What Are the Biggest Challenges to Our Collective Sexual Health?

After the near eradication of syphilis in 2000 and historically low gonorrhea infection rates in 2009, the U.S. is now in the midst of an epidemic of sexually transmitted diseases (STDs) and STIs nearly 10 years in the making.

Each year, 26 million new cases of STIs are diagnosed, and incidence rates of reportable STDs, such as gonorrhea, syphilis and chlamydia, are the highest in 50 years.

At the same time, novel viruses such as mpox have emerged, and some diseases—think super gonorrhea—are becoming increasingly resistant to antibiotics.

These conditions, if left untreated, can have broad and significant impacts on people's health, bearing life-altering and sometimes deadly consequences.

For example, cancer—including carcinomas of the sexual and reproductive organs—remains prevalent in the U.S. And while the incidence and mortality rates of conditions such as breast, cervical, prostate and colorectal cancers have decreased overall, there are some concerning caveats, such as an increased incidence of advanced cervical cancer.

Human papillomavirus (HPV) is an STI that almost everyone will get at some point in their lives. More than 42 million Americans already have HPV, and another 13 million will become infected each year, according to the Centers for Disease Control and Prevention (CDC). HPV is responsible for more than 90 percent of cervical cancer cases.

Other effects of untreated STIs range from infertility to organ damage.

Certain STDs tend to be more prevalent among specific communities, but they transcend demographics. For example, men who have sex with men have historically been more susceptible to syphilis, but rates among this community declined slightly in 2020. In contrast, syphilis cases among heterosexual women increased by 30 percent between 2018 and 2019 and by 21 percent from 2019 to 2020.

Rates of congenital syphilis have also increased dramatically since 2012, according to the CDC. From 2013 to 2021, there were 2,268 reported cases and 766 related stillbirths and infant deaths.

HIV, which can be successfully prevented with pre-exposure prophylaxis (PrEP) and rendered untransmittable with antiretroviral therapy, has seen a decline in incidence, and the prognosis for infected people has substantially improved. Still, about 1.2 million people nationwide have the virus, and it's estimated that about 13 percent of those are unaware of their HIV status.

The rate of reported STI cases fell early during the COVID-19 pandemic—perhaps due to decreased testing during that period—but rose again at the end of 2020, according to the CDC.

According to the 2020 STD Surveillance Report, rates of gonorrhea and primary and secondary syphilis increased 10 percent and 7 percent, respectively, compared to 2019, while congenital syphilis increased 15 percent from 2019 and 235 percent from 2016. Chlamydia declined 13 percent, although it should be noted that nearly 1.6 million new cases were reported in 2020.

Stigma, coupled with issues such as lack of sufficient services and sex education, contributes greatly to the crisis, according to Kristen Mark, Ph.D., M.P.H., a professor and Joycelyn Elders chair in sexual health education at the Institute for Sexual and Gender Health at the University of Minnesota in Minneapolis.

"We don't feel comfortable talking about these things. There's not a lot of frank and open communication," she said. "When we look at the STI rates, the lack of an ability to talk to an intimate partner about that, and to talk about STI status, to make that an inherent part of a conversation when you start seeing somebody, those are some of the main drivers of why we're in an STI epidemic."

The public health infrastructure in the U.S., with perceived issues that include a lack of universal healthcare, institutional racism, poverty, and discrimination based on sex, gender and sexuality, can make it challenging for large swaths of the population to access quality care.

This challenge primarily affects people of color, members of the LGBTQIA+ community, undocumented individuals, people in rural communities and women.

"The U.S. is notorious for spending a large amount of money on health and healthcare but not seeing the benefits of this investment because we have other structural issues that prevent people from fully benefiting," said Arden Handler, Dr.P.H., M.P.H., a professor and the director at the Center of Excellence in Maternal and Child Health at the University of Illinois Chicago School of Public Health.

Barriers to care come in the form of structural inequities such as racism and poverty, which are deeply intertwined, Handler explained. Many of the same areas that are healthcare "deserts" also are deserts for pharmacies, food and housing, she noted.

Lack of access to these fundamentals substantially affects myriad aspects of the health and well-being of individuals and families.

More than 2.2 million women of reproductive age live in maternity care deserts with no hospital that offers obstetric care or a birthing center, according to March of Dimes.

Power to Decide, a national nonprofit organization based in Washington, D.C., states that more than 19 million women of reproductive age who require publicly funded contraception live in contraceptive deserts.

