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[edit] Sexual Health Education

The World Health Organization defines Health Education as: “Education that increases the awareness and favorably influences the attitudes and knowledge relating to the improvement of health on a personal or community basis.” Sexual health education includes, but is not limited to, issues of sexually transmitted infections, family planning and pregnancy, the physical and emotional consequences of sexual assault, mental health with regards to one’s body, sexuality, and sexual activity, and other health issues relating to sexual organs, behaviors, and attitudes. In addition to widely educating general and high-risk populations, sexual health education should also be targeted towards individuals such as health service providers and policy makers so that they may better understand, prevent, and treat sexual health issues and their causes.

The following overview is by no means comprehensive, but is instead intended to highlight some of the background and current issues related to sexual health education and the importance of sexual health to lifelong wellbeing.

The Global Burden of Unsafe Sex and Poor Sexual Health

According to The Global Burden of Disease (1996), a widely regarded publication on global public health, unsafe sex is the third largest risk factor for global disease burden (mortality and loss of healthy life), and it accounts for approximately thirty percent of the total disease burden among young adult women in Sub-Saharan Africa. By 2020, the report projects, HIV/AIDS alone will be the tenth leading cause of global disease burden as measured in Disability Adjusted Life Years (DALYs). The health effects of unsafe sex, such as sexually transmitted infections (STIs) and consequences of unwanted pregnancy, disproportionately burden women in all regions of the world. In 1990, for example, sexually transmitted diseases resulted in the death of 413,300 individuals, including 183,000 men and 230,300 women. When disease burden is measured in DALYs, STIs accounted for 9.1 million DALYs in males and 16.2 million DALYs among females – for a total of 25.3 million DALYs in 1990.

A more recent 2002 report by the Comparative Risk Assessment Collaborating Group shows that the global burden of unsafe sex and poor sexual health has continued its rapidly increasing trend. The report estimates that unsafe sex is the second highest contributor to loss of health life, estimated at 92 million DALYs – less than 43 million DALYs among males and more than 49 million DALYs among females - and 6.3% of total global DALY. It attributes approximately 2,886,000 deaths -1,370,000 males and 1,516,000 females – to unsafe sex in 2000, 149,000 deaths to lack of contraception, and 79,000 deaths to the consequences of childhood sexual abuse. This ranks unsafe sex as the fourth highest risk factor for mortality worldwide.

In developing regions, half of the ten leading causes of global ill-health, measured according to Disability Adjusted Life Years (DALYs) are related to maternal reproductive ill-health, including the consequences of unsafe abortion and chlamydia. Almost all of this loss could be avoided given adequate sexual health education, resources, and treatment. Recognizing this, the Millennium Project’s Task Force on Child Health and Maternal Health lists as its fourth principal recommendation towards achieving the Millennium Development Goals that: “Sexual and reproductive health and rights are essential to meeting all the MDGs, including those on child health and maternal health.”

The following statistics from the United Nations Population Fund, the Joint United Nations Programme on HIV/AIDS, and the World Health Organization portray a particularly striking picture of the consequences of unsafe sex worldwide – and the great need for sexual health education:

Consequences of Unsafe Sex measured in Estimated Daily Occurrences

Cases of Curable STIs: 930,000

Pregnancies: 575,000

Births: 365,000

Abortions: 130,000

Cases of HIV infection: 13,000

Deaths from AIDS: 8,000

Deaths from childbirth complications: 1, 500

Deaths from STIs (excluding AIDS): 500

Deaths from unsafe abortions: 200

Sexually Transmitted Infections (STIs)

The highest incidences and prevalence of sexually transmitted infections (STIs) as a whole occur among sexually active men and women ages 15 to 49; the most consequential risk factors include the number of sexual partners, the type of sexual partners, and the use of barrier protection such as condoms. A 2001 estimate from the World Health Organization suggests that in 1999 there were 340 million new adult cases of curable STIs (such as gonorrhea, chlamydia, and syphilis) worldwide; the vast majority of these occurred low- and middle – income countries. Additionally, the vertical transmission of sexually transmitted infections from mother to newborn infant, including STIs such as syphilis, gonorrhea, HIV/AIDS, genital herpes, HPV, and Hepatitis B, is an issue of importance especially in low- and middle- income countries. Most of these can have serious, and often life-threatening, health consequences which may be manifested in unique ways in the infant. For example, infant eye infections in infants who contracted chlamydia during birth are one of the leading causes of childhood blindness in the developing world.

