A lot of people don’t know that STIs (sexually transmitted infections) spiked during the pandemic. This is related to a general trend where people didn’t go to the doctor for non-urgent medical issues. When people finally went in – Boom! STI rates soared. But it’s also related to the fact that we’re not great at measuring and addressing sexual health in the US until it’s often too late.
Today poor sexual health outcomes are both common and expensive. STIs like chlamydia are among the top most frequently reported infectious diseases in the US. Incidence rates of HIV remain too high, and 13% of those infected aren’t aware they are positive. Almost half of pregnancies are unintended. Sexual violence is common. Sexual dysfunction is reported in more than half of Americans over age 50. Reproductive cancers affect close to half a million people. The consequences are costly. For example, STIs cost over $16 billion dollars annually; unintended/teen pregnancy costs over $5 billion; and rape and other forms of sexual assault costs over 12 billion. And these estimates don’t even include the emotional and mental cost.
It’s high time that the US established a better set of measures designed to keep an eye on the state of sexual health and allow for measurement across time. Measurement of these poor sexual health outcomes is the first step to addressing them. Over the past few years, I’ve been working with colleagues to develop a comprehensive scorecard that could help us better measure key sexual health indicators. This has been done in other places like Public Health England and by the World Health Organization. But we haven’t done it here in the US.
Why? Because issues related to sexuality continue to be stigmatized or treated as isolated, shameful problems. Some of this is historically based. Since the start of the 20th century efforts to stop the spread of STIs tended to fuel stigma, blame and shame. Imagine STD prevention posters with a wayward woman. The same pattern has been true for unintended pregnancy and other sexual health conditions. That is, our central cultural discourses on sexuality have been dominated by ideas of disease, danger, fear, sin and humiliation rather than a focus on sex as healthy, fantastic part of life.
What we need is a more a holistic approach that focuses on sexual health as part of broader health and well-being. We need to educate Americans on what it means to be sexually healthy and how to access comprehensive sexual health services. Doctors should routinely ask about sexual health so that we can address our sexual health outcomes head on and without shame.
Thankfully, we’re finally starting to see national movement in the right direction. The Department of Health and Human Services (HHS) recently developed a blueprint for how to include sexual health across all HHS programs, including Medicare and Medicaid. In 2021, the National Academies of Sciences, Engineering, and Medicine argued it was time to move away from a narrow focus STI prevention toward a holistic sexual health approach addressing structural determinants of sexuality. Other groups are also embracing a sexual health approach, such as: the STI National Strategic Plan, CDC’s new STI treatment guidelines, Healthy People 2030, WHO Strategy on STIs, National Strategy on Gender Equity and Equality.
All this is to say, it’s time for us to really start keeping track. We need indicators that map onto the central domains of sexual health including: 1) knowledge/attitudes (e.g. comprehensive sex education; attitudes toward same-sex sex); 2) sexual behaviors (e.g. condom use; sexual pleasure); 3) sexual health services (e.g. testing; vaccinations); and 4) sexual health outcomes (e.g. STI, unintended pregnancy, sexual violence rates.)
Collecting better measures of pleasure and sexual health won’t just benefit recent spikes in STI rates, it will help address other co-occurring epidemics (i.e. syndemics) such as HIV, substance use, and mental health disorders.
What would be the dream? A national survey of US sexual health. They already do this in England with the National Survey of Sexual Attitudes and Lifestyles (NATSAL). Ideally, we’d have our own reoccurring survey to measure sexual health in America. We have some sexual health adjacent surveys such as the National Survey of Family Growth (NSFG); yet their purpose is often adjacent to sexual health (i.e. NSFG is focused on reproduction). We need our own reliable, repeated measures of sexual health.
Now is the time for action! Let’s actually measure our pleasure and sexual health in this country. Let’s name and claim areas where we need work. Let’s embrace better sexual health indicators because they have broad-reaching impact beyond the STI epidemic and can support holistic health.