"When you and I go to our OB-GYN, we have a certain level of privilege to be able to access whatever method of contraception is best for us and to have health insurance coverage for that method," said Rachel Fey, the vice president of policy and strategic partnerships at Power to Decide. "But if you have to put gas in your car when you're struggling to make ends meet, arrange for time off from work—possibly from an hourly job where you're going to lose wages—maybe secure childcare, all just to get to a clinic that offers that method, let alone whether you have the insurance coverage to access it, that's a crisis in this country."

The Dobbs court decision has exacerbated inequities in access to reproductive care and forced many sexual health providers to shut their doors or curtail services to align with states' new or impending legislation on abortion restrictions, Fey said.

A statement issued in June 2022 by the American College of Obstetricians and Gynecologists (ACOG) concurs:

"Allowing states to set individual restrictive abortion policies, including restrictions and outright bans on this essential component of medical care, results in an increase in the inequities that already plague the healthcare system and this country. These oppressive laws will force many people to face the known risks associated with continuing a pregnancy, including potential pregnancy-related complications and worsening of existing health conditions, as well as the morbidity and mortality associated with childbirth. The impact of this irresponsible [court] decision will fall disproportionately on people who already face barriers to accessing healthcare, including people of color, those living in rural areas and those without ample financial resources. This decision, which has been foreshadowed for many months, confirms that this is a dark and dangerous time for the women and doctors of America."

Besides curbing access to abortion care, the court decision's fallout has substantially diminished access to a broad spectrum of sexual health services, including contraceptives and STI prevention, testing and treatment, Fey said.

While primary care providers can offer some services, Horowitz said many people don't have such a provider. Plus, because of the stigma surrounding sex and sexuality, many who do have doctors may not want to seek sexual health services from them.

"Sex is a stigmatized topic, so they may want to go to the clinic where they know they're going to get anonymous care and culturally competent care," Horowitz said.

Even when facilities are accessible, fear of discrimination may prevent many individuals—especially people of color and members of the LGBTQIA+ community—from accessing care.

A survey by the Center for American Progress found nearly half of the people who identify as transgender and 68 percent of trans people of color reported having been mistreated by a medical provider in the previous 12 months.

A study published in 2020 found nearly a quarter of transgender people avoided seeking care due to anticipated discrimination. Communities of color, especially Black people, report similar degrees of discrimination.

Some individuals express distrust in the healthcare system due to lived experience and historical horrors such as the Tuskegee syphilis study and forced sterilizations.

Sexual health education is paramount to individual and public health. Ample evidence indicates it can yield myriad benefits for students and communities, from preventing teen pregnancies and STI transmission to improving relationships and emotional development.

The curriculum should be medically accurate, developmentally appropriate, culturally relevant, inclusive of all students, and address 20 topics ranging from puberty and pregnancy prevention to consent and communication, according to the CDC.

Most schools in the U.S. don't teach such a curriculum, and some don't teach sex ed at all.

Only 29 states and the District of Columbia mandate sex education, and just 19 require instruction on condoms or contraception, according to SIECUS, an organization dedicated to the advancement of sex education through advocacy, policy and coalition building. Meanwhile, 35 states require schools to emphasize abstinence, and of the states that require sex education, fewer than half require it to be medically accurate. Just seven have policies that affirm LGBTQIA+ identities, while nine mandate instruction that explicitly discriminates against the LGBTQIA+ population.

Multiple studies have shown a correlation between abstinence-only education and higher rates of teen pregnancy. Yet research by the Guttmacher Institute, a policy and research organization, found that from 2015 to 2019, approximately 80 percent of adolescents received information about saying no to sex or waiting until marriage, while less than 50 percent were told where to obtain birth control.

Only 55 percent of males and 60 percent of females were taught how to use a condom.

Mark said there are a few reasons for the lack of consistency and quality in the nation's sex education. One is a lack of clear communication to the school and broader community regarding sex education's contents and benefits. Local and state policymakers are responsible for designing and implementing sex education.

Some school districts grappling with tight budgets and precious curricular hours don't prioritize it, Mark said.

Another reason is a fear of backlash targeted at administrators and policymakers. Research indicates more than 90 percent of parents support comprehensive sex education in middle and high school, Mark said. But large, well-funded lobbying groups that campaign against sex education often present themselves as the voice of the community.

