Where and How Does Sexual Healthcare in the U.S. Fall Short?

"At the same time, there are so many barriers to good sexual health," she said. "There are cultural barriers, structural barriers and systemic barriers in this country that make it difficult for people to achieve good sexual health."

These barriers can include a lack of access to affordable, high-quality sexual healthcare; poverty; a lack of access to comprehensive, medically accurate sex education; and discrimination.

The cultural context, in which stigma is often attached to sexuality and sexual health conversations, can make it challenging to achieve high levels of good sexual health.

Another issue is that sexual health services for LGBTQIA+ individuals are practically nonexistent in some regions of the U.S., particularly for transgender individuals, said Jamie Bichelman, M.S., a mental health researcher in New York City with master's degrees from Harvard University and New York University.

"Additionally, conceptualizing sexual and reproductive health services as either women's or men's only further serves to marginalize transgender and gender-expansive individuals," he said.

Bichelman also brought up the decision by the U.S. Supreme Court to overturn the constitutional right to an abortion. SCOTUS's decision in Dobbs v. Jackson Women's Health essentially reversed Roe v. Wade, the court's 50-year-old decision that guaranteed a woman's right to obtain an abortion.

"The map of U.S. states where abortion services are not protected largely reflects the correlation between poor—or nonexistent—sexual education and the hostility toward individuals who need an abortion," he added.

In the majority decision, Justice Samuel Alito wrote, "The Constitution does not confer a right to abortion," and added that states have the right to outlaw procedures deemed "gruesome and barbaric."

As of June 2022, 61 percent of U.S. adults thought abortion should be legal in all or most cases, while 37 percent believed abortion should be illegal, according to data from Pew Research Center.

There are a lot of factors at play, Gilbert explained, which can make it difficult for individuals to achieve good sexual health. But why is that so important?

Sexual health isn't a niche issue. The topic is central to overall health and well-being, said Jennifer Rogers, M.P.H., a senior program area director and senior research scholar at Child Trends in Bethesda, Maryland.

"It's often pushed to the side and only dealt with if there is a problem," she said. "It's hard to get people to recognize sexual healthcare should be routine, and it should be at the forefront of healthcare."

If sexual health is ignored, it can have serious consequences on people's physical, mental, emotional and financial health.

Sexual and reproductive health services can make an essential contribution to individual and population health in multiple ways, including:

• A lack of understanding about body autonomy, consent or sexual coercion can lead to life-damaging situations. For example, sexual and relationship violence rates are high.
• Despite cervical screening and human papillomavirus (HPV) vaccination programs, cervical cancer is still prevalent.
• If left untreated, sexually transmitted diseases (STDs) can lead to serious health consequences, such as infertility.
• Unwanted pregnancies can affect the mental, emotional, physical and financial health of people who give birth, as well as their children and families.

The toll of poor sexual health on society and the economy is another compelling reason why good sexual health should be a priority. Direct medical costs for sexually transmitted infections (STIs) acquired in 2018 alone cost the American healthcare system nearly $16 billion, according to the Centers for Disease Control and Prevention (CDC).

Part of this figure is due to the fact new human immunodeficiency virus (HIV) infections cost $13.7 billion and new HPV infections cost $755 million in direct lifetime medical expenses.

However, the rates of STDs and STIs are rising, with the majority occurring among young people ages 15 to 24 who should arguably be receiving more comprehensive sex education.

The Guttmacher Institute reported in February 2022 that young people are not getting access to medically accurate, inclusive, and age- and culturally-appropriate information so they can make informed decisions about sexual behavior, relationships and reproductive choices.

The institute’s fact sheet stated:

"About half of adolescents (53 percent of females and 54 percent of males) reported in 2015 to 2019 that they had received sex education that meets the minimum standard articulated in Healthy People 2030 [an initiative promoted by the U.S. Department of Health and Human Services]. Among teens reporting penile-vaginal intercourse, fewer than half (43 percent of females and 47 percent of males) received this instruction before they first had sex."

"It's no surprise to me that we have issues around STIs, unintended pregnancies and problems with sexual violence, because a lot of young people are not getting the sexuality and relationship education they need," Gilbert said.

