|Home | About | Journals | Submit | Contact Us | Français|
In 2011, both the National Prevention Strategy and Healthy People 2020 recognized “reproductive and sexual health” as a key area for improving the lives of Americans.1,2 This increasing national emphasis on sexual health provides an important opportunity to refocus the efforts of U.S. health-care professionals. While reproductive health has historically been considered a U.S. public health priority,3 the addition of sexual health to the short list of national priorities has important implications for clinicians and patients. Broadly embracing the concept of sexual health in health-care settings has the potential to reduce redundancy in care compared with current, more categorical approaches and to minimize the stigma associated with some aspects of sexuality and related adverse outcomes. These changes could increase both clinical efficiency and the proportion of the population receiving sexual health services.
To foster sexual health, the National Prevention Strategy and Healthy People 2020 recommend increasing access to sexual health services, emphasizing sexual health education and encouraging screening for sexually transmitted infections (STIs) including human immunodeficiency virus (HIV).1,2 To be most effective, these activities should involve both health-care providers (physicians, nurses, and related clinical providers) and patient audiences. Although this new national emphasis represents an opportunity to improve sexual health throughout the country, it also represents a challenge for the health-care community. The approach to patient care in matters of sexuality and sexual behavior will need to be reframed in subtle but critical ways. To meet this challenge, educational efforts for both health-care providers and patients will need to shift to support a more comprehensive approach to understanding and promoting sexual health throughout the life span.
Definitions of sexual health have been developed by a number of organizations.4–6 For example, the Centers for Disease Control and Prevention (CDC)/Health Resources and Services Administration (HRSA) Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment recently recommended the following definition:
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.5
However, strategies for operationalizing sexual health in health-care settings are less developed.7,8 A sexual health framework conceptually represents a broad, comprehensive approach to the prevention and treatment of adverse outcomes related to sexual activity including HIV, other STIs, viral hepatitis, unintended pregnancy, reproductive tract cancers, and sexual violence.6,9 It also provides a platform to address potential functional problems of later life such as relationship health and sexual responsibility; menarchal, peripartum, and menopausal changes; and prostatism and erectile dysfunction. While issues such as these are often addressed as separate clinical problems, from a broader perspective, they all fall within the realm of sexual health. Employing a sexual health approach has the potential to improve providers' management of patients in different life stages or risk groups and also to influence the way the public perceives sexual health and wellness. Realizing these benefits will require a greater focus on education and training in sexual health.
Stigma related to adverse outcomes of sexual activity, particularly STIs and HIV, may hinder both the seeking and provision of sexual health care. The stigmatization of people with, at risk, or being screened for various health issues related to sexual behavior stems from negative messages concerning sexual health outcomes that have been in use in the U.S. for more than 100 years.7,10 Such messages are, in part, a result of early public health efforts to control STIs. These efforts were initiated in alliance with social and religious reformers who viewed STIs, by virtue of their mode of transmission, as a threat to families and society. Once STIs, and by extension sexuality, became a focus of social and religious causes, health-care professionals tended not to engage in public education about sexual health. If addressed at all, STIs were portrayed as a consequence of socially proscribed behaviors, such as prostitution, and this climate acted as a deterrent to sexual health education, health-care seeking, STI screening, and prevention efforts such as notification of potentially infected sex partners.10
In addition, stigma stems from other negative, fear-based messages regarding sexual health, often related to the typically disproportionate impact of adverse sexual health outcomes on sexual and racial/ethnic minorities.11,12 For example, the singling out of those at risk for HIV as represented by the “four H's”—Haitians, hemophiliacs, homosexuals, and heroin addicts—early in the epidemic may have positioned acquired immunodeficiency syndrome (AIDS) as a disease affecting “the other.”11,13,14 Overall, negative, fear-based messages can perpetuate the stigmatizing attitudes that lead to society's discomfort with sexual health,15 particularly when such messages are not fact-based and exaggerate the risk of adverse outcomes.12 Data indicate that in certain contexts (e.g., areas of high HIV prevalence) fear-based appeals have been effective when they emphasize the actual risk in an area. But messages that go beyond the facts and rely on exaggerated fears can be counterproductive and stigmatizing.11,12,15,16 Alternatively, by encouraging dialogue that values sexual health and presents facts accurately, educational efforts could combat stigma by helping health-care providers speak more openly with patients and better tailor care.
To reduce current stigma regarding health issues related to sexual behavior, promoting the positive aspects of sexual health could be beneficial on multiple levels. A sexual health approach is not a new concept; rather, it represents a more inclusive framework that presents a range of prevention and clinical messages and issues in a different format.17 Such an approach could enhance communications between health-care providers and patients if sexual health were viewed as an intrinsic aspect of overall health and if the current predominantly “loss-frame” (disease and consequence-emphasizing) approach to care were shifted to a “gain-frame” (wellness and benefit-emphasizing) approach. Gain-frame messages can positively influence individuals' choices concerning sexual health and disease prevention compared with loss-frame messages.18,19 When employing a sexual health approach, gain-frame messages may be useful because they stress the benefits provided by adopting a healthy outlook toward sexuality and sexual health, rather than the consequences (e.g., STIs, cancer, and unintended pregnancy) of not doing so. Strategies to maintain good sexual health will vary for groups in different life circumstances and require different areas of emphasis over the life course.
