One evening, during the week of the 2001 ISSTDR meeting in Berlin, I met with a couple of colleagues for beers after the day’s proceedings. We lamented the fact that the focus of these types of conferences was always on disease and that a broader sexuality frame work was missing. “It is time to put sex into STD prevention”, one of my colleagues said. The comment was a bit wistful at the time and I don’t think any of us could have foreseen that a decade later our field is expressing so much more interest in sexuality and sexual health. This shift has been accentuated by the CDC’s recent efforts in developing a sexual health framework that signals an overall shift from disease prevention to health promotion. Credit goes to Dr. John Douglas, the Chief Medical Officer in the National Center for HIV, Hepatitis, STD and TB Prevention, who spearheaded this effort in the past 3 years and has created a broad coalition of stakeholders across the political and cultural spectrum to endorse the main tenets of a national strategy for sexual health.
Of course, the CDC’s efforts did not arise in a vacuum and there have been a number of developments in the past decade that have fostered a broad-based discussion of sexual health. For me, one of the heralding events in the sexual health discourse was Dr. Amy Schalet’s presentation on teen sexuality at the Jacksonville STD Prevention Conference in 2006. I have always been taken by Dr. Schalet’s work – perhaps because as a chauvinist Dutchman (born and raised in Amsterdam) I liked her findings that a more liberal attitude towards sexuality among Dutch teens and their parents is associated with much lower rates of teen pregnancy and STIs in the Netherlands compared to the U.S. Her book: “Not Under My Roof” was published last year (a podcast interview with Dr. Schalet is available online).
However, association does not causation make. There is a lot to like about a more positive approach towards sexuality, but a causal link between better sexual health and lower pregnancy and STI rates ultimately requires scientific evidence that goes beyond intuitive reasoning. For example, it has been said that prevention messages that use a positive “gain” frame (i.e., focus on health) are more effective than messages that use a negative “loss” frame (i.e., focus on disease). Intuitively, this sounds good but what’s the evidence? Not much, at least not in the field of STD/HIV prevention. The one study that looked into loss frame vs. gain frame messaging among HIV care providers for ongoing prevention with their patients, actually found greater efficacy of loss frame messaging. As you may know, this study formed the basis of the Partnership for Prevention intervention, which has been widely disseminated by the Diffusion of Effective Behavioral Interventions (DEBI) program.
One can argue about this study (or about the DEBI project for that matter), but the point is that for a sexual health strategy to work, we must develop a sexual health science. For starters, what parameters best measure a person’s sexual health? How are these parameters assessed and how are they related to the outcomes we are interested in: unintended pregnancy, STIs, sexual violence? Finally, can interventions be designed to influence these parameters that can be shown to improve sexual health and reduce negative outcomes?
If our forays into sexual health do not yield something more than what we are already doing now, i.e., testing and treating for HIV/STI, counsel our patients to reduce numbers of partners and increase condom use; our journey may have been interesting, but ultimately proven to be a detour.
At the end of the day, I am still an STD prevention guy. And, while I am a strong believer in sexual health promotion, we need science and not just good will to show that this approach is working.
Fortunately, there is some good research at the interface of sexuality and STI/HIV/pregnancy prevention. One of the leaders in that field is Dr. Dennis Fortenberry (indeed: he of the “wistful” comment cited above) at Indiana University School of Medicine. He has become a frequent speaker at national and international STI conferences on sexual health topics. Among these was a presentation at the AIDSImpact meeting last year in Santa Fe, NM, where he proposed a sexual health research paradigm that encompasses and links the full spectrum of sexual expression, including sexual abstinence, masturbation, and partnered sex. For example, he presented very interesting data on the linkage of masturbation and condom use (click here for a copy of this presentation). He has also proposed that in the context of sexual health, a much greater focus must be placed on pleasure and desire.
--Kees Rietmeijer, MD, PhD
Cornelis ‘Kees’ Rietmeijer, MD, PhD is medical director of the Denver Clinical Prevention Training Center. He is also a professor in the Department of Community and Behavioral Health at the Colorado School of Public Health.
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