Sexual health: Time for a national strategy?

As a reproductive health clinician, you might be looking to upcoming health care reform to make a difference in improving the status of sexual health care in the United States. Don't be so sure, though. No mention is made once regarding "sexual health" in the more than 1,000 pages of the new health care reform legislation, say co-authors of a current commentary in the Journal of the American Medical Association.1

The time is now to raise the issue among policyholders for a national strategy to promote sexual health, say Jonathan Zenilman, MD, professor of medicine at Johns Hopkins University School of Medicine and chief of the Infectious Diseases Division at Johns Hopkins Bayview Medical, both in Baltimore, and Andrea Swartzendruber, MPH, a PhD student in the Johns Hopkins Bloomberg School of Public Health in Baltimore. Such a strategy can serve as a unifying goal and provide a framework for building on proven evidence, they state.

One problem in developing a national sexual health initiative lies in the way current health care is delivered, says Zenilman. As in all facets of healthcare, the health system does not get paid if people are healthy, he notes; it gets paid if people are sick. Given the intensive nature of care needed in educating and counseling people about sexual health, many providers might not provide such care because they cannot get reimbursed for it, says Zenilman.

Prevention reduces STD incidence, and STD interventions have been shown to be highly cost-effective, state Zenilman and Swartzendruber. However, the 30-year experience correlating prevention funding with subsequent STD rates has been ignored, they state; when inflation is factored in, federal STD prevention investment per capita has decreased more than 25% since 1973, they state.2

Many providers are not properly educated to address sexual health issues, says Zenilman. A 2008 report issued by the National Campaign to Prevent Teen and Unplanned Pregnancy and the Association of Reproductive Health Professionals looked at providers' perspectives of unintended pregnancy and barriers to more effective contraceptive use. The report notes there is no clear picture of the amount of didactic and hands-on experience health care providers receive in contraception and family planning during their training.3

The consequence? Lack of training is the primary reason cited by health care providers for not taking a sexual health history from patients on a routine basis, followed by provider embarrassment and a belief that sexual health is not relevant to the patient's visit.4

Boost care, information

Reproductive and sexual health are key primary health issues for adolescents and young adults; however, up until 2010, federal dollars were aimed at abstinence-only sex education. A body of evidence now indicates that such education is ineffective; findings from a 2007 analysis of four abstinence-only education programs indicate that abstinence-until-marriage programs do not keep teens from having sex.5 In that same year, the National Campaign to Prevent Teen and Unplanned Pregnancy released a comprehensive review of sex education evaluation research that concluded that "there does not exist any strong evidence that any abstinence program delays the initiation of sex, hastens the return to abstinence, or reduces the number of sexual partners."6 Two reviews by the Government Accountability Office (GAO) found that many of the curricula used by grant recipients for abstinence-only programs included false claims about condoms, other contraceptive methods, abortion, and sexually transmitted infections.7,8

"Abstinence-only sex education is not effective," state Zenilman and Swartzendruber in their commentary. "No one advocates lifelong abstinence; providing accurate and comprehensive information to protect adolescents' health and prepare them for responsible decision making are public health, family, and community responsibilities."

Funding must be included for ensuring sexually active adolescents have access to contraception and other sexual health services, say the two authors. Teens should have easy access to contraceptives and condoms at low or no cost via schools, health plans, Title X, Medicaid, and other federally funded programs. Health plans and federally funded services should cover the cost of contraceptives for all women without restriction, they advocate.


  1. Swartzendruber A, Zenilman JM. A national strategy to improve sexual health. JAMA 2010; 304:1005-1006.
  2. Douglas J. Challenges and opportunities to STD prevention in the US. Presented at the CDC HRSA Advisory Committee on HIV and STD. Atlanta; May 20, 2009. Accessed at
  3. National Campaign to Prevent Teen and Unplanned Pregnancy, Association of Reproductive Health. Professionals Provider's Perspectives: Perceived Barriers to Contraceptive Use in Youth and Young Adults. Washington, DC; 2008. Accessed at
  4. Lazarus CJ, Brown S, Doyle LL. Securing the future: a case for improving clinical education in reproductive health. Contraception 2007;75:81-83.
  5. Trenholm C, Devaney B, Fortson K, et al. Impacts of Four Title V, Section 510 Abstinence Education Programs. Princeton, NJ: Mathematica Policy Research; 2007.
  6. Kirby D. Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2007.
  7. United States Government Accountability Office. Abstinence Education. Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs. Washington, DC; October 2006. Accessed at
  8. United States Government Accountability Office. Abstinence Education. Assessing the Accuracy and Effectiveness of Federally Funded Programs. Washington, DC; April 23, 2008. Accessed at