The Need to Promote Sexual Health in America: A New Vision for Public Health Action

Abstract

Sexual health is considered to be a state of wellness with physical, emotional, mental, and social dimensions. Sexual health can contribute to our overall well-being in each of these dimensions. However, despite the intrinsic importance and positive aspects of sexuality in our lives, the United States presently faces significant challenges related to the sexual health of its citizens, including human immunodeficiency virus, other sexually transmitted infections, viral hepatitis, unintended pregnancies, sexual violence, sexual dysfunction, and cancers in reproductive tracts with serious disparities among the populations affected. In particular, high rates of poverty, income inequality, low educational attainment, stigma, racism, sexism, and homophobia can make it more difficult for some individuals and communities to protect their sexual health. Given that many pressing public health issues in the United States are related to sexual health and that sexual health has been increasingly recognized as an important national health priority, now is the time to energize and focus our efforts toward optimal sexual health of the population. In this paper, we outline the rationale for addressing sexual health as a means to better promote overall health and address sexuality related morbidities. In addition, we present a logic model outlining an approach for advancing sexual health in the United States, as well as a range of action steps for consideration by public health practitioners, researchers, and policymakers.

In Brief

The United States presently faces significant challenges related to fostering and sustaining sexual health for its citizens. In this article, we present a logic model outlining an approach for addressing sexual health as a means to better promote overall health.

The term “sexual health” refers to a broad, inclusive conceptualization of health relating to the multiple health-related elements of sexuality. The World Health Organization (WHO) defines 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. 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.”¹

Currently, the United States faces significant public health challenges that impact multiple facets of sexual health-related morbidity, including human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), viral hepatitis, unintended pregnancy, sexual violence, sexual dysfunction and cancers in reproductive tracts. Despite progress in some areas, current sexual health morbidity exceeds rates for most other developed nations.² Today, the United States shows a high prevalence of sexual assault on college campuses.³ Meanwhile sexual dysfunction remains prevalent across age groups.^4,5 Disparities in sexual health outcomes exist for many, including sexual minorities and communities of color.² Stigma is a prominent impediment to efforts to improve sexual health and reduce related morbidity^2,6,7).

A growing body of research shows that addressing sexual health in a more integrated, positive way can help reduce adverse outcomes related to sexual behavior.^2,7–9 Building off existing research, in this article, we outline a new logic model for public health action to promote and improve sexual health in the United States. This model expands and operationalizes recent proposals for a sexual health framework.^8,9

Using existing research on health promotion and data on the epidemiological and economic burden of poor sexual health, we discuss why adoption of a novel logic model for promotion and provision of sexual health is needed. The logic model we propose is intended as a starting point for public health practitioners, researchers, and policymakers. It is our hope that this model will help this public health audience to consider the importance of a positive, inclusive, and integrated approach to sexual health, which addresses sexual health as an intrinsic element of overall health.

Health Promotion and Sexual Health

Health promotion—defined as any planned combination of educational, political, regulatory, and organizational supports for actions and conditions of living conducive to the health of individuals, groups, or communities¹⁰—has improved health outcomes for numerous health conditions including injuries, chronic, and infectious diseases.¹¹ Over the past decade, support has increased for public health efforts that address health issues linked to sexuality through a health promotion approach that recognizes sexual health as an important aspect of the overall health and well-being of individuals, families, and communities.^8,12–16 This type of approach can complement more conventional prevention strategies, which often emphasize negative outcomes.^14–16