Though there is no cure for viral STIs such as HIV, genital herpes, and HPV, vaccination against certain types of STIs may become increasingly possible. An HPV vaccine, Gardasil, was approved in the United States in June 2006 to women ages 9- 26, and is highly recommended for girls ages 11-12. The vaccine protects against four types of genital HPV, or human papillomavirus, which cause approximately seventy-percent of cervical cancers and ninety-percent of genital warts. Though cervical cancer will kill an estimated 3,700 American women in 2006, according to the American Cancer Society, approximately 400,000 women die from cervical cancer annually in the developing world. If and when this vaccine will be made available globally, and how it will be distributed to women in the developing world, are complex questions that remain to be addressed.

Women age 15-27 are three times as likely to be infected with HIV/AIDS as young men (www.unfpa.org/hiv/women/report/index.htm). Women are the fastest growing group of newly infected people, and more than half of all new HIV cases are in women and children. It is three to eight times more likely for an infected man to pass HIV to an uninfected female partner than for an infected female to transmit HIV to an uninfected male partner, and some other STIs are also more easily transmitted from males to females. Young women are especially more vulnerable to contracting STIs, as the less-mature cervix is more susceptible to infection and injury. Additionally, social factors such as violence against women, early marriage of females to older men, lack of power to negotiate safer sex, and tolerance for premarital and extramarital relations for men also contribute to the higher risk of sexually transmitted infections in women. International efforts to develop effective antiviral creams that women can use without the knowledge or necessary consent of their partner may help address the spread of HIV for women in such circumstances. Women often suffer more severe health complications from STIs, such as pelvic inflammatory disease (PID) – the leading cause of infertility in women in the U.S., serious damage to the reproductive system, cervical cancer, the effects of STIs during pregnancy, and greater illness at lower viral levels of HIV. Women generally also face harsher social consequences if they are infected with an STI.

Because sexuality and sexual health education can be such a contentious issue, there is great diversity in the approaches taken to address STI prevention, especially with regards to HIV. The ABC approach to HIV/AIDS education – Abstain, Be Faithful, and Use Condoms – gained popularity in countries such as Uganda. The success of this strategy in Uganda has caught the attention of many major donors such as the United States. Yet although the President’s Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy (PEPFAR) purports to support the ABC strategy, closer examination by organizations such as Human Rights Watch show that U.S. support for programs that provide comprehensive sex education is lacking, as focus instead is placed increasingly on abstinence-only -until-marriage programs. Under PEPFAR, the U.S. will provide at least $133 million annually to abstinence-only programs in 15 countries in Africa, the Caribbean, and in Vietnam – totaling a minimum of $665 million in five years (SIECUS). Studies by the Sexuality Information & Education Council of the U.S. and Human Rights Watch, among others, repeatedly show that this method of sex education is far from adequate, and the need for comprehensive sexual health education is made more salient by the global HIV/AIDs epidemic. Though abstinence-only-until-marriage programs are an ineffective means of HIV/AIDS education and prevention for many reasons, some of the most significant reasons include their failure to address high-risk populations, such as lesbian, gay, bisexual, transgender, and queer individuals, victims of sexual assault, commercial sex workers – among whom as many as 70-85% are estimated to be infected with HIV, and women whose husbands are or will become infected during extramarital relations.

Additionally, lack of effective and comprehensive sex education contributes to especially high rates of HIV and other STIs in young people. UNICEF studies from 40 countries suggest that more than 50% of young people ages 15-24 have serious misconceptions about how HIV/AIDS is transmitted (www.unicef.org/publications/files/pub_youngpeople_hivaids_en.pdf). Worldwide young people ages 15-24 account for half of all new HIV infections; 15-29 year olds account for up to 60% of new HIV infections in some countries (www.who.int/school_youth_health/en/). In the United States, which has highest rate of STI infection in the developed world, 60% of young people under the age of 24 have contracted an STI; there are approximately 10-12 million new cases of STIs in young people annually in the U.S.

Adequate, population-specific, and comprehensive sexual education regarding sexually transmitted infections is a crucial aspect of effective prevention of STI transmission via sexual contact or vertical mother-infant transmission, and plays a critical role in stemming what is truly a devastating and increasing global epidemic of STIs.

Addressing Unintended Pregnancy and Related Health Issues

Knowledge of and access to contraception is a key component of sexual health education. It is estimated that nearly 30% of all pregnancies worldwide are unplanned or unwanted, and unintended pregnancies are associated with higher rates of maternal, fetal, and infant complications and deaths. Control over the number and timing of pregnancies has a profound impact upon the quality of individual and familial lives as well as society as a whole. Poverty, infant and maternal mortality, and high birth rates are very often strongly linked, and reducing unintended pregnancies and providing birth control options has many physical and socio-economic health benefits for women and their families.

