Understanding Sexual Health and Its Role in More Effective Prevention Programs

This supplemental issue of Public Health Reports (PHR) presents a variety of articles addressing the science and practical applications of sexual health, an important health promotion concept with the potential for improving population health in a broad range of areas related to sexual behavior, including human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), sexually transmitted diseases (STDs), viral hepatitis, teen and unintended pregnancy, and sexual violence. The focus of these articles is especially timely given the population burden of these conditions in the United States and other nations, and the growing recognition that, despite the sensitive nature of the topic, addressing the broad construct of sexual health can enhance the national dialogue in this area and increase the effectiveness of public health programs.^1–4

The concept of sexual health has evolved since its initial articulation by the World Health Organization (WHO) in 1975,⁵ but it has generally emphasized well-being across a range of life domains (e.g., physical, mental, and emotional) rather than simply the absence of disease or other adverse outcomes.⁶ The definition of sexual health currently in most widespread use is that developed by WHO in 2002:

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.⁷

More recently, the Centers for Disease Control and Prevention(CDC)/Health Resources and Services Administration Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment (CHAC) has developed the following revised definition of sexual health recommended for use in the U.S.:

Sexual health is a state of well-being in relation to sexuality across the life span that involves physical, emotional, mental, social, and spiritual dimensions. Sexual health is an intrinsic element of human health and is based on a positive, equitable, and respectful approach to sexuality, relationships, and reproduction, that is free of coercion, fear, discrimination, stigma, shame, and violence. It includes: the ability to understand the benefits, risks, and responsibilities of sexual behavior; the prevention and care of disease and other adverse outcomes; and the possibility of fulfilling sexual relationships. Sexual health is impacted by socioeconomic and cultural contexts—including policies, practices, and services—that support healthy outcomes for individuals, families, and their communities.⁸

Similar to the WHO definition, this newer definition is health-focused, emphasizing well-being related to sexuality that is beyond the absence of specific health problems, in multiple dimensions of life, as well as positive and respectful approaches to sexuality and relationships. Moving beyond the WHO definition, the CHAC definition also specifically emphasizes attributes of sexual health at both the individual level (e.g., individual understanding of benefits, risks and responsibilities, and prevention and care of health outcomes) and the social level (e.g., impact by socioeconomic and cultural contexts and healthy outcomes for families and communities as well as individuals).

In the past decade, there has been increasing attention to the importance of addressing the concept of sexual health,^1–4 with the premise that promotion of sexual health has great potential to complement traditional disease control and prevention efforts for a range of conditions of public health importance—not with the intent of replacing those efforts, but rather of improving their acceptance and, thus, the impact of those prevention efforts on the population. It is from this perspective that this supplemental issue of PHR has been developed, with the purpose of bringing together a range of articles addressing new insights into research, surveillance, program practice, and broader perspectives that can influence our understanding and progress on the broad topic of sexual health. It should be noted that “sexual health” is a concept undergoing evolution, not only in its definition, but also in its practical application. The term generally includes a focus on health and wellness rather than disease, an appreciation for the intrinsic importance of sexual health as part of overall health, and an attempt to address comprehensively a range of outcomes of public health importance; however, some of the articles in this supplement address a relatively narrower focus (e.g., STD and pregnancy prevention^9–11), while others include a broader spectrum.^12–17 Such variety is a necessary and important aspect of the uptake of the sexual health concept into the science and practice of public health.

SEXUAL HEALTH RESEARCH

Four articles address important research questions in key areas relevant to sexual health. First, Penman-Aguilar and colleagues conducted a detailed literature review to assess the impact of socioeconomic disadvantage on teen childbearing.⁹ While the factors evaluated varied by study, the authors discovered a consistent theme across the review, with all studies that considered socioeconomic factors as determinants finding a significant association with teen birth rates, including factors at the family level (e.g., lower levels of parent education and family income) and the community level (e.g., lower per capita income and higher rates of unemployment and racial segregation). The review found that relatively few studies assessed factors at both the family and community levels, an important priority for future research.