Alongside growing emphasis on health promotion, sexual health has also been increasingly recognized as an important US public health priority.¹⁷The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior (2001) was the first formal US government recognition of the need to comprehensively promote sexuality, sexual health and responsible sexual behavior to enhance population health.⁶ Of note, the term “responsible” in this context is not intended to be normative or proscriptive. Instead, the Call to Action encourages individuals “to be responsible in your own behavior and to help others become aware of the need for responsible behavior in their sexual lives.⁶” As such, being responsible could mean differently things in different contexts, with the central goal being to promote health. More recently, the importance of this approach was reflected in the 2010 National HIV/AIDS Strategy, the 2011 National Prevention Strategy, and in Healthy People 2020 indicators.^11,18,19 In 2010 and 2015, commentaries in JAMA highlighted the need for a shift from the longstanding and stigmatizing focus on morbidity toward national strategies focused on sexual health rather than disease.^9,17

Sexuality and Health

Sexuality is fundamental aspect of human life that encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships.^12,15 Although sexuality can include all of these dimensions, each is not always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious, and spiritual factors. In this article, the concept of sexuality will be used, in the broadest sense, to refer to all the ways that people expresses themselves as sexual beings. The concept of sexual health will be used more specifically to refer to health and well-being in relation to sexuality, in line with the WHO definition of sexual health.

Both individuals and communities are affected by and contribute to sexual health. Studies show that optimal sexual health can lead to lifelong benefits including economic stability, accomplishment of life goals, longer life, better relationships, educational and employment opportunities, and overall life satisfaction.^6,14–16 Sexually healthy individuals integrate sexuality into their lives, while minimizing harmful consequences for themselves and the community.⁶ Yet many factors influencing sexual health are not controlled directly by the individual (eg, sexual networks, STI/HIV prevalence in a given community, gender power dynamics, poverty, availability of affordable preventive and clinical services, and receipt of sexual health education), making community dynamics and resources important contributors to an individual’s sexual health.

Historical Dimensions of Efforts to Address Sexual Health

Over the past decade, global recognition of sexual health as a core element of overall health has been accompanied by calls for improved public policy, education, and research to advance sexual health.^2,6,12,20 Many nations that have formally designated sexual health strategies and guidelines including England, Wales, Scotland, Ireland, Australia, New Zealand, Cambodia, Mauritius, Liberia, and Canada.^21–28 Additionally, several organizations have developed foundational resource and guidance documents, including the Pan American Health Organization,^12,29,30 the WHO, Supplemental Digital Content https://links.lww.com/OLQ/A197,³¹ and the World Association for Sexual Health.²⁰ These organizations also promote research and provide programmatic guidance to support culturally competent sexual health efforts across the globe.

Today, it has been more than 15 years since The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior (2001). Yet, the sensitivity of this topic has slowed our national response. In particular, stigma is a tremendous driver of our failure to routinely integrate sexual health into overall health policy and practice. Stigmatizing attitudes and behaviors in local communities, in health care settings, and from society at large hinder both the seeking and provision of sexual health care.⁷ To combat stigma, public health professionals have an important role to play in encouraging a national, normalized dialogue around sexual health and effecting public policy. Respecting our differing viewpoints, values, and beliefs, this article outlines an opportunity for our nation to harness understanding, creativity, and patience to advance sexual health for the sake of our nation’s future.

The Public Health Problem

Epidemiologic and Economic Burden

The United States faces significant public health challenges related to sexual health with high levels of adverse outcomes including HIV, other STIs, viral hepatitis, unintended pregnancy, sexual violence, sexual dysfunction, and cancers in reproductive tracts. The large burden of adverse outcomes related to sexual behavior result in a substantial economic impact in the United States. Estimates of the epidemiologic burden (Table 1) and economic burden (Table 2) below are presented separately for each health concern, but many may occur in the same subpopulations and individuals, creating overlapping epidemics, or syndemics (ie, 2 or more health-related problems,⁷ contributing to excess burden of disease).