According to the Millennium Project’s Task Force for Child Health and Maternal Health, complications from unsafe abortion account for 13 percent of maternal deaths worldwide. These deaths could be prevented through access to contraception and safe abortion (where legal) and postabortion care services. The report’s policies and interventions to address sexual and reproductive health needs include providing information and services to adolescents and people in emergency situations; access to information regarding family planning options and choices; prevention, surveillance, and care for gender-based violence; postabortion care; and where legal, safe abortion services.

Abstinence-only education has also shown not to reduce the number of unintended pregnancies, especially among teenagers. In the United States, more than one third of all school districts currently provide abstinence-only sex education; yet nearly one million teenagers will become pregnant annually in the U.S., and the U.S. has one of the highest rates of teenage pregnancy in the developed world. A lack of information on and access to contraception for young people is a large contributor to this problem; sexually active U.S. teens, when compared to teens in other developed nations, do not differ significantly in the age of initiation or levels of sexual activity, but are less likely to practice safer sex. Instead, studies show sexually active teenagers in the U.S. who receive comprehensive sexual health education are more likely to use contraception, and those who are not sexually active are no more likely to initiate sexual behavior.

Other issues in sexual health and sexual health education

In addition to the psychological trauma of sexual assault, sexual violence often results in great physical trauma such as tearing and damage to the vagina or rectum, as well the possibility of pregnancy in women and STIs, and may require immediate medical attention. Unfortunately, in many areas of the world, victims of sexual assault are not able to access sensitive care due to factors including the stigma attached to sexual assault. Education for individuals such as health service providers on how to physically, emotionally, and socially help a survivor of sexual assault or abuse recover is crucial.

On a disability scale of 1 to 7, the Global Burden of Disease classifies rectovaginal fistulas as a 5 and erectile dysfunction as a 3, recognizing that sexual health issues such as these have serious negative health – and very often social - consequences for the individuals affected by them. Education can contribute to health workers’ ability to recognize, treat, prevent, and de-stigmatize such sexual health issues.

An aspect of sexual health that is often overlooked, especially for women, is emotional/mental health regarding a woman’s body, her sexuality, and her sexual activity. Mental health as a whole is largely neglected as a global health problem, yet The Global Burden of Disease identifies poor mental health (specifically, unipolar depression) as the leading cause of disease burden for women and projects that depression will be the second leading cause of total disease burden by 2020. For many individuals - such as survivors of sexual assault and abuse, lesbian, gay, bisexual, and transgender people, and women who feel restricted by gender oppression – mental health has a critical sexual health component.

For women in particular, a lack of being familiar with one’s own body is a common contributor to sexual health issues. Yet knowing one’s body and being able to identify what is and is not normal is an important aspect of prevention against more serious cases and complications of problems such as urinary tract infections, yeast infections, vulvodynia, pregnancy complications, and STIs.

Ensuring that health service providers are prepared to handle patients with problems such as these in a knowledgeable and sensitive way is crucial to physical and psychological sexual health and recovery.

Examples of effective sexual health education programs

In Thailand during the 1970s and 80s, Mechai Viravaidya’s highly successful campaign around family planning and HIV prevention through widespread distribution of and education about condoms significantly lowered Thailand’s birthrate and helped to evade an HIV/AIDS epidemic that was initially projected to be disastrous. The 100% Condom Campaign in the 1980s targeting commercial sex workers dramatically increased condom use and decreased HIV infection rates, especially among Thai military conscripts and men in general.

Brazil received Bill and Melinda Gates Award in 2003 in recognition of its success in stemming an anticipated HIV epidemic by launching massive HIV education campaigns and condom distribution, as well as treatment programs, and including high-risk populations such as sex workers in prevention efforts.

Obstacles to sexual health education and promotion

Health education, in order to be effective, ultimately includes: ensuring that addressing sexual health education can result in behavior change; providing the necessary resources - such as increased access to affordable condoms and birth control; and providing treatment for individuals who are affected by STIs, unwanted pregnancies, or other sexual health issues. It is imperative to combine health education efforts with affordable, available, and sustainable resources to ensure that the healthier option is a viable option for both individuals and societies.

A significant obstacle to STI prevention, especially in the developing world, stems from issues relating to traditional gender roles and cultural norms regarding sexual behavior. Many men do not want to use condoms, for example, and women may risk physical abuse, rejection, or loss of financial support if they try to insist that their husband, boyfriend, or customer use a condom. Stigma of individuals, especially women, who have STIs such as HIV may result in ostracism and abuse. In countries where men hold substantially more social power, focusing STI prevention efforts on men may be an important step in the struggle against HIV, but it is far from adequate in addressing sexual health problems as a whole and the issues that contribute to them.

