Sexual Health

Background

The World Health Organization defines sexual health as a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity [1]. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.

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Sexual health is attained though both access to opportunities and information as well as the development of skills that support lifelong physical, emotional, mental, and social well-being. 

In addition to information about human anatomy and reproductive physiology, sexual health includes knowledge and skills related to decision making and goal setting about when and if to have a family; creating safe relationships; developing self-acceptance and a positive identity; and communicating with health professionals, partners, and families [2]. 

Sexuality and sexual health also include how biological sex, gender identity, sexual orientation, relationships, gender presentation, and gender expression make up who individuals are (3). The figure to the left illustrates the spectrum of identity, orientation, and gender expression [3,7].

The DC Healthy People 2020 goals related to Sexual Health include:

1. Community capacity and access to services allows for timely and comprehensive diagnosis and treatment of Sexually Transmitted Infections (STIs) and complications.

2. District residents are engaging in healthy sexual behaviors.

3. Stigma is reduced surrounding STIs.

Sexually Transmitted Infections

Acknowledging that sexual health is much more than the study of STIs, they are an important set of health outcomes that should be analyzed and reduced in order to improve population health. Sexually transmitted infections (STIs) refer to more than 25 infectious organisms that are transmitted primarily through sexual activity [4]. Some of these infections, however, can also be transmitted non-sexually, such as from mother to infant during pregnancy or childbirth.

STIs can cause many harmful, at times irreversible, and costly clinical complications, such as:

              • Reproductive health problems
              • Fetal and perinatal health problems        
              • Cancer
              • Facilitation of the sexual transmission of other STIs, such as HIV.

Despite their burdens, costs, and complications, and the fact that they are largely preventable, STIs remain a significant public health problem in the United States as well as in the District of Columbia, where for example, the rate of chlamydia has been nearly double the national rate for the past decade [5].          

Young people are disproportionately affected by gonorrhea and chlamydia infections, and infections in all ages are trending upward. Primary and Secondary Syphilis infections do not disproportionately affect any one age group, but we do see patterns over time with regard to geography. All three of these infections can be effectively treated with antibiotics, but reinfection is possible and is an important consideration, especially in a population with a high prevalence.

HIV

It is estimated that nearly 1.1 million people living in the United States have been infected with Human Immunodeficiency Virus (HIV). According to the most recent data, as of 2017 there are 13,003 current residents of the District, or 1.9% of the population who are living with HIV [6], a rate that far outpaces the prevalence rate in the rest of the United States. However, prevalence includes new diagnoses as well as those living with HIV, which, with proper access to treatment, can now be managed similar to a chronic disease. New HIV diagnoses have been dropping over time and, in 2017, there were no babies born with HIV in the District meaning 100% of perinatal HIV cases were averted. African Americans living in the District are disproportionately impacted by HIV with nearly 75% of District residents living with HIV identifying as African American/Black. Over 90% of all females in the District living with HIV are African American, experiencing a rate over 24 times the rate of White women in the District [6]. 

Advances in HIV prevention and treatment have helped reduce the burden of the infection and have allowed persons living with HIV (PLWH), with proper treatment, to control the infection similar to a chronic disease. However, people still do die of advanced HIV infection every year in the District. Those living with HIV face barriers to access to care due to stigma and other social determinants (e.g. low levels of education, income, discrimination, etc.). PLWH can live many years without symptoms or passing HIV on to sexual and injection drug use partners. The 90/90/90/50 Plan is a framework that aims to end the HIV epidemic in the District by the year 2020. The four goals of this plan include:

Goal 1: 90% of HIV-positive District residents know their status

Goal 2: 90% of District residents diagnosed with HIV are in treatment

Goal 3: 90% of District residents with HIV who are in treatment reach viral load suppression

Goal 4: 50% reduction in new HIV infections

Factors that Affect Transmission

The spread of STIs is directly affected by social, economic, and behavioral factors. Such factors may cause serious obstacles to STI prevention due to their influence on social and sexual networks, access to and provision of care, willingness to seek care, and social norms regarding sex and sexuality. Among certain vulnerable populations, historical experience with segregation and discrimination exacerbates the influence of these factors [4].

Social and Structural Factors

Perhaps the most important social factors contributing to the spread of STIs in the United States are the stigma associated with STIs and the general discomfort of discussing intimate aspects of life, especially those related to sex [4]. These social factors separate the United States from industrialized countries with low rates of STIs. Sex positivity is the idea that sex and sexual pleasure is different for everyone. Sex positivity is about being non-judgmental, honest, and informed. The concept affirms that sex can be personal, scary, pleasurable, confusing, and fun. No matter if, when, or how individuals choose to have sex, the most important part of sex positivity is knowing yourself and respecting other people’s process in understanding themselves [3]. 

Behavioral Factors 

Behavioral factors that can prevent and appropriately treat STIs include using condoms during sex and getting regularly screened for common STIs. Youth in the District who are sexually active report using a condom during their most recent sexual intercourse compared to the national average (in 2017 among high school students--61.2% in DC vs. 53.8% in the US), [8] but some groups use condoms less than others. For instance, lesbian, gay, and bisexual high school students were 45% less likely to use condoms compared to heterosexual students [8]. Among adults, 59.9% reported not using condoms the last time they had sex, but income and education levels had an impact on lack of condom use [9]. 

Source: DC YRBS 2017

District Adults who Did Not Use a Condom the Last Time they had Sexual Intercourse by Education

Source: DC BRFSS 2017

Source: DC YRBS 2017

Assets & Resources

 • Sex Is DC…

Sexual Health Discussion Guide for Adolescents

Sex Positivity Resources

DC Health Finder: resources for youth based on where you are located in the city

Speak Up DC: learn about youths rights to sexual health

LGBTQ Rights

Youth Advisory Board

Free Condom

DC Health & Wellness Center: Testing, Diagnosis, Vaccinations, Sexual Health Education & Free Condoms

inSPOT: Notify someone anonymously that they need to get tested and treated from an STI

PrEP (Pre Exposure Prophylaxis) Drug Assistance Program

PEP (Post Exposure Prophylaxis)

Hepatitis Resource Directory

HIV Services for free and reduced cost services (i.e. medical care, food, housing, and more)

Living with HIV (ADAP-AIDS Drug Assistance Program)

New Diagnosis of HIV

Managing HIV 

Promising Practices & Policies

• STI-I Increased screening for STIs, included as a part of preventive care checkups.

• HIV-I Improve enforcement of HIV surveillance data sharing and reporting.

• HIV-II Care coordination to incorporate routine opt-out HIV testing into primary care visits.