Second, using nationally representative data from the National Longitudinal Study of Youth and the U.S Census Bureau, Biello et al. conducted an in-depth analysis of the impact of various dimensions of residential racial segregation on the risk for early initiation of intercourse—an important risk factor for STD and teen pregnancy—among black and white adolescents.¹⁷ The finding that black youth were more likely than their white peers to have initiated sexual intercourse in adolescence was significantly modified by several measures of segregation (e.g., concentration and unevenness) with a particularly notable black-white disparity in highly segregated areas. While preliminary, these findings contribute to our growing understanding of the complex interplay between social determinants and individual sexual health outcomes and should stimulate further research in this area.

Third, to understand the association of relationship characteristics and attitudes about STD and pregnancy outcomes with the use of dual protection strategies (i.e., both highly effective contraception and condoms), Crittenden Murray and colleagues conducted formative research among young African American women attending reproductive health clinics.¹⁰ The study found a tension from trying to balance the desire to establish and maintain intimate relationships with the use of protection strategies (e.g., condom use could be seen as a sign of mistrust). The authors conclude that a more holistic approach, with a focus on healthy adolescent and young adult relationships, is crucial in interventions to prevent STD and unintended pregnancy, an issue that can be especially important in environments where trust is often violated (e.g., due to frequent concurrent partnerships) and childbearing at younger ages is accepted.

Fourth, acknowledging the wide spectrum of opinion and values about how to address issues related to sexuality in the U.S., Robinson et al. conducted research to develop a framework for stakeholders from diverse perspectives to use in discussing sexual health.¹² Through a series of steps including stakeholder consultation, interviews with professionals, and online surveys of diverse members of the general public and health professionals, the authors identified several themes and messages that were effective across a range of respondents, particularly “Navigating a Journey/Protection” (e.g., “life is a series of choices, including sexual choices… all people need information and skills to make healthy choices”) and “Health Promotion/Wellness” (e.g., “living a healthy lifestyle is important to good health, including sexual health… it's time we focused on promoting and encouraging behaviors that improve sexual health”). This article is the first to systematically explore and develop messages about sexual health and is an important scientific step in determining how to enhance the national dialogue in an effective manner.

SEXUAL HEALTH SURVEILLANCE

The important issue of surveillance and the measurement of various domains of sexual health are the focus of three articles, one from Canada and two from the U.S. Smylie et al. describe a process by which the Public Health Agency of Canada and collaborating investigators developed and validated a comprehensive set of indicators of sexual health among Canadian young people, intended for future collection of population-level data.¹³ Notably, there was a specific effort to expand beyond traditional measures such as risky behaviors and adverse health outcomes, and the indicators were conceptually grounded in the WHO definition of sexual health, including the areas of physical, mental, emotional, and social well-being in relation to sexuality; approach to sexuality; sexual relationships; sexual experiences; and discrimination, coercion, and violence.

From the U.S., Ivankovich et al. describe a complementary effort in which collaborators at CDC surveyed existing national data systems to identify currently collected information on a similarly wide range of domains relevant to sexual health, including knowledge, communication, attitudes, service access and utilization, sexual behaviors, relationships, and health outcomes.¹⁴ Although the U.S. domains vary somewhat from the areas on which the Canadians focus, they are likewise grounded in a conception of sexual health as a component of overall health (as defined by CHAC) and are intended to include both positive and negative measures.

The article by Thomas and colleagues focuses on education about STD prevention as a component of sexual health. The authors collected data on attitudes of the general public in the state of New York about appropriate communication platforms, messages, and the need for STD education campaigns, using an innovative state-initiated supplemental module to the Behavioral Risk Factor Surveillance System (BRFSS) survey.¹¹ A large majority of respondents reported that more open discussion of STDs was needed and that most potential venues—television, radio, newspapers, and, particularly, education in schools—were acceptable places for those discussions. Messages about partner communication, condom use, and STD risk were considered as appropriate by the public, as was statistical information on STD rates. Because the BRFSS surveys have sufficient size to provide state-level data, the approach described by Thomas et al. is a promising one to assess public attitudes that may be useful in other jurisdictions.