Reframing dialogue to embrace a positive sexual health perspective can help reduce the stigma and misconceptions that surround many sexual health issues15,20 Currently, because STIs and other adverse sexual health outcomes are associated with socially sensitive behaviors, individuals may deny risky behaviors or attribute symptoms to other, nonsexual causes, leading to a delay or failure to seek important preventive services and treatment.21 For example, recent research suggests that many—perhaps the majority of—STIs are infections acquired in relationships described as monogamous, in which individuals see their sexual risk behaviors as socially appropriate and, therefore, low risk.22 Because adverse sexual health outcomes are often assumed to be the consequence of less socially acceptable behaviors, individuals in relationships or practicing behaviors considered socially acceptable, such as monogamy, may incorrectly believe they do not need sexual health services.
Stigma and misperceptions about sexual health can affect both health-care providers and the patients they serve. Ironically, while clinicians and their patients often fail to openly discuss patients' personal issues related to sexuality during clinical visits, the promotion of sexuality in the media (e.g., advertising and entertainment) remains pervasive and often sensationalized.23,24 These two extremes—too little attention to sexuality in clinical settings and, conversely, excessive attention in the media—can create a confusing dynamic for patients and providers. If both providers and patients could view sexuality and maintenance of sexual health from a more balanced, positive perspective—as something to be sought and maintained, rather than avoided and stigmatized—misconceptions regarding sexual health might be more easily addressed.
Education to promote sexual health within the clinical setting has two important target audiences: health-care providers and patients. Although specific educational methods are not outlined in this article, we do present some of the advantages and challenges of educating these audiences.
Health-care providers could benefit from shifts toward education and training in comprehensive sexual health, rather than the more common disease-focused training (e.g., in STI, HIV, and cancer prevention and management, and in family planning). A sexual health approach could benefit providers by increasing the efficiency of patient visits and creating more nonjudgmental and inclusive clinical environments. Employing a sexual health approach may increase efficiency because messages such as “staying healthy” and “screening is good for you and your partner” can reinforce each other, allowing multiple sexual health issues and referrals to be addressed in the same visit. For instance, a broader sexual health focus could enhance the provision of a more comprehensive package of related services (e.g., STI/HIV screening, provision of contraception, and risk-reduction counseling).
In addition, a sexual health perspective can present reproductive and sexual health screening and management in a nonjudgmental context where conversations about sexuality are normalized.25,26 For example, the health of a mother and child can be addressed in the context of routine prenatal care where offering syphilis and HIV testing is done as part of optimizing maternal and child health. Likewise, making conversations about sexuality a routine part of care can engage patients, increase their comfort, and enhance partner notification.26 Providers can normalize interactions regarding sexual health by using gain-frame messages and discussing sex in everyday contexts (e.g., “Many people who have STIs typically may not know they have them; thus, testing is good for you and your partner.”). Such an approach may be particularly valuable in addressing health-care concerns of committed couples or older patients. Of importance, in facilitating this approach, providers may need to examine how their own attitudes and values about sexual health affect patient interactions.27
A sexual health approach can also address tensions about how to best achieve sexual health.6,17 Currently, certain prevention strategies, (e.g., promoting abstinence) are sometimes seen as being at odds with other strategies (e.g., promoting safe sex). However, within a sexual health approach, various strategies such as abstinence, condom use, and recommended testing and immunization would all be valued as potential contributors to the maintenance of health.
Provider education and training is directly relevant to the issues described. Although patients generally feel that clinical settings are an appropriate place to discuss sexual health and would like their providers to initiate such discussions, providers often have difficulty adequately addressing sexual health issues for a number of reasons, including provider reticence and a lack of training.25,28 In many cases, current training and educational materials may benefit from revision to help providers navigate the difficult balance between acknowledging the seriousness of sexual health issues and avoiding overemphasis of negative consequences.29 When patients do experience sexual health problems, it may be helpful for providers to encourage them to move away from blaming others and to focus on enhancing their own health and reducing future risks. Finally, sexual health strategies will vary by practice setting and clientele. For instance, primary care practices may only require a three-question sexual history, while an HIV-care clinic may need 30 minutes or more for transmission prevention counseling.30 These issues should all be considered when designing sexual health educational materials for providers.