TABLE 1: The Epidemiologic Burden of Sexual Health

TABLE 2: The Economic Burden of Sexual Health

Health Equity

Disparities in sexual and reproductive health outcomes are among the most striking of all health inequities. All individuals should have the opportunity to live sexually healthy lives; however, conditions, such as poverty, income inequality, low educational attainment, racism, sexism, and homophobia, can make it more difficult for some to live sexually healthy lives.^{60s, 69s} Environmental factors, such as housing, living conditions, social networks, and access to services affect health and limit the delivery, effectiveness, and impact of current prevention efforts. These social determinants of health are linked to a lack of opportunity and resources to protect, improve, and maintain health for many Americans and can lead to substantial health inequities among populations.²

Broader Factors Influencing Sexual Health

Contemporary American society is confronted with many obstacles to achieving optimal sexual health including: limited access to complete and accurate sexual health information, attitudes of secrecy, lack of public discourse, and unclear language about sexual health.^70s Although there are many influences on an individual’s sexual heath, stigma, media, parents and families, and health care providers have particular importance, each as risk and protective factors.

STIGMA

Stigma and secrecy contribute to adverse sexual and other health outcomes.^{70s, 71s} Stigma is bred and perpetuated by social and cultural norms as well as institutional sources, including fear-based STI prevention efforts, stigmatizing messages in the media, and a lack of training among health care providers. Stigma can hinder the acquisition of knowledge and guidance. It also discourages people from seeking recommended testing or effective vaccines. Stigma prevents infected persons from disclosing their status to partners or adhering to treatment, and it adds to psychosocial and interpersonal stress that can impact other health outcomes. In communities, stigma impedes advocacy and support efforts for prevention and control programs.^{17, 71s, 72s} In particular, stigma may disproportionately impact young people and minorities.¹⁷ Stigma around reproductive health is also a barrier to interactions between health care providers and their clients, including recommended STI screening and vaccination, contraceptive and abortion care-seeking, access to services, and related public health advocacy.^6,7 Increased efforts to normalize dialogue around sexuality, sexual health and responsible sexual behavior may help reduce stigma, support healthy individual attitudes and choices, and enhance open discussions between health care providers and patients about matters related to sexual health.

MEDIA

Sexual images and messages are pervasive throughout the media, including television, radio, magazines, newspapers, advertising, and the Internet. Although media images and messages can create and reinforce unhealthy attitudes around gender roles, power, body image, as well as sexual behavior, relationships, reproduction, and violence,^73s–75s the media could also be an agent for positive change by serving as one component of a multifaceted approach to change social norms and provide audiences with accurate information. Mass media and social marketing provide opportunities to reach audiences with health messaging through popular programming (entertainment education) and advertising, and to link specific communities to public health platforms.^76s Such approaches can also include media literacy to empower audiences to think critically about media messages and images, rather than being passive consumers of it.^{13, 77s, 78s}

PARENTS AND FAMILIES

Youth need accurate information to have respectful relationships that include honest conversations about sexuality, sexual health, and responsible sexual behavior. Parent-child communication is most effective at reducing adolescent sexual risk when it occurs early, before sexual initiation, when it covers a broad range of topics, and when it is conducted in an open, and receptive manner.^79s–83s Communication conducted by parents who are knowledgeable, skilled, comfortable, and confident in communicating with their children about sexual health is associated with delays in sexual initiation, improved partner communication, increased condom use once sexually active, and decreased overall sexual risk.^{84s, 85s} Parents and families can also play a critical role in providing their children with safe, stable, and nurturing environments, healthy social and emotional development, and protection from abuse to promote sexual health and responsible sexual behavior.⁶

HEALTH CARE PROVIDERS

Health care providers and the information they share are respected by patients.^{86s, 87s} Many patients consider general practice settings an appropriate place to discuss sexual health and would like their providers to initiate such discussions.^88s–90s However, for a number of reasons, including a lack of training, comfort, communication, time or resources, providers often have difficulty bringing up and adequately addressing sexual health during clinical encounters.^91s–93s Better sexual health training in both medical school and throughout providers’ careers could provide important sexual health knowledge and the confidence and skills to discuss, address, value, and treat individual sexual health needs more routinely and effectively.^94s–97s In particular, routine sexual history assessment could enhance patient understanding of the need for and uptake of recommended clinical preventive services such as immunization, testing, and counseling.^{2, 98s}

