How Sexual Healthcare in the United States Can Be Improved

COVID-19 strained every facet of the healthcare system, from staffing to infrastructure. How can the same exhausted and overextended system deal with the additional problem of an increase in gonorrhea, syphilis and congenital syphilis cases?

Increasing funding to increase staff so the public health system is not as overburdened is critical, said Rebekah Horowitz, M.P.H., the director of STI programs with the National Association of County and City Health Officials (NACCHO) in Washington, D.C.

There's also an opportunity to expand efforts to nontraditional resources and get other entities involved, she said.

"Schools, libraries, rec centers, churches, primary care providers, OB-GYNs should all play a role in STI prevention. If only the health department is coming in to deal with a case or prevention, it will never be enough," she explained.

The strength to tackle a problem like this can only happen in numbers.

"We predicted a dip in 2020. Not due to a lack of cases, but due to a lack of testing since sexual health clinics were shuttered, family practice sites went remote and routine OB-GYN screening was pushed off," said Casey Pinto, Ph.D., an assistant professor in the public health sciences department at the Penn State Cancer Institute in Hershey, Pennsylvania.

Since some STDs and STIs—chlamydia and gonorrhea included—are asymptomatic about 70 percent to 80 percent of the time, she explained, a lack of testing likely allowed them to spread further. Preliminary CDC data backs that line of thinking as the case numbers for 2021 are higher.

STIs are not going away, and a lack of access to screening is a barrier to lowering those rates, Pinto warned.

"More healthcare providers should see it [testing] as part of their role to assess the sexual health needs of patients," said Leandro Mena, M.D., M.P.H., the director of the CDC's STD prevention division in Atlanta.

He pointed out that while the increase in STIs is widespread, it falls disproportionately on certain groups.

"The preliminary 2021 STI data shows that some racial and ethnic minority groups, gay and bisexual men, and our nation's youth continue to be disproportionately impacted by higher rates of STIs," he explained. "[It illustrates] a failure to provide access to quality sexual healthcare to everyone who needs it."

While COVID-19 strained the healthcare system, it also impacted equitable access to care.

"The COVID-19 pandemic has increased awareness of something we've long known about STIs: that longstanding and ingrained social and economic factors must be addressed so that everyone can achieve optimal health," Mena said. "There are social and economic conditions that make it more difficult for some populations to stay healthy." 

He listed several barriers that thwart access, including the following: 

• A higher burden of STIs in some communities
• A lack of medical insurance or a primary care provider
• Poverty
• Stigma and misinformation
• Unstable housing situations

To add insult to injury, STD clinics and prevention services were on the front lines of the mpox outbreak, which further taxed an already-strained workforce and its limited resources, Mena noted. The public emergency around that outbreak was lifted on Jan. 31, 2023, but only after eight months of being a critical health issue in America.

Sex education, a resource for youth to learn sexual health safety skills, is not federally mandated. State and local school districts decide who has access.

Only 19 states require instruction on condoms or contraception where sex education or HIV/STI education is taught, according to SIECUS, the Sexuality Information and Education Council of the U.S. The council is dedicated to the advancement of sex education through advocacy, policy and coalition building.

Quality sex education has long-term benefits, such as lowering STI rates by reducing risky activities such as unprotected sex. There are no federally funded programs dedicated to comprehensive sex education, which is regarded as the gold standard of sex ed, according to the Guttmacher Institute, a national research and policy organization.

Experts agree that for sexual education to improve, it needs to exist across the board.

"The data [points] are very clear that sex education, when taught according to the National Sex Education Standards, improves health—both physical and mental—and relationship outcomes for a person's life span," said Michelle Slaybaugh, the director of social impact and strategic communications at SIECUS in Washington, D.C.

Not everyone has access to the kind of sex education that Slaybaugh references, though. State and local school districts govern which type of sex education students should receive and whether or not they receive it at all.

Only 29 states and the District of Columbia require sex ed. Out of these states, 16 require abstinence-only sex ed, and 13 states do not require sex ed to be medically accurate, age-appropriate or evidence-based.

Comprehensive sex ed is a curriculum- and evidence-based form of sex education that covers a wide range of topics, such as sexual health, safety, dating, personal skills and gender. A 2021 study by New York University researchers indicated that comprehensive sex education reduces teen births and sexually risky behaviors, such as unprotected sex.

An article published in 2021 in the Journal of Adolescent Health examined three decades of sex education research.

"This publication specifically highlights the many benefits of comprehensive sex education programs outside traditionally sought-after health outcomes of lowering STI transmission and teen pregnancy," Slaybaugh said.

As indicated by a cache of questions that revolve primarily around STIs, Edward W. Hook, M.D., professor of infectious diseases at the University of Alabama at Birmingham School of Medicine, added that without help from a provider or sex education, people are left with many misconceptions about STIs. The primary misconception is that all STIs are symptomatic, so you'll be able to tell when you have one. That's not true, he noted.

A poll published in 2020 by the Kaiser Family Foundation indicated that the majority of Americans did not know how common STIs were. Surveillance data from 2020 published by the CDC found more than half of new STI cases were among adolescents and young adults 15 to 24 years old, making sex ed even more essential.

One such program in need of more funding to serve a broader population is the CDC's Division of Adolescent and School Health (DASH), which promotes environments in which youth can gain fundamental health knowledge and skills, establish healthy behaviors and connect to health services to prevent HIV, STDs and unintended pregnancy, Slaybaugh said.