One of the challenges with sex education is the lack of guidance and policy implementation at the federal level, according to Michelle Slaybaugh, the director of social impact and strategic communications at Washington, D.C.-based SIECUS: Sex Ed for Social Change (formerly the Sexual Information and Education Council of the United States). There is a varying patchwork of state laws that determine what, how and if sex education is being taught.

"When it comes to education, policy decisions have largely been left to local control," she said. "The exception is when the policy at the federal level is necessary to ensure equity in learning—for example, anti-segregation/discrimination."

The problem is that this leads to a huge gap in sex ed, and the quality of education young people receive is largely dependent on their ZIP code.

A significant change that could make a difference would be to pass legislation in the form of the Real Education and Access for Healthy Youth Act (REAHYA), Slaybaugh said.

"At both the federal and state level, the egregious attacks on safe spaces for all youth, as well as vast learning outcomes, means it is time to pass another federal piece of legislation that would ensure all young people, including LGBTQIA+ young people, are protected, included and respected," she said.

Passing and enacting the Real Education and Access for Healthy Youth Act could create the first federal funding stream for comprehensive sex education and eliminate abstinence-only-until-marriage program funding.

Slaybaugh said the promotion of sex education legislation in states that are currently without any policies would be key to ensuring protections at both levels of government.

Sex education is one piece of the puzzle when it comes to promoting good sexual health. If you look at where the highest rates of STIs and other significant sexual health problems are occurring on a map, there's often a link between those locations and the people who don't have access to affordable healthcare.

Access to preventive services

"We've made progress because of the Affordable Care Act," Rogers said. "There have been significant improvements in coverage, but we still have 8 percent of the population who have no form of health insurance, which translates into 26 million people."

A significant number of people are not receiving the recommended preventive services, such as STI screenings, HPV vaccines and HIV testing.

Sexually active women ages 24 and younger should undergo chlamydia and gonorrhea screenings annually, Gilbert said, but statistics show only about half of them do so. The problem, she explained, is no universal access to comprehensive, inclusive, medically accurate sexual health information and education, and not everyone has access to affordable, high-quality sexual health services.

"Because it's an uneven patchwork across the U.S., we're not providing people an equal opportunity to enjoy good sexual health," she said.

Equipping people with sexual health information and skills

Society has to recognize it's about more than telling people what to do and giving them the facts, according to Gilbert. It's not enough just to say to people, 'Here are the facts about condoms, and here are the facts about STI testing.'

It's about educating people and giving them the skills they need. That could mean talking openly with their partners about safer sex and consent, having conversations with healthcare providers about their sexual history and practices, or teaching them how to build positive relationships.

Providers need to be inclusive and accepting

Another critical piece to the puzzle is access to healthcare providers you trust, who will provide inclusive, nonjudgmental healthcare to all patients, according to Gilbert. This includes patients of different gender identities, sexual orientations, races/ethnicities, body types, ages, physical and mental abilities, and income levels.

"People need to be able to build rapport and trust with their healthcare providers if we expect them to have open and honest conversations about their sex lives," she explained.

If not, patients may not actually access the sexual health services they need.

Start sexual health conversations young

Historically, there is a stigma surrounding sexual health and having conversations about the topic.

"We need to start conversations at a young age, talking to children about things like self-esteem and consent," Gilbert said, adding that the negative stigma surrounding sexual health is beginning to shift and that there are examples of culture change.

"There are some positive forces out there in the media space now in terms of social media influencing others who are using their power to talk about sexual health," Rogers said.

Tying to encourage the dialogue and role modeling more, and exploring these issues through popular channels, is vital in promoting good sexual health, she added.

Despite the remaining inequalities and downfalls in providing sexual health services, it's not all doom and gloom. As well as a shift in culture change, there have been positive sexual health trends across the past decade.

Gilbert highlighted the fact that there are fewer unintended pregnancies, reduced HIV infections and more women are using contraception during sex.

"We know from our research with the public through focus groups and surveys that most people are interested in having good sexual health," she said. "We're in a place where lots of people want good sexual health, physically and emotionally. There's a lot of room for improvement and a lot we can do as a society to enable people to achieve it."

The next installment in our State of Sexual Health series will take an in-depth look at the state of sex education in the U.S. Why is there such a disparity in the quality of sex ed across states? How has it changed in recent decades—for better or worse? How does quality sex ed equate to high levels of sexual health? And how popular is the concept of sex ed in schools?