SEXUAL HEALTH PROGRAMS

Two articles describe innovative approaches for turning the potentially abstract concept of sexual health into practical efforts for program implementation. First, MacDonald outlines the evolution and scope of the U.S. Navy's Sexual Health and Responsibility Program (SHARP) from its inception in 1999 as an HIV prevention train-the-trainer program to a broader effort that utilizes a sexual health promotion program to address prevention of STDs and unplanned pregnancies as well as HIV/AIDS.¹⁵ SHARP's perspective is compelling: that a more comprehensive sexual health promotion message emphasizing the right and responsibility to make healthy choices is more likely to include a concern of relevance to a given individual and, thus, more likely to be internalized and acted upon by that individual. A decade following this transition, SHARP has found that this approach has helped to normalize comprehensive sexual health messages, enhanced efficiency in Navy training and prevention programs, supported program and policy coherence, and enhanced cross-organizational collaboration.

Second, Nystrom and colleagues describe the development and implementation of the Oregon Youth Sexual Health Plan.¹⁶ Similar to the genesis of SHARP, the Oregon plan evolved in 2009 from a focus on a specific issue—teen pregnancy prevention—to a more holistic focus on the broader framework of positive youth development and youth sexual health that includes prevention of STDs and sexual violence in addition to teen pregnancy. The state developed the plan explicitly from evidence-based and promising practices, and relied upon community engagement and youth participatory research to develop its strategies. Outcomes occurring since the release of the plan include increased collaboration with a range of public and private sector partners (particularly in the areas of services and education for youth and families, youth development, and health inequities), expansion of school-based health centers, and passage of a revised K–12 sex education law. Evidence suggests that the Oregon experience has led other states to consider developing their own youth sexual health plans.¹⁸

OVERARCHING PERSPECTIVES ON SEXUAL HEALTH

The final three articles provide an overarching context for the field of sexual health. First, Ford et al. provides a broad perspective on how improved training and education of health-care providers and the general public in human sexuality and sexual health can help address the stigma that often surrounds and impedes public health efforts, especially in the areas of STD and HIV prevention, and thereby improve health outcomes.¹⁹ They emphasize that while patients across the adolescent and adult years are interested in and supportive of their health-care providers addressing sexual health concerns in the clinical setting, their providers are often reluctant to do so for a variety of reasons, including lack of comfort with the topic and perceived time constraints. The authors posit that a more explicit focus on sexual health through education of providers at various levels (i.e., undergraduate, residency, and practice) and education of the general public could reinforce the importance of sexual health as an integral aspect of overall human health.

Second, as outlined by Ivankovich et al., from a public health perspective, the concept of sexual health has its greatest potential as a health promotion framework that doesn't seek to replace conventional strategies for the prevention and control of public health problems related to sexual behavior, but rather to support and expand them through an approach that explicitly emphasizes health and well-being.²⁰ National efforts to address sexual health have been endorsed by WHO and undertaken by an increasing number of nations. As noted previously, for implementation efforts that are currently under way, such as those in SHARP and the Oregon plan, this approach has several potential benefits: the engagement of new and diverse partners; enhanced dialogue about sexual health and responsibility; the potential to reduce stigma, fear, and discrimination; and opportunities to improve the efficiency and effectiveness of clinical care and public health programs.

Finally, former Surgeon General David Satcher²¹ provides valuable historical understanding of national efforts to address the holistic framework of sexual health, with both “The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior” (released by Dr. Satcher during his tenure as Surgeon General)¹ and the recently released National Prevention Strategy (by current Surgeon General Regina M. Benjamin)³ representing important milestones on a long journey. His identification of three key sectors in this journey—youth education, the health-care system, and faith-based organizations—points to the diversity of partners with an interest in and potential contributions to make toward more effectively addressing sexual health.

LOOKING TO THE FUTURE

As the range of contributions to this supplemental issue indicates, sexual health is an extraordinarily diverse field that touches many aspects of public health and the larger culture. Increasing evidence shows that the more holistic and health-focused approach described in many of the articles can positively affect public health problems related to sexual behavior. It is our hope that the information presented in this supplement will contribute to increased interest in and dialogue about sexual health among researchers, public health professionals, health-care providers, educators, and others interested in this area, enhancing the opportunity to impact the health of the population across the life span.