America’s puritanical roots are rarely more apparent than in the nation’s sexual health discourse. Comprehensive sexuality education is often regarded with suspicion; people living with human immunodeficiency virus (HIV) often face stigma and discrimination; and sex work is heavily criminalized. As a nation, we are far from embodying the World Health Organization’s ideal of approaching sexual health and sexuality with a positive, respectful and affirming approach that enables people to have safe, pleasurable sexual experiences free of coercion, discrimination and violence. Although many sexual decisions are made privately, the larger social and political contexts implicitly and explicitly affect individual decision-making. To achieve a freer and healthier society, sexual health policy should not impede individuals’ ability to decide how to engage (or not engage) in sexual activity and how to reduce the risk of undesirable outcomes.
Reframing the way American approaches sex, sexuality and sexual health cannot be accomplished solely with policy. Normalizing conversations about sex and sexuality can decrease stigma and provide opportunities to educate people about sexual health, as those who feel shame around seeking sexual healthcare are less likely to take actions that improve or protect their health. Policies that can support this more inclusive, stigma-free and accessible vision of sexual health, pleasure and freedom include comprehensive sexuality education; access to contraceptives and family planning information; equal rights for people of all sexual and gender identities; and wider access to other sexual health services.
Sexual Health Education
Educating people about the spectrum of sexuality and the specifics of sexual health is one way to empower individuals to manage their sexual health and risk while also reducing stigma. This starts with adolescents. Comprehensive sexuality education, which consists of age-appropriate, scientifically accurate information on human development, anatomy, reproductive health, contraceptives, sexually transmitted infections (STIs) and more, has been shown to decrease unintended pregnancy and delay the first time young people have sex. Additionally, comprehensive sexuality education gives young people the tools and knowledge they need to make informed choices about their sexual health going into adulthood. State and local governments and boards of education are the primary arbiters of curriculums, meaning that implementing comprehensive sexuality education requires buy-in from these governing bodies and sexual health curriculums vary widely. Although comprehensive sexuality education is the ideal curriculum to promote sexual health, the reality is that many jurisdictions are moving further away from implementing such standards. Though there are some locales where it is unlikely that mandatory comprehensive sexuality education standards will exist, scientifically and medically accurate information in all sexual health curriculums is vital to the nation’s health.
STI Testing and Prevention
In 2020, the United States saw 1.6 million cases of chlamydia, 677,769 cases of gonorrhea and 136,093 cases of syphilis. Furthermore, the estimated direct, lifetime medical costs of STIs in 2018 was $16 billion. Nevertheless, access to STI testing is limited, especially for marginalized populations. Many STI clinics have closed permanently, and others have cut budgets, laid off staff, reduced clinic hours and increased patient co-pays, creating barriers to STI testing. Increasing and expanding federal funding, including Title X, for community health centers and STI clinics is one way to increase access to testing, especially for uninsured or low-income populations.
While diagnosing STIs is important, preventing them from occurring in the first place is ideal. Pre-exposure prophylaxis (PrEP) is a pill or injection that reduces the risk of acquiring HIV by up to 99 percent when used as directed. Unfortunately, the Centers for Disease Control and Prevention (CDC) reports that in 2020, only 25 percent of people who could potentially benefit from PrEP had been prescribed the medication. Similarly, after HIV exposure, post-exposure prophylaxis (PEP) can be prescribed within the first 72 hours. Studies show that PEP is underutilized for non-occupational HIV exposures, with one meta-analysis finding that only about five percent of men who have sex with men (MSM) had previously used PEP. How much of this is due to access versus awareness is unclear, although it has been estimated that about 60 percent of MSM are aware of PEP, and 68 percent of MSM who were aware of PEP thought they would know how to get a prescription for it, but only 40 percent of MSM who were aware of PEP knew that it must be taken within 72 hours of exposure. Thus, education about these medications’ availability and optimal timing is needed, as are policies to help expand access to PrEP and PEP.
In 2019, California passed legislation that allows pharmacists to prescribe a patient a 60-day prescription for PrEP every two years and a 28-day supply of PEP with no restrictions on frequency. Although patients are still required to see a doctor to obtain an ongoing PrEP prescription, allowing pharmacists to prescribe a starting supply—or a bridge supply should a patient’s prescription from a doctor expire—can decrease the barriers to starting or staying on PrEP. This legislation also decreases barriers to obtaining a PEP prescription within the indicated 72 hours after HIV exposure.
Cost can also be a barrier to PrEP. In 2021, both the U.S. House of Representatives and Senate introduced legislation known as the “PrEP Access and Coverage Act,” which would have ensured public and private insurers covered prescription drugs to prevent HIV and the associated medical care; however, the legislation did not gain traction. Resurrecting this legislation would help expand access to preventive care for HIV. When it comes to preventing other STIs, the Department of Health and Human Services’ Sexually Transmitted Infection National Strategic Plan also calls for accelerating research and considering scaling up post-exposure prophylaxis for syphilis and chlamydia using doxycycline.
Over-the-Counter Hormonal Contraceptives
On July 11, 2022, HRA Pharma submitted an application to the Food and Drug Administration (FDA) seeking approval to offer the first over-the-counter birth control pill in the United States. Making a birth control pill accessible over-the-counter and ensuring it is covered by public and private insurance would expand access and decrease barriers for those who wish to prevent pregnancy. In fact, a review of the literature on over-the-counter birth control pills found broad acceptability and interest. The same study found some evidence that people who obtained birth control pills over-the-counter were more likely to continue using the medication than people who obtained birth control pills by prescription.
Similarly, it is also important to ensure continued access and insurance coverage for emergency contraception, also called “the morning after” pill, which has been available over-the-counter since 2006. A recent systematic review comparing over-the-counter emergency contraceptive access to prescription access found that bringing emergency contraception over-the-counter resulted in no negative effects on sexual or reproductive health outcomes and broad support from users and providers. Furthermore, over-the-counter access to contraceptives helps maintain individual autonomy and allows people to have more control in the management of their sexual health.
Reframing how the United States approaches sex and sexuality is paramount to achieving better sexual health outcomes. And until we achieve broad acceptance that sex is an important part of the life experience and that it cannot be experienced fully without access to stigma-free, evidence-based sexual healthcare, STI rates will remain unconscionably high; our unintended pregnancy rate will remain significantly higher than those of many other developed countries; and people will not have the freedom to safely discover how sex and sexuality fit into their lives.