Ensuring that sexual health is a priority for health-care providers will require revision of educational efforts on three levels: undergraduate clinical education, postgraduate residency training, and continuing education for clinicians in practice. For providers in medical, nursing, and related fields, having improved curricular materials and faculty/provider role models interested in expanding education on sexual health would help students and residents become better providers.31,32 Research suggests that medical and nursing students are often taught to initiate discussions on sexual health, but lack the skills to continue and direct such conversations effectively.31–35 Recent reviews of medical school curricula found that only 3–10 hours during four years of study were dedicated to sexual health, and that coverage of sexual health topics was often arbitrary and inconsistent across the U.S.32,36 The literature suggests similar gaps in nursing and related schools.33,37,38 Training on the sexual health needs of lesbian, gay, bisexual, and transgender (LGBT) patients is particularly inadequate. While medical students may be trained to assess sexual preference, they are often not attuned to the medical and social factors affecting LGBT patients, despite the demonstrated impact of these factors on health outcomes.31 Arguably, expanding medical education on LGBT sexual health could serve as a starting point for developing better overall training on sexuality, gender identity, and other sexual health issues for providers throughout their careers. Following formal medical education, more emphasis could be placed on assessment and maintenance of sexual health. For example, sexual health proficiency could be designated as an area in which medical residents must demonstrate formal competency to complete their residency.
Sexual health education should not end with residency, but should continue for providers in practice. Trainings and workshops should be available and encouraged for all providers to periodically update their skill sets. Training-focused organizations including the National Network of STD/HIV Prevention Training Centers, AIDS Education and Training Centers, and agencies such as CDC and HRSA have shown interest in sexual health training for providers.9,39–41 Of note, recent recommendations by the U.S. Preventive Services Task Force have prompted Medicare to provide coverage of high-intensity behavioral counseling to prevent STIs,42 a step that may influence other payers and, thus, further increase provider interest in strategies to address sexual health in the clinical setting. Overall, better continuing medical education and training could provide practicing clinicians with important sexual health knowledge as well as the confidence and skills to more effectively and routinely address individual sexual health needs.
Patients also stand to benefit from a better understanding of sexual health. In most clinical visits, patients are seeking information, explanations, or support from providers.20 Thus, like health-care providers, patients can benefit from normalized conversations, nonjudgmental contexts, and efficiency in clinical settings.
One way to reframe education for patients would be to explain sexual health through a life-course perspective, emphasizing it as a routine aspect of health care similar to healthy nutrition. This approach could result in more opportunities to tailor preventive services and treatment to individual sexual health needs. Optimally, patient interactions addressing sexual health would occur and evolve over the life course, depending on the target age and personal circumstances, such as relationship status, sexual orientation, gender identity, and pregnancy intent. For instance, evolving areas of emphasis over a lifetime could include anatomy for children; abstinence, contraception, STI/HIV screening, sexual development, and healthy relationships for adolescents and young adults; peripartum changes for young or midlife adults; and management of perimenopausal changes, prostatism, and erectile dysfunction for midlife and older adults.43 If patients viewed the recognition and management of sexual health-related issues as a routine, normal part of health care, the stigma preventing many individuals from seeking care or discussing symptoms might be reduced.
The Internet could also play an important role in increasing patient understanding of sexual health, helping to decrease stigma and normalize conversations about sexual health with providers. Currently, many people use the Internet to familiarize themselves with and manage health issues independently as well as to decide when to see a health-care provider.44 Because sexuality and sexual health information is widely available on the Internet, there may be healthier ways to frame this information and help patients use it. The GYT: Get Yourself Tested campaign website, which promotes talking openly about sexual health, is an example of an effort directed toward normalizing sexual health.45 Likewise, recent literature reviewing HIV information websites indicates that quality ratings for websites and demographically tailored information may make Internet materials more useful for patients and providers and help address the potential problem of dissemination of inaccurate information.46–48
Other issues relevant to educating patients in sexual health include issues of discomfort, shame, and worry about providers' reactions. In studies of clinical settings, patients often had specific ideas about how providers should inquire about sexual health.25,27,34 Many patients felt their doctors should explain their rationale for asking sexual health questions, and some patients felt sexual health should only be discussed if a specific symptom or problem were present. Patients also reported feeling ashamed of their sexual problems or worried that providers might perceive them as sexually abnormal. Some older patients assumed any sexual problems were solely the result of aging and, thus, inevitable.27 Overall, patients need to better understand their own ability to start, stop, and control the direction of any patient-provider discussions of sexual health.20 Efforts to educate patients should take these important factors into account.
Despite the obvious challenges of better training and educating health-care providers and patients about sexual health, the contributions of such efforts to improving sexual health nationally could be quite important. Across various levels of society—from individuals and their relationships to school, community, and clinical settings—normalized discussions of sexual health could help all types of providers and patients become more informed and thoughtful about sexual health. Effective training has the potential to enhance providers' ability to comfortably discuss sensitive sexual health issues, provide more holistic patient-centered care, and ultimately reduce adverse sexual health outcomes in their practice settings. If providers throughout the U.S. could better address sexual health issues, they could increase the availability of preventive health services and treatment to avoid poor sexual health outcomes. Likewise, greater patient interest in open dialogue with their providers about sexual health could enhance patients' seeking of needed services and their satisfaction with care. Ultimately, for both providers and patients, better education and training in sexual health can help support the goal of maintaining sexual health throughout the life span.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.