True integration of prevention programs requires broad focus on sexual health.

Each year, approximately 10 million 15-to 24-.year-olds in the United States contract a sexually transmitted disease (STD), almost 20,000 young people are infected with HIV, and nearly one million teenagers become pregnant.

The link between STDs, HIV, and adolescent pregnancy is clear--by age 19, four out of five American teenagers have had sexual intercourse; nearly half of sexually active high school students did not use a condom the last time they had sexual intercourse; and one third of sexually active teens have had three to six sexual partners.

The similarities between STDs, HIV, and teen pregnancy extend beyond the fact that they are caused by the same behaviors. Today, all three of these issues disproportionately impact young people and women, especially those from underserved communities and communities of color.

To the outside observer, the concept of integrating programs might seem matter of fact. Yet, professionals in the field realize that when it comes to both services and prevention, these three topics are usually handled separately.

THREE CULTURES

It is unlikely that the public health field set out to separate these clearly related issues. What is more likely is that public health professionals responded to the problems with which they were faced. The result is that family planning services, STD clinics, and later, HIV/AIDS prevention and care, each developed into its own culture with its own set of priorities, methods, and messages.

For example, STD clinics usually operate at times of client crisis, after symptoms have appeared. Their top priority is treatment and prevention of further transmission. Therefore, their messages to clients involve considering partner selection, reducing the number of partners, and increasing condom use.

In contrast, family planning providers focus almost exclusively on women and often develop a long-term relationship with clients designed to prevent unplanned pregnancy and to time the births of children throughout a woman's reproductive years. The messages to clients, therefore, focus on coital frequency, coital timing, and contraception. Those contraceptive methods that have the best track record for preventing pregnancy (such as the pill, the IUD, or even sterilization) offer no protection from STDs.

The separate cultures of STD care and family planning were already in place when the AIDS epidemic began in the early I 980s. Although HIV shared many similarities with other STDs, its life-threatening nature and the accompanying sense of urgency set it apart and a third culture began to emerge.

At the beginning of the epidemic, health care professionals working in the field of HIV and AIDS had a very different set of tasks and priorities than those working in related fields. They were faced with understanding a new disease, trying to stop its spread, and providing care for dying patients.

Early detection of HIV and the introduction of anti-retroviral drug therapy has since changed these tasks and priorities, but by this time, three distinct cultures existed within the public health community.

FUNDING KEEPS THEM SEPARATE

Today, however, the biggest obstacle to integration is not these separate priorities, practices, and messages; it is separate funding streams. An infrastructure has developed around these issues under which government funding and oversight is handled separately for family planning, STDs, and HIV. This has ramifications not only for care but for prevention programs and advocacy efforts as well.

On the federal level, for example, public health issues across the board--from sexual health to heart disease--are, in essence, competing with each other for a limited amount of resources. Sexual health advocates undoubtedly realize the equal importance of care and prevention for family planning, STDs, and HIM However, they are often forced to prioritize in their efforts to ensure maximum funding.

Organizations that provide care and prevention are also forced to choose priorities. Too often they are bound by restrictive funding to provide health and education services that focus on either STDs, HIM or unintended pregnancy.

Even when advocates and providers recognize that simultaneously addressing these issues would benefit those they serve, the system that has become firmly entrenched makes this an extremely daunting task.

PREVENTION EFFORTS ARE SEPARATE, TOO

While this funding infrastructure impacts prevention efforts, the narrow focus of many prevention programs is also philosophical in nature. Adults in this country are uncomfortable with the concept of adolescent sexuality. They do not like to think of their teenagers as sexual beings and often try to ignore the fact that teens engage in sexual behavior. This discomfort extends to sexuality education. Many schools and communities approach the subject with trepidation, often out of a misguided fear that teaching teens about sex is tantamount to encouraging sexual behavior and experimentation.

At the same time, adults are unable to ignore the fact that many teens are becoming infected with STDs, including HIV, and facing unintended pregnancy and the harsh realities of teen parenthood. The existing feeling that something had to be done about the problems facing our young people only intensified in the face of the AIDS epidemic. The reality of a life-threatening disease spurred many schools and communities into creating education programs.

This dichotomy--a need to face public health crises among young people coupled with discomfort about the behaviors that connect these problems--led to programs that focused exclusively on preventing either STDs, HIM or teen pregnancy. Rather than broad-based education about sexuality that includes information on sexual development, behavior, and relationships, these programs have a narrow focus and goal that could be described as "disaster prevention."

In many communities and schools such programs remain the only form of sexuality education. As abstinence-only-until-marriage programs have gained popularity and schools have worked to restrict sexuality education, "disaster prevention" programs are often the only politically viable way to provide any education about sexuality, HIM STDs, or teen pregnancy. They also remain the only financially viable option. The government provides no funding for comprehensive sexuality education. This leaves community based organizations with few choices--an abstinence-only until-marriage program that adheres to the federal government's strict rules or a narrowly-focused prevention program that can qualify for money under either the STD, HIM or family planning funding streams.

