Sexuality and health challenges: responding to a public health imperative.

The situation of sexual health and sexual behavior in the United States presents a challenge. As we are able to better measure STDs (including HIV) in the population, and as broad surveys show the extent of sexual dysfunctions and sexual abuse, it is apparent that we are presented with a challenge. If we do not address this challenge, we may be presented with a crisis in the future. Part of the challenge is the relative silence surrounding sexual issues in the community. Where sexuality is discussed, it is largely by the entertainment industry, through scandal reported in the media, and by commercial sources. What has been missing is widespread debate in the community and among health professionals which determines what the community values and concerns are, and how sexual health and promotion of responsible sexual behaviors are to be addressed. It is clear that the dangers of not discussing sexual health and responsible sexual behaviors now strongly outweigh any possible advantages of silence.

What are the sexual health issues which challenge us at the start of the new millennium? These include the prevalence of STDs and HIV, infertility and cancer resulting from STD infections in women, the rate of sexual dysfunctions in the population, sexual abuse and discrimination on the basis of sexuality, and the level of unwanted pregnancy.

SEXUALLY TRANSMITTED DISEASES

STDs are prevalent in U.S. society and their levels are alarming. Five of the top 10 most commonly reported diseases in the U.S. are STDs. Rates of curable STDs in the U.S. in 1995 were the highest in the developed world and higher than in some developing regions (Eng & Butler, 1997).

Chlamydia is the most commonly reported infectious disease in the United States. The reported rate for women in 1998 was five times the rate reported for men, and the highest rates in women were among 15 to 19 year olds. The rates in White non-Hispanic women were 161.9 per 100,000; in Hispanic women, 599.1 per 100,000; and in Black non-Hispanic women rates were 1,444.6 per 100,000 (Stamm, 1999).

Gonorrhea increased by 8.9% between 1997 and 1998. Like Chlamydia, rates were highest in 15 to 19 year old women and Black non-Hispanic people accounted for 77% of cases. Of considerable concern, nearly 30% of gonococcal samples collected in 1998 were resistant to penicillin, tetracycline, or both. Thus, gonorrhea is becoming resistant to the two of the most common drugs used to treat it (Hook & Handsfield, 1999).

A significant source of Infertility (accounting for 15% of infertility in women) is Chlamydia and Gonorrhea. After one infection, about 8% of women will be infertile through damage to their Fallopian tubes; after two infections, 20%; and after three, 40% of women will be infertile (Hook & Handsfield, 1999). Up to two thirds of cases of Chlamydia and Gonorrhea in women, and up to a quarter in men, have no clear symptoms.

New genital herpes cases are estimated at 1 million per year. It is estimated that 45 million people are infected with genital herpes (about 21%, or over 1 in 5 of the adult U.S. population: Fleming et al., 1997). Less than 10% of these were aware of their herpes infection. There is no cure for genital herpes and the infection persists for life.

Human Papillomavirus (HPV) is a sexually transmissible virus which causes genital warts, and four HPV subtypes are also responsible for an estimated 95% of cases of cervical cancer. In 1992, cervical cancer was the most common cause of STD-related death in women. A significant number of cervical cancer cases are detected early and treated successfully by women having regular Pap smears to detect it. It is estimated that there are 5.5 million new genital HPV infections per year, and the estimated cost of treating cervical cancer exceeded $4.5 billion in 1994 (Koutsky & Kiviat, 1999).

By the end of 2000, a total of more than 775,000 AIDS cases had been reported to CDC and it is estimated that for every case of AIDS, a further seven people are infected by HIV, the virus which causes AIDS. While the number of cases of AIDS has dropped, the number of women with AIDS has steadily increased to 23% in 1999 (Centers for Disease Control and Prevention [CDC], 2000a) and the epidemic has disproportionately affected minorities: Rates per 100,000 for males in 1999 were White non-Hispanic, 16.2; Black non-Hispanic, 124.8; Hispanic, 54.4; and American Indian, 18.0. Comparable rates for women were White non-Hispanic, 2.3; Black non-Hispanic, 49.0; Hispanic, 34.6; and American Indian, 11.3. The fact that AIDS cases are over 7 times higher in African American men and over 3 times higher in Hispanic men than White men, and over 21 times higher in African American women and over 6 times higher in Hispanic women than White women illustrates the severity of the spread to minority populations.

SEXUAL DYSFUNCTION

Sexual dysfunctions are relatively common and frequently untreated in the population. Sexual dysfunctions (disorders of sexual desire such as underactive sexual desire, sexual arousal disorders such as male erectile dysfunction, orgasmic disorders such as inability to achieve orgasm, and premature ejaculation) are very prevalent, with estimates for individual disorders ranging from 8% to 33% of the adult population (Laumann, Paik, & Rosen, 1999). These are often associated with other disorders such as diabetes, blood pressure abnormalities, smoking, and depression and anxiety.

Sexual abuse contributes to sexual dysfunctions and other public health problems such as drug abuse and mental health problems. There are an estimated 104,000 child victims of sexual abuse per year ("Child maltreatment, 1998," 2000), and the proportion of adults who are sexually abused is estimated at 22% of women and 2% of men (Laumann. Gagnon, Michael, & Michaels, 1994).

While rates of teen pregnancy (women aged 15-19) (CDC, 2000b) have dropped (from 116.5 per 1,000 in 1991 to 98.7 per 1,000 in 1996), dropping most steeply for African American teenagers, they are still unacceptably high compared with similar developed countries.