Sexual health education, for obvious reasons, is one of the most contentious health education issues and is greatly complicated by issues of diversity, religious beliefs, cultural norms, gender roles, and oppression. Providing culturally sensitive yet effective sexual education can be a challenge among many populations, especially those in which cultural and religious values discourage conversation about sex and sexuality and which prohibit education addressing issues that conflict with their sense of sexual morality. Many women may not have access to contraception because of dominant culture or religious condemnation of it, and sexual behavior which places individuals at risk but does not fall within the confines of approved relations may be publicly ignored - with significant consequences. There is no simple way to reconcile the need to address issues of sexual health education in such societies while maintaining cultural sensitivity and recognizing the necessity to avoid cultural imperialism and paternalism.

Health educators face increased obstacles in working with disempowered and marginalized populations, such as trafficked persons, commercial sex workers, and women within highly traditionally-gendered societies. Funding for sexual health education among commercial sex workers, for example, is often limited by governmental aid policies; the U.S. Agency for International Development (U.S. AID) and the Trafficking Victims Protection Reauthorization Act of 2003, for example, deny funding to international organizations that do not follow constraining guidelines in opposing prostitution and/or may be construed as supporting prostitution. Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals are hard to reach, especially in the developing world, where stigma is often harsh and homosexuality may be illegal. The inability to identify and reach out to men who have sex with men (regardless of their labeled sexuality) and women who have sex with women, in addition to taboos that prevent discussion of LGBTQ health issues at large, are substantial barriers to providing sexual education and ensuring the sexual health of this marginalized and often ignored community. Ethnic and language minorities often face higher disease burdens and are less easily reached for a myriad of complex reasons. Other populations, such migrants, refugees, and individuals in rural communities often do not have access to adequate sexual health education due to geographic, economic, and political barriers.

Related Resources and Possible Funding sources for research or work in sexual health education:

-Association of Reproductive Health Officials: http://www.arhp.org/

-Bill and Melinda Gates Foundation: The largest philanthropic organization in the world; it has an emphasis on global public health.

-Ford Foundation, New York, NY One of the foundation's three program areas, Asset Building and Community Development, includes Reproductive Health and Population and a focus on adolescent sexuality and AIDS prevention. Most of the foundation's grant funds are given to organizations.

-Howard Hughes Medical Institute: Participates in public health research and also provides funding for graduate students and medical students, along with limited undergraduate internships.

-National Institutes of Health, Washington, DC See the NIH Guide for Grants and Contracts. Grants related to sexuality and reproduction may be found through several of the institutes, including NIA, NIAID, NICHD, NIDA, and NIDA.

-Public Welfare Foundation The Public Welfare Foundation offers annual grants for priority projects which targets specific topics on health advocacy, access and reforms, hunger, nutrition, mental health, reproductive and sexual health. Amounts: $25,000-$50,000 Deadline: Rolling, Applications accepted year-round Website: http://www.publicwelfare.org

-Womenshealth.gov funding page, the federal government site for women’s health information: http://www.4woman.gov/fund/

-The World Health Organization: www.who.int/en

-BRAC: www.brac.net

-Global Health Education Consortium: www.globalhealth-ec.org

-Global Health Council: www.globalhealth.org

-Human Rights Watch: www.hrw.org

-Sexual Information and Education Council of the United States (SIECUS): www.siecus.org

-United Nations Organizations. http://www.un.org/aboutun/chart.html, especially

-UNFPA (United Nations Fund for Population Activities), UNICEF, and the UNHCR

Page created by J.Koch as part of coursework for EDHS589: Fieldwork in Global Public Health

Other References:

The CDC’s “HPV Vaccine Questions and Answers” available at: http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine-hcp.htm

Ezzati M, Lopez AD, Rodgers A, VanderHoorn S, Murray CJL and the Comparative Risk Assessment Collaborating Group. Selected major risk factors and global regional burden of disease. The Lancet 2002; 360: 1347-60. http://image.thelancet.com/extras/02art9066web.pdf.

"Freedman, Lynn P. et al. “Who’s got the Power? Transforming Health Systems for Women and Children.” UN Millennium Development Project. Task Force on Maternal and Child Health. 2005

Insel, Paul M. and Walton T. Roth. Core Concepts in Health: Tenth Edition. New York: McGraw-Hill, 2006.

McKelevey, Tara. “Of Human Bondage.” The American Prospect. 24 Nov 2004.

Murray and Lopez, eds. The Global Burden of Disease. Murray and Lopez eds. 1996.

Reingold, Arthur L. and Christina R. Phares. “Chapter 4: Infectious Diseases.” International Public Health by Merson, Black and Mills 2006.