Mobilizing Public Health Action

Interventions that incorporate sexual health promotion can broadly complement more disease-focused prevention efforts. Interventions operationalizing the WHO definition of sexual health have better outcomes than alternative, more topic-focused interventions for attitudinal or behavioral outcomes.¹⁵ Demonstrated benefits include a range of outcomes: effective communication, healthier attitudes toward sexuality, reduction of risk behaviors, increased use of prevention services, and decreased adverse health outcomes.^14–16 Research shows that these sexual health interventions are complementary to, rather than alternatives to conventional interventions.^14,15

Notably, some state and federal public health agencies have begun to implement programs that incorporate sexual health promotion as a means of enhancing conventional approaches. For example, the 2012 Minnesota Chlamydia Strategy was the first comprehensive, statewide action plans to promote and destigmatize STI testing through a larger vision of sexual health.^99s Similarly, in 2009, to boost the effectiveness of statewide teen pregnancy prevention, Oregon shifted from a predominantly risk-focused messaging to communications centered on positive youth development and youth sexual health promotion. Since release of the plan, sexual health services have increased in Oregon through the expansion of school-based health centers and revised state sex education policies.^{100s, 101s}

Given the burden of the public health problem, the broad contributing factors, and the effectiveness of evidence-based interventions to improve sexual health, it is (past) time to reframe approaches to sexuality-related conditions in this country. A broader focus on sexual health can enhance collaborative efforts to improve the prevention of HIV, STIs, viral hepatitis, pregnancy, sexual violence, sexual dysfunction and cancers in reproductive tracts. Accurate, honest, and timely information, knowledge, and skills can help individuals make healthier sexual choices, with the potential to reduce health costs. Here, we propose a new model for mobilizing public health action to more effectively promote sexual health in the United States.

In this novel model for action, our goal is for public health partners to promote sexual health and respectful sexual behavior across the lifespan by adopting and building on a sexual health framework as a central component of all sexual and reproductive health intervention activities.^8,9 This sexual health framework is based upon four key principles: an emphasis on wellness, a focus on positive and respectful relationships, acknowledgement of sexual health as a component of overall health, and an integrated approach to prevention.⁹

Our logic model outlines key outcomes to focus on in the short and medium-term time frames (Fig. 1), with the intent of achieving four primary long-term objectives. To accomplish these objectives, public health partners at the national, state, tribal, local, and territorial level can advance sexual health by pursuing a range of multisectoral strategies. In the following section we elaborate on some of the strategies and action steps that could help the public health community work toward these objectives. The purpose of the suggested action steps is to provide a guide for the kinds of activities that would help promote sexual health. While this model for action and suggested strategies is intended as a blueprint to guide public health action, it is not a fully developed implementation plan. In that spirit, the blueprint should be considered as a starting point for persons working in a range of fields, with a variety of focuses, to consider opportunities for promoting sexual health.

Figure 1: Sexual health model for action. This logic model depicts the approach public health partners can take to advance sexual health in the United States.

Long-Term Outcomes

1. Increased knowledge, communication, and respectful attitudes regarding sexual health.
Much of sexual behavior is based on individual knowledge, communication, and attitudes. To ensure that individuals receive accurate and complete knowledge and develop respectful attitudes regarding sexuality and sexual behavior, a broader conversation and integration of sexual health as part of overall health and wellness is needed. This involves reframing dialogue to embrace a positive sexual health perspective, which can help decrease misconceptions and the stigma around many sexual health issues.

2. Increased healthy, responsible, and respectful sexual behaviors and relationships.
Healthy, responsible, and respectful behaviors and relationships are essential to overall health and wellbeing. Making healthy choices and maintaining healthy relationships requires accurate knowledge, respectful attitudes, and proper communication with one’s partner, and is contingent on supportive social and environmental conditions.