While prevention programs can be very effective, many educators realize that they are not enough. Even so, those education providers who wish to expand their prevention efforts are often bound by the source of their funding to cover only a narrow topic area.

Integration has recently become a buzzword for both prevention education and health care services. National advocacy groups and community-based organizations have begun to openly discuss the potential for reaching more clients, providing more services, and creating more effective prevention programs by addressing STD, HIM and teen pregnancy prevention in the same setting.

While many pilot projects have worked to integrate these issues, a fundamental shift in how American society views adolescent sexuality and education must occur before a real change can take place.

SEXUALLY HEALTHY ADOLESCENTS

Everyone agrees on what is not sexually healthy for young people. Unintended pregnancy, STDs, and HIV top that list. While preventing any and all of these problems remains a top priority, many adults will agree that simply seeing our young people reach their eighteenth or twenty-first birthday without having experienced an unintended pregnancy or STD is not enough to ensure that they will have a happy and healthy sexual life as an adult. Unfortunately, adults have a much harder time deciding what exactly they do want when it comes to the sexual health of young people.

To help answer this question, SIECUS convened the National Commission on Adolescent Sexual Health in 1995. This group of experts in the fields of adolescent development, medicine, and sexuality recommended that helping adolescents become sexually healthy be set forth as the ultimate goal.

According to the Commission, sexual health encompasses sexual development and reproductive health as well as such characteristics as the ability to develop and maintain meaningful interpersonal relationships; appreciate one's own body; interact with both genders in respectful and appropriate ways; and express affection, love, and intimacy in ways consistent with one's own values.

In its report, the Commission defined the characteristics of a sexually healthy adolescent, looked at readiness for mature sexual relationships, and suggested the necessary components of responsible intimate relationships. They also made recommendations for parents, media, health care providers, and policymakers as well as comprehensive sexuality education and community-based programs.

INTEGRATED EDUCATION 

While it is possible for a program to integrate STDs, HIM and teen pregnancy without adopting this focus on sexual health, it seems clear that moving away from "disaster prevention" and towards sexual health is a decisive move toward integration.

By its nature, prevention focuses on problems and paves the way for programs that concentrate on STDs, HIM or unintended pregnancy without dealing with sexual behavior or other aspects of adolescent sexuality. Programs that hold as their goal helping young people become sexually healthy shift this focus from problems that happen to young people to the young people themselves.

Education that has the goal of developing sexually healthy adolescents would encourage young people to delay sexual behaviors until they are physically, cognitively, and emotionally ready for mature sexual relationships and their consequences. Such education would provide them with accurate information about sexuality; foster responsible decision-making skills; and help them explore their own values and the values of their families and communities. Programs would also discuss intimacy; sexual limit setting; resisting social, media, peer, and partner pressure; benefits of abstinence; and pregnancy and sexually transmitted disease prevention.

This type of program allows educators to focus on the entire person; to look at the values, attitudes, behaviors, and skills (or lack of skills) that lead young people to make certain decisions and face (or avoid) certain consequences; and to address each of these components. A program that does this will by its very nature integrate the topics of STDs, HIV, and unintended pregnancy.

MOVING TOWARD INTEGRATION

It has been almost eight years since the National Commission on Adolescent Sexual Health released its report and recommended a move toward sexual health programs. Unfortunately, this vision is not yet a reality. In today's environment, students are lucky if they have the opportunity to attend a program focusing on either STD, HIV, or teen pregnancy prevention.

Rather than despair over what we have yet to achieve, we must look for new opportunities. The current attention paid to the idea of integration on the part of service providers, educators, and funders gives us an opportunity to shift our approach.

A move toward integrated prevention programs will take a great deal of effort. It will take the commitment of the government to reexamine their infrastructure and relax funding requirements that enforce segregation of programs and services. It will take leadership by national organizations who can help those working on STD, HIV, and teen pregnancy prevention to get together. It will take the hard work of educators as they move toward more expansive programs.

And finally, it will take the understanding that "disaster prevention" is not enough; that young people need and deserve greater efforts on the part of adults to ensure that they come out of adolescence not just problem-free but healthy.

RELATED ARTICLE: PROGRAMS INTEGRATING SEXUALITY EDUCATION INTO YOUTH DEVELOPMENT PROGRAMS

SIECUS is developing a companion publication to its Guidelines for Comprehensive Sexuality Education, K-12 designed to help youth development professionals infuse sexuality education into their programs.

SIECUS wants to highlight successful youth development programs across the country that address sexuality-related issues and topics. This includes any creative approaches from programs such as sports, mentoring, arts, after-school, and drop-in centers.

Do you know of any programs that fit this description? If so, please e-mail Kate McCarthy, SIECUS school health coordinator, at [e-mail] or call her at 212/819-9770, extension 304. Your submission should include general descriptions as well as overall goals, specific strategies, and implementation challenges.