The internet has always been a double-edged sword, Mark explained. On one hand, it can connect people to resources and information to help them understand and take charge of their health. On the other hand, it's rife with disinformation and misinformation, which can be detrimental or even dangerous.

Along with a lack of sex education in schools, the stigma around sex and sexuality may be one of the factors that allows misinformation and disinformation to be so ubiquitous.

When people aren't comfortable talking with peers, healthcare providers, pharmacists or others about their sex life, they have fewer opportunities to receive—and pass along—medically accurate and culturally competent information, Horowitz said.

Anyone can be susceptible to such misinformation, but she noted that marginalized groups are often most affected because they have a more difficult time finding the information they seek due to inadequate support, additional stigmatization and other barriers to care.

A 2013 study by the University of New Hampshire and the Gay, Lesbian and Straight Education Network examined 5,542 teenage internet users. It found approximately 19 percent of heterosexual youth and 78 percent of LGBTQIA+ youth searched for sexual health information online. Researchers also found LGBTQIA+ youth were more likely than their peers to seek information online because they didn't have anyone to ask.

"It just makes everything harder," Horowitz said. "Instead of people just having a lack of knowledge, they actually have misinformation or disinformation and incorrect knowledge, which means we have to overcome some perceived notion that they already have to then give them the information they need."

While some disinformation and misinformation are innocuous, certain concepts can be harmful. Examples range from the purported efficacy of DIY condoms to the conflation of contraception and abortion, which the Food and Drug Administration and scientific communities clearly delineate.

For medically sound sexual health information and support, Fey suggested resources such as Power to Decide's Take Charge of Your Sexual Health Guide and Five Action Steps to Good Sexual Health. Mark also recommended SIECUS, the Guttmacher Institute and Advocates for Youth.

Additionally, the CDC's National Center for HIV, Viral Hepatitis, STD and TB Prevention provides information on a variety of topics, from condom effectiveness to STI testing. The National Coalition for Sexual Health has a compendium of information on multiple subjects, as does the Society for Adolescent Health and Medicine.

Since the Supreme Court's Dobbs decision, 13 states have banned most abortions, according to the Guttmacher Institute. Georgia has banned abortions from six weeks of gestation—before many women realize they're pregnant—and four additional states have banned abortions from 15, 18 or 20 weeks.

More states have bans or restrictions in the works. About half of them are expected to implement some form of restriction.

The court decision was in opposition to public support for legal abortion, Fey said, with polls immediately before and after the ruling indicating most people in the U.S. supported the upholding of Roe v. Wade.

It's the first time in more than a century that the Supreme Court has taken a right away. The last time was in 1883 when the court ruled the Civil Rights Act of 1875—it forbade discrimination in public spaces, including trains and hotels—was unconstitutional.

For years, many states have refused public funding for sexual health clinics that simultaneously offered contraceptive and abortion services. Now, several of the same locales with abortion restrictions permit pharmacists and healthcare providers to refuse to administer birth control.

Although the right to contraceptive access is federally upheld by Griswold v. Connecticut, many experts worry this, too, could be curtailed, despite overwhelming public support for contraceptive rights.

"Certainly, we saw that Justice [Clarence] Thomas, in his concurring opinion on the Dobbs decision, questioned whether there was a constitutional right to contraception. And while the House passed the Right to Contraception Act a few months ago, it was blocked in the Senate," Fey said. "So we know some of these members are against even a right to contraception as a bill, and that should give everyone in this country serious pause."

U.S. Rep. Kathy Manning, a Democrat representing the 6th district of North Carolina, introduced the Right to Contraception Act to enshrine the right to birth control into federal statutory law to protect against restrictions on reproductive freedom.

The House of Representatives passed the bill by a vote of 228-195 in July 2022. That same month, Sens. Ed Markey, D-Mass., Mazie Hirono, D-Hawaii, and Tammy Duckworth, D-Ill., introduced a companion bill in the Senate that has so far stalled.

Moreover, some of the abortion bans passed by various states assert pregnancy begins at conception or fertilization, Fey said. Research, including a 2011 study published in the American Journal of Obstetrics and Gynecology, indicates the scientific community is divided on the matter.

But Fey said such definitions contradict the position of the American College of Obstetricians and Gynecologists (ACOG), which states pregnancy begins when the fertilized egg implants in the uterus. Based on the assertion that pregnancy begins before implantation, lawmakers are then seeking to ban contraception methods such as intrauterine devices and Plan B, which prevent fertilization or implantation.

