexual and reproductive health services and rights. With a focus on Southeast Asia, the paper offers an account of context-specific drivers of disparity and exclusion that preclude the attainment of comprehensive SRHR for all, and especially for stigmatised and marginalised groups. It describes the paradigm shift that must occur if the ideals of inclusiveness and equity as promised by the SDGs are to be attained in and through SRHR.