PUBLIC HEALTH RESPONSES TO THE CHALLENGE OF HIGH STD/HIV INFECTIONS

From a public health perspective, the prevalence of STDs and their impact on health and fertility, and the rates of unwanted pregnancy, require individual responsibility for sexual behavior. Avoiding transmission of infections is most easily and effectively achieved by abstinence from sexual contact or limiting sexual contact to partners known to be uninfected, and maintaining mutual monogamy. Americans have in practice limited the number of sexual partners: a recent study of their sexual behavior (Laumann et al., 1994) showed that the median number of lifetime sexual partners was three (males six, females two).

There are also significant sections of the population who have larger numbers of sexual partners. Where abstaining or limiting the number of sexual partners (the most effective way of avoiding STDs/HIV) does not occur, condom use may significantly reduce the transmission of infection. However, while it is commonly recognized that condoms, appropriately and consistently used for penetrative sex, can effectively prevent HIV transmission, there are a number of STDs such as genital herpes and Human Papillomavirus where condoms are relatively ineffective in prevention of STD transmission even when properly used. Nor is it widely understood that STDs can be carried and transmitted in the absence of any signs or symptoms of disease, or their role in producing infertility or some cancers. While there are significant and justifiable pleasures associated with sexuality, there are also significant risks and responsibilities involved where the individual has multiple sex partners or partners whose infection status for STDs and HIV, or use of contraception, is unknown.

Similarly, preventing unwanted pregnancy requires appropriate and responsible use of contraception, and recognition that STDs and HIV may be transmitted even when pregnancy is being prevented. Regardless of the position people hold in the abortion debate, there is consensus that abortions should be reduced and that decreasing unwanted pregnancies is one of the most effective ways to achieve this.

PUBLIC HEALTH RESPONSES TO THE CHALLENGE OF SEXUAL HEALTH

Sexual health is not just the absence of disease or dysfunction, but includes the ability to understand and weigh the risks, responsibilities, outcomes, and impacts of sexual behavior. It includes freedom from sexual abuse, and the ability to integrate one's sexuality into one's life. Where there are sexual responsibilities, there are also rights to privacy and, in communities, rights to express sexuality in culturally and religiously appropriate ways provided they do not infringe the law or the rights of others. Some of the rights that need to be considered are those of access to accurate and age-appropriate sexuality information, to diagnosis and treatment of sexual dysfunctions and STDs, and to access to adequate professional training in sexuality-related issues for health professionals.

It is clear that the challenge in the area of sexual health and responsible sexual behaviors has the potential to become a crisis if left inadequately debated and addressed. It is also clear that sexuality involves sensitive and deeply held attitudes and beliefs which cover a diversity of opinions. The solution to the challenge is a call to action which initiates careful and thoughtful public debate across communities on how, as individuals and as communities, we meet this challenge. The cost of continuing silence over these issues will be to elevate a health challenge to a health crisis.

REFERENCES

Centers for Disease Control and Prevention. (2000a). HIV/AIDS surveillance report. Retrieved from the World Wide Web: www.cdc.gov/hiv/stats.

Centers for Disease Control and Prevention. (2000b). Youth risk behavior surveillance--United States, 1999. Morbidity and Mortality Weekly Report Surveillance Summaries, 49, (SS-5).

Child maltreatment, 1998: Reports from the States to the National Child Abuse and Neglect Data System. (2000). Washington, DC: U.S. Government Printing Office.

Eng, T. R., & Butler, W. T. (Eds.). (1997). The hidden epidemic: Confronting sexually transmitted diseases. Washington, DC: National Academy Press.

Fleming, D. T., McQuillan, G. M., Johnson, R. E., Nahamias, A. J., Aral, S., Lee, F. K., & St. Louis, M. E. (1997). Herpes simplex virus type 2 in the United States 1979 to 1994. New England Journal of Medicine, 337, 1105-1111.

Hook, E. W., & Handsfield, H. H. (1999). Gonococcal infections in the adult. In K. K. Holmes, P. A. Mardh, P. F. Sparling, S. M. Lemon, W. E. Stamm, P. Piot, & J. Wasserheit (Eds.), Sexually transmitted diseases (3rd ed.; pp. 451-466). New York: McGraw-Hill.

Koutsky, L. A., & Kiviat, N. B. (1999). Genital human papillomavirus. In K. K. Holmes, P. A. Mardh, P. F. Sparling, S. M. Lemon, W. E. Stamm, P. Piot, & J. Wasserheit (Eds.), Sexually transmitted diseases (3rd ed.; pp. 347-360). New York: McGraw-Hill.

Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunctions in the United States: Prevalence and predictors. JAMA, 281, 537-544.

Laumann, E. O., Gagnon, J., Michael, R., & Michaels, S. (1994). The social organization of sexuality: Sexual practices in the United States. Chicago: University of Chicago Press.

Stamm, W. E. (1999). Chlamydia trachomatis infections of the adult. In K. K. Holmes, P. A. Mardh, P. F. Sparling, S. M. Lemon, W. E. Stamm, P. Piot, & J. Wasserheit (Eds.), Sexually transmitted diseases (3rd ed.; pp. 407-422). New York: McGraw-Hill.

Eli Coleman
University of Minnesota

Address correspondence to Michael W. Ross, PhD, MPH, WHO Center for Health Promotion and Prevention Research, School of Public Health, University of Texas, PO Box 20036, Houston TX 77225; e-mail: [e-mail].