3. Increased use of high-quality, coordinated educational, clinical, and other preventive services that improve sexual health.
Developmentally age and situation-specific education, prevention programs, voluntary screening and counseling, treatment, and other related services are essential to support optimal sexual health practices over the lifespan. It is important that all members of society have an opportunity to access and use these services to enhance overall health and wellbeing.

4. Decreased adverse health outcomes, including HIV/STIs, viral hepatitis, unintended pregnancies, sexual violence, sexual dysfunction and cancers in reproductive tracts.
Adverse sexual health outcomes have a detrimental effect for individuals, families, and entire communities. Progress on the first three objectives will substantially increase our ability to advance this last objective, with measurable public health impact.

Strategies to Accomplish these Objectives

1. Provide leadership.
Collaborative work is needed for multi-sector partners at the national, state, tribal, local, and territorial levels to improve the sexual health, including educating, mobilizing, and supporting partners to implement the sexual health framework.

2. Enhance Strategic Partnerships. Inclusion of groups across the political, religious and social spectrum is crucial to a sexual health effort. Dynamic partnerships must be developed with health departments, providers, professional associations, educators, researchers, private industries, foundations, nonprofit organizations, faith communities, and local, tribal, state, federal, and international agencies.
3. Expand and strengthen the science base: surveillance, monitoring and evaluation, and research. Monitoring and evaluation are critical to assess implementation of sexual health strategies and activities as well as attitudes about sexual health issues among the public and providers. Research is needed to develop and assess new prevention approaches using the sexual health framework.
4. Promote effective policy actions. Federal, state, tribal, local, and territorial policies should be clear and in place. These policies can involve the provision of sexual health information and services, using measures of sexual health as policy assessment benchmarks, and ensuring protection from discrimination related to sexuality.
5. Strengthen infrastructure and training. Opportunities arising from increasing access to health care for delivery of clinical preventive services should enhance sexual health service delivery. Populations bearing a disparate impact should receive particular emphasis.
6. Promote awareness and increase knowledge through communication and education. To meet our goal, it is critical to increase awareness and knowledge about sexual health among the public, community organizations, governmental and educational institutions, health care providers, and institutions in society at large.
7. Normalize discussion of matters related to sexuality, sexual health and responsible sexual behavior. Although issues around sexuality can be difficult to discuss because they are sensitive and personal, it is time to begin that discussion. This means appreciating the diversity of our culture while engaging in mature, attentive and respectful discussions in families, communities and clinical, public health and policy settings.

Action Steps for Promoting Sexual Health

Government agencies can:

• Provide assistance to diverse partners, collaborators, and stakeholders engaged in the promotion of sexual health to ensure evidence-based activities are implemented to support prevention policies and practices.
• Invest in research related to sexual health and disseminate findings widely.
• Address sexual health in newly developed funding opportunity announcements
• Address sexual health in training curricula and materials for providers and educators.

Public health agencies can:

• Work with partners at their jurisdictional levels (eg, schools and other youth-serving organizations, the health care delivery sector, faith-based organizations, and private industry) to educate key stakeholders about the importance of promoting sexual health.
• Evaluate and implement policies in their jurisdictions impacting sexual health.
• Seek opportunities to coordinate prevention program efforts that address sexual health outcomes.
• Strengthen delivery of culturally competent sexual and reproductive health services (eg, family planning, testing and referral, and immunization), and other wellness services by building internal capacity related to the understanding of sexual health, cross-training providers, and enhancing referral systems.

Health care providers can:

• Include regular sexual health assessments as part of routine care and help patients identify ways to reduce risks for adverse sexual health outcomes identified in this way.
• Promote a more holistic approach to sexual health within health care settings.
• Comply with recommended screening recommendations regarding prevention of sexual health-related outcomes.

EDUCATION.