Efforts to diminish contraceptive access began well before Dobbs and have manifested in many ways, including cuts to the Title X family funding program, Fey stressed. Some states have banned certain providers from offering contraceptive care through Medicaid because of those providers' affiliation with abortion services.

Fey and Brown both emphasized that marginalized communities are disproportionately affected by these measures.

Brown argued that access to abortion and contraception is a fundamental and broadly recognized human right that can be lifesaving, particularly for Black people and other marginalized communities. Where access is curtailed, maternal mortality rates increase while the health and quality of life diminish for birthing people and their children.

"Access to abortion and contraception is crucial to public health because it lives inside of a broader framing for reproductive justice," Brown explained.

She said such services are a part of basic healthcare and necessary for people to achieve reproductive well-being.

This basic requirement pertains to physical, mental and emotional health, and underpins the ability to achieve economic and educational goals and provide for a family, Fey explained.

"To make it very personal, if I couldn't prevent pregnancy at certain points in my life as I was pursuing my education or pursuing my professional goals, that would have had a dramatic impact on my trajectory and my success for what I wanted for my life," she explained. "And I think the same is true for millions and millions of people around this country."

The U.S. surpasses 11 other high-income countries, including Canada and Australia, in maternal mortality rates. Meanwhile, the availability of maternal healthcare providers and child and family services lags far behind.

"Though vast in its services, the U.S. struggles to address unmet needs associated with lack of access to respectful, high-value, culturally congruent, trauma-informed maternity services," Brown said. "Unfortunately, giving birth and accessing perinatal healthcare in the U.S. is already far more dangerous, especially for Black women and other birthing people of color, than in many other countries."

The nation's maternal mortality rate in 2020 of 24 deaths per 100,000 live births was more than three times that of other wealthy countries, according to the Commonwealth Fund. But the state of affairs is even worse for Black and brown parents. Fey described the situation as "abysmal."

"Black women in the United States are three times more likely to die from pregnancy-related causes than their white counterparts. When you adjust for education and income, that inequity remains," Fey said. "I think we're way past sounding the alarm. It is absolutely unconscionable that we have the maternal mortality rate that we do in this country."

Such persistent disparities have little to do with the nation's capacity to provide equitable healthcare, Brown said. Despite the lack of public funding for certain types of sexual health services and the absence of universal healthcare, the nation spends trillions of dollars—$4.3 trillion in 2021—on healthcare every year.

Research shows the quality of care varies drastically from one site to another, with consistently lower quality scores and higher maternal morbidity rates in hospitals in predominantly Black communities.

"The maternal mortality and morbidity crisis in the U.S. has met many families with the unthinkable: one day celebrating a baby shower and a few short months later, planning a funeral, or sometimes two," Brown said. "Black families, in particular, have been faced with the grave consequences of this crisis that is more than numbers, but lives, names, dreams deferred, and nightmarish realities for families and communities. From both a 30,000-foot view and at ground zero, the numbers are abysmal."

The effects of inequities and inadequacies persist well after a child is born because, in addition to insufficient reproductive care, the U.S. lacks crucial supports like a social safety net that most nations possess, Brown and Handler said. The U.S. is also the only high-income country in the world, and one of six in the United Nations, without national parental leave.

"There is a major maternal/parental support and leave—and I would add childcare—crisis in the United States," Brown said, noting that while some progress has been made, there is still much further to go. "We are far behind our peer nations when it comes to supporting parents with adequate leave and support as well as surrounding the family with comprehensive support systems that are integrative, coordinated and responsive to their needs and conditions."

The COVID-19 pandemic also had a significant effect on sexual health and related services, said Horowitz, Brown and Vincent Guilamo-Ramos, Ph.D., dean of the Duke University School of Nursing in Durham, North Carolina.

"People didn't stop having sex, but they did stop being able to access the services that they would've wanted for testing and treatment," Horowitz said.

In addition to clinics shutting their doors and limiting in-person appointments in the early days of the pandemic, Horowitz and Guilamo-Ramos described how many staff members in the sexual health sector had to pivot to address the coronavirus, reducing their capacity to provide their usual services.

"Large segments of the sexual health workforce were redeployed as part of the national effort to respond to COVID-19, further limiting the capacity of the sexual health system to maintain service delivery in an identical way to before the pandemic," Guilamo-Ramos said. "Barriers to accessing a large range of sexual health services were higher during the COVID-19 pandemic than they were before.

"For example, the CDC estimates HIV services during the COVID-19 pandemic were negatively impacted by service disruptions, hesitancy to use available services and supply bottlenecks."

Case counts for gonorrhea and syphilis dropped below 2019 levels in March and April 2020, the CDC reported, but surged in the following months. The agency posits the initial dip in cases was likely due to decreased testing, as well as the behavior-modifying effects of lockdowns and social distancing. By the end of 2020, reported cases of both gonorrhea and syphilis had increased by 10 percent and 7 percent, respectively, from 2019. According to the CDC, this might partly reflect an increase in testing services as health clinics reopened, as well as higher disease transmission post-lockdown.

The pandemic markedly affected access to contraceptive services as well, with more than half of U.S. clinics postponing or canceling visits for contraceptive services, according to a 2022 review published in BMJ Global Health.

The impact on pregnant and postpartum people was also considerable, with many facing barriers to care and being separated from family and support systems before, during and after delivery, Brown said.

Research confirms this viewpoint. A report published by the CDC indicated the U.S. maternal mortality rate increased by 60 percent during 2019 to 2021, from 754 to 1,205 deaths. Another report published by the U.S. Government Accountability Office cited the coronavirus as a significant factor in at least 400 of the deaths in 2021, and previous reports indicated approximately 25 percent of maternal deaths in 2020 and 2021 were related to the virus. Pregnant people with COVID were nearly eight times as likely to die as those without the virus, found a meta-analysis published in BMJ Global Health. Reports cite peripheral pandemic-related factors, including a strained healthcare system and diminished prenatal care, as other contributing factors.

Research, including a 2021 review published in Reproductive Health and a 2022 study published in Perspectives on Sexual and Reproductive Health, indicates "severe increases" in maternal mental health issues, including depression and anxiety. Moreover, domestic violence appeared to spike while working mothers struggled to meet increased childcare demands, among other effects.

Issues with healthcare accessibility for pregnant and postpartum people and the general population was additionally compounded by the loss of insurance and income for millions of Americans who lost their jobs or experienced underemployment during the pandemic. Research by Families USA, a nonpartisan consumer advocacy group, indicates about 5.4 million people lost health insurance between February and May 2020 due to the pandemic and the resulting economic crash.

The impact of COVID-19 on mortality and morbidity in the U.S. is very clear in the data, Guilamo-Ramos said. But according to him, with backing from the CDC, COVID-19 infections were only one contributing factor. Healthcare curtailments, including diminished testing and treatment for chronic conditions such as diabetes, cardiovascular disease and cancer contributed.

A 2020 review published in the Journal of Clinical Oncology, for example, found that in the first four months of the pandemic compared to the same time in 2019, breast cancer screenings were down by 89 percent and colorectal cancer screenings had decreased by 85 percent. In a 2023 review published in Current Oncology, researchers posit such delays meant many patients were diagnosed at later stages of the disease, potentially affecting survival rates.

The pandemic primarily exacerbated preexisting issues, though, including the lack of public health prioritization and infrastructure funding, Horowitz and Guilamo-Ramos said.

"There often is a lot of focus on COVID-19 for exacerbating some of the preexisting sexual health inequities we experience in the U.S., with the emphasis on 'preexisting,'" Guilamo-Ramos said, citing a report published in the academic journal Milbank Quarterly. "Many of the sexual health and broader health challenges we experience today are associated with a longstanding under-prioritization and underinvestment in U.S. public health."

Despite the harm it caused, Guilamo-Ramos said the pandemic provided one positive in the form of an opportunity to improve sexual health services.

"The challenges imposed by the pandemic also necessitated inventiveness and innovation in the ways sexual health services are delivered. For example, telehealth proved to be an equally effective, and in many ways more efficient and convenient, option for the delivery of some sexual health services as compared to in-person appointments," he explained. "Furthermore, the time frames for refilling important sexual health prescriptions were extended to reduce the burden on patients and providers during the pandemic. Both of these innovations still have utility as we begin to emerge from the pandemic emergency."

Knowing what the challenges are regarding sexual health, part four of the State of Sexual Health series will look at the question of how sexual healthcare in the U.S. can be improved. It will examine the barriers to access for many people, including funding that has been diverted to COVID care. In addition, the report will highlight how to improve and expand sex education, the need for more funding and where to spend it, and how progress can be made.