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Sexual Health in America

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Improving Patient Care and Public Health


August 25, 2015

Reproductive and sexual health morbidity in the United States continues to far exceed that of other developed nations. Calls for greater attention and new strategies to address this fact usually begin with a ceremonial nod to the numbers of associated adverse health outcomes (an estimated 50 000 new human immunodeficiency virus [HIV] infections, 20 million sexually transmitted infections [STIs], 3 million unintended pregnancies, and 1 million rapes annually).1 This morbidity has substantial national economic implications: each year STIs, including HIV infection, cost nearly $16 billion; teen childbearing an estimated $11 billion; and rape and other sexual assaults an estimated $12 billion.1 The personal and social costs of these diseases on interpersonal relationships, self-image, and mental health are often lifelong but poorly quantified. In 2010, Swartzendruber and Zenilman2 highlighted the need for change and promoting a shift from the longstanding and stigmatizing focus on morbidity toward a national sexual health–oriented strategy focused on health rather than disease. Five years later there has been little change despite steady accumulation of evidence in favor of shifting from a categorical, stigmatizing morbidity focus to a broadly integrated, health-promoting approach to sexual health. This needed shift could positively affect all levels of health care provision.


Sexual health has been defined in various ways. The World Health Organization (WHO) definition is most often cited, stating that sexual health is “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. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled.”3

In the United States, sexual health has been increasingly recognized as a national health priority. In 2001, The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior was the first formal US government recognition of the need to broadly promote sexual health and responsible sexual behavior to enhance population health.4 More recently, Healthy People 2020, the 2010 National HIV/AIDS Strategy, and the 2011 National Prevention Strategy have also promoted sexual health, emphasizing wellness, respect for others, and prevention.


A range of prevention approaches can address components of sexual health at all levels of society and the health system, as suggested by Frieden5 with the “Health Impact Pyramid” framework (eFigure 1 in the Supplement). This framework consists of 5 elements (top to bottom): counseling and education, clinical interventions, long-lasting protective interventions, changing the context to make individuals’ default decisions healthy, and socioeconomic factors. The choice of which interventions to implement will vary based on local context and resources. Comprehensive efforts to address sexual health can be optimized by implementation at multiple levels to maximize synergy and sustainability.5 For example, in clinical settings, greater attention to integrating related services relevant for individuals (eg, STI and HIV screening, family planning and counseling, and vaccination for human papillomavirus infection and hepatitis B) can efficiently provide more comprehensive care.


A broader use of a sexual health framework, which operates across multiple levels of the health impact pyramid is needed. Using this framework, disease control and prevention remain a central public health focus. However, the framework also stresses the complex factors at the individual, relationship, community, and societal levels that influence health outcomes and shape an individual’s ability to be sexually healthy across the life span (eFigure 2 in the Supplement). This framework could support, streamline, and enhance existing disease control and prevention activities, using 4 key principles.

Emphasis on wellness. The sine qua non of this sexual health framework is a new emphasis on health and wellness in addition to the prevention of adverse outcomes. This approach can be readily incorporated into existing efforts focused on population health, yet it also works to combat the silence and stigma that often compromise efforts to address this important area of health.

Focus on positive and respectful relationships. Sexuality is a fulfilling, pleasurable, integral part of life for many individuals. Positive and respectful relationships (between parents and children, teachers and students, and intimate partners, etc) have been shown to be protective factors for multiple health issues.4 Given the value of healthy and respectful relationships, explicitly acknowledging their importance for sexual health can provide common ground for discussion and engagement across diverse groups of stakeholders.

Acknowledgment of sexual health as an element of overall health. Sexuality fulfills an array of personal, reproductive, and social needs, which influence behaviors and affect health. By acknowledging the effect of sexual health on overall health, the sexual health framework can encourage more holistic health interventions and elevate the importance of this critical area.

An integrated approach to prevention. This sexual health framework encourages an integrated approach to prevention that focuses on connections between health-related problems and considers those connections when developing public health responses. This broad and inclusive framework can strengthen interactions across disease areas and enhance collaborative work among programs, services, and other prevention activities.


An increasing number of studies indicate the effectiveness of interventions and programs that use sexual health promotion to complement more conventional prevention strategies. Existing efforts have demonstrated positive effects for a range of outcomes including: reduction of risk behaviors, increased use of prevention services, and decreased adverse health outcomes.6– 8 Moreover, a recent meta-analysis found that sexual health interventions were not competitors to more traditional disease-focused interventions.6,7 Rather, sexual health interventions were enriching, complementary, and compatible with many existing interventions.


Adoption of this sexual health framework could have great benefits at local and national levels and for individuals and patients. First, this sexual health framework has the potential to engage new and diverse partners, thus broadening the coalition for effective prevention. Second, this framework would help to normalize conversations regarding sexual health. Such conversations should acknowledge the contributions of sexuality, relationships, and sexual behavior to overall health. For example, communication about adolescent sexuality, in which parents encourage open discussions about their values, expectations, and available services, can yield healthier outcomes for adolescents.6,7 Third, because STIs and other adverse health outcomes are highly stigmatized conditions, use of a broader, sex-positive, health-focused framework has the potential to reduce the stigma, fear, and discrimination associated with these conditions. Discrimination and violence on the basis of sexual orientation, gender identity and expression, infection status, relationship status, disability, or other related characteristics affect access to and uptake of prevention resources and care. Use of the sexual health framework could improve the reach of prevention messages and programs, thereby improving health outcomes and health equity. Fourth, this sexual health framework provides opportunities to enhance the efficiency and effectiveness of prevention messages and services for the general public, health care practitioners, and public health professionals by packaging an array of messages and services within a comprehensive structure. Effective service integration and message bundling can reduce health care costs while enhancing efficiency of health care encounters and improving health on the part of patients. For example, childhood immunization programs have achieved a high degree of effectiveness and efficiency by focusing on child health and well-child visits, rather than prevention of specific diseases (eg, measles and polio).


Importantly, sexual health issues evolve across the lifespan. Sexuality is experienced in different ways at different stages. Communities and health care professionals can take appropriate action using this sexual health framework to support sexual health at different life stages (eFigure 2 in the Supplement).


Physicians and healthcare professionals can take several important actions in their practices. These may include the following: Address sexual health regularly within the context of ongoing medical care. Emphasize wellness. Acknowledge sexual expression over the lifespan. Address relationships. Situate sexual health within overall health. Provide holistic care.

Implementing activities aligned with the sexual health framework would improve a range of outcomes important to health across the life course. This framework supports responsible behaviors and healthy, respectful relationships. Evidence-based education, clinical, and other preventive services could also be strengthened. Ultimately, these changes would lead to a reduction in central public health outcomes including HIV/AIDS, STIs, viral hepatitis, unintended pregnancy, and sexual violence.

Although matters related to sexuality can be challenging to discuss, the associated public health concerns are sufficiently important that this complexity should not impede national dialogue on issues of sexual health and responsible sexual behavior. The elements described here present an overdue opportunity to promote a key aspect of overall health and thereby enhance progress on a critically important set of public health issues.

read more at JAMA

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