Educators can:

• Provide widespread access to sexual health education that is medically accurate, developmentally and culturally appropriate, incorporates skill-building components, and is delivered by trained instructors to promote healthy sexual relationships and behaviors across the lifespan.
• Teach local organizations, policy makers, health care professionals, and families about sexual health and what they can do to address it and reduce adverse outcomes.

Schools can:

• Create positive school environments that protect students from harassment and bullying, encourage peer norms that promote healthy communication and behavior, and ensure that pregnant and parenting youth are supported in completing their education.

Researchers can:

• Develop new sexual health measures to fill gaps in existing surveillance systems or develop new surveillance systems to adequately measure population sexual health at the individual, relational, community, and societal levels.
• Strengthen the evidence base for the effectiveness of interventions addressing sexual health by comparing interventions that explicitly address sexual health versus those that do not, measuring the impact of sexual health on other dimensions of health, and conducting sexual health research across the lifespan.
• Further investigate the pathways between sexual health promotion and disease prevention outcomes. For example, evaluate the feasibility, acceptability and efficacy of interventions focused on addressing and mitigating these structural determinants.

Private industry and foundations can:

• Provide health coverage, employee assistance programs, time off for accessing care, as well as employment policies and practices to lessen stigma.
• Provide philanthropic support of educational and public awareness efforts regarding sexual health.
• Media and advertising initiatives can portray sexuality and sexual behavior in a positive, responsible, and accurate way.

Community, nonprofit, and faith-based organizations can:

• Refine existing prevention programs to acknowledge sexual health, thereby creating a more comprehensive and cost-effective portfolio of prevention programs.
• Encourage opinion leaders to address issues related to sexual health and responsible sexual behavior in ways that are informed by the best available science and that respect diversity.
• Strengthen families by supporting stable and committed adult relationships, including marriage, and providing resources for parenting skills and dealing with conflict, stress, and crisis.
• Encourage respect for diversity and freedom from stigmatization and violence on the basis of gender, race, ethnicity, religion or sexual orientation.
• Address social issues associated with adverse sexual health outcomes, such as poverty, homelessness, racism, sexism, and discrimination.

parents and caregivers can:

• Approach sexual health as a normal discussion topic by communicating with their children about sexuality and sexual behavior (eg, the importance of delaying sex, avoiding pregnancy, using effective birth control, having respectful and honest relationships, and being aware of dating violence).
• Provide their children with safe, stable, and nurturing environments, healthy social and emotional development, and protection from abuse.

Sexually active individuals can:

• Talk with partners before having sex about their sexual history, their relationship expectations, HIV, and other STI prevention and testing, and reproduction including birth control options.
• Ensure that sexual interaction only occurs when welcomed.
• Reduce risk for HIV, other STIs, and unintended pregnancy by using recommended and effective prevention methods (eg, immunizations, contraception, condoms, pre-exposure prophylaxis, recommended screening tests).
• Discuss sexual health concerns with their health care provider, parent, and faith leader.

CONCLUSIONS

This article encourages dialogue in our families and communities and action to promote sexual health and responsible sexual behavior across the lifespan in the United States. It provides a rationale for addressing sexual health more comprehensively and builds upon a previously proposed sexual health framework to include a model for action, and suggested objectives, strategies, and action steps. Grounded in the principles of public health, we believe that a more explicit focus on sexual health promotion can enhance core disease control and prevention activities with a more holistic, health-focused approach. This greater emphasis on sexual health has the potential to engage new and diverse partners; normalize conversations regarding sexuality; reduce fear, discrimination, and stigma; and enhance the efficiency and effectiveness of prevention efforts.⁹

To advance sexual health, optimize its benefits throughout the lifespan, and reduce adverse consequences for the population, opportunities to improve sexual health must be considered at every level of society. Collaborative action by public health partners has tremendous potential to address a critically important set of public health problems and to create a healthier society for generations to come.

TABLE 3: Inequities in Sexual and Reproductive Health Outcomes