Another essential initiative that requires continued funding is the Teen Pregnancy Prevention program overseen by the Office of Population Affairs, she added. While teen birth rates have declined in the U.S., the numbers are much higher compared with other industrialized nations. The teen program is a national, evidence-based grant program that funds organizations working to prevent unintended teen pregnancy across the nation.

"We, as a country, are in a critical place where more needs to be done by the federal government to ensure all of our schools are a safe place to learn for all students and that teachers are supported in their efforts, not targets of political posturing," Slaybaugh explained.

She recommended passing the Real Education and Access for Healthy Youth Act (REAHYA), which would fund comprehensive sex education programs across the U.S. and eliminate abstinence-only-until-marriage federal funding.

The bill, first sponsored in 2020 by Sen. Cory Booker, D-N.J., has been read twice in the Senate and has now been referred to the Committee on Health, Education, Labor and Pensions. The bill proposes to provide for the overall health and well-being of young people, including the promotion and attainment of lifelong sexual health and healthy relationships.

The elimination of sexual risk avoidance education (SRAE) funding would be another step forward that Slaybaugh recommended. This funding supports abstinence-only programs that reinforce what she calls harmful gender stereotypes, negatively portray sex outside of heterosexual marriages, and perpetuate seeing sex through a negative lens.

Although providing sex education in schools has long been debated for political reasons, it's something the overwhelming majority of citizens want for high school students. A meta-analysis conducted by the CDC and San Diego State University analyzed 23 surveys conducted between 2000 and 2016. Researchers found 87.7 percent of people in nationally representative surveys support sex ed in schools. The number jumped to 90 percent in surveys that included only parents or were oversampled for parents.

"Unfortunately, we are doing more with less," said Pinto, identifying increased federal funding as a chief priority to expanding sexual healthcare.

Due to cuts to federal dollars, some of the biggest STI testing centers in the country are moving toward a cost-sharing model with patients, she explained, and many smaller organizations are considering doing the same.

Pinto highlighted that direct-to-consumer methods of STI testing—where individuals buy an STI testing kit and screen themselves at home—have been helpful.

"Notable work in progress is improving the direct-to-consumer testing, so it's appropriate," she said. "But this leaves out patients without money to afford the direct-to-consumer testing. So we would encourage all the public health sites to continue free screening and treatment like they [currently] are."

Although some state and local governments—and many nonprofit organizations—are working to fund and create sexual health resources within their own communities, this is not uniform across states or local jurisdictions within them, Horowitz explained.

But which area of the government is responsible for STIs? 

Diagnosis and treatment should occur locally and surveillance efforts should be coordinated at state and federal levels, according to a study report titled, "Sexually Transmitted Infections: Adopting a Sexual Health Paradigm," a publication of the National Academies of Sciences, Engineering and Medicine.

Researchers noted a lack of "pragmatic coordination" in managing STIs at the federal, state and local levels. They reported that despite increased STI rates, federal funding has stagnated. The U.S. Department of Health and Human Services provides most federal support.

For low-income individuals, the Office of Population Affairs plays a significant role in distributing the Title X Family Planning Program, which supports HIV and STI prevention, testing and treatment. However, Title X underwent changes during President Donald Trump's administration that caused providers to leave the program. President Joe Biden has since restored the program.

Approximately 2.5 percent of all health spending in the U.S. is spent on public health and prevention programs. In 2021, the Biden administration announced a $1.3 billion investment to strengthen the disease intervention specialist workforce in the CDC, although it should be noted that the funding is mostly for pandemic response.

More funding for resources is required from the government, Horowitz explained. In the absence of this funding, nonprofit groups could help bridge gaps in providing aid, but as of right now, this isn't happening.

"When these resources and education are not provided by the government equally across their jurisdictions, it is highly likely that understanding of sexual health and how to make safer sex choices will be unequally available to individuals in those communities," she said.

"The public health department for sexual health is doing an amazing job with the little resources they have. They provide free screening and services, analyze data, create mini-interventions and partner with local organizations," Pinto explained, adding that it's vital to support the public health department's initiatives through funding and allowing them into every community.

There is also an opportunity to increase personal advocacy around improving sexual health in America. Personal stories could play a prominent role in making change, according to Horowitz.

"It is significantly easier to get funding from all levels of government if the policymakers and purse holders can keep a real person's story in mind when making these decisions," she said.

Increasing funding is essential, but so is decreasing the stigma around STDs and STIs. Both goals are achievable with better sexual health education and accessible information.

"We need more money since we have continually increasing STIs," Pinto explained. "We need less stigma around STIs. We need more public knowledge that STIs are a problem and should be tested for so we can treat them early."

As shown by the pandemic, taking care of a public health crisis involves myriad efforts.

"Turning the STI epidemic around is going to require increased accountability for controlling STIs to partners beyond CDC and health departments," Mena said. "[That change will require] reenvisioning how we provide STI services to people to better meet them where they are, and innovative solutions to bring STI testing, treatment and prevention into the 21st century."

"STIs are here and continuing to rise," Pinto said. "The earlier we can diagnose someone with an STI, the earlier we can cure the STI or initiate treatment for those that we can't cure. This prevents the spread to other people and complications from untreated STIs."