ASHA publishes Position Statements on emerging issues in health policy as part of its advocacy work. These statements are intended to reflect the perspective of Americans affected by sexually transmitted infections and outline the key reasoning and evidence behind ASHA’s recommendations.
The truth is that sexually transmitted infections (also called sexually transmitted diseases or STDs) are an enormous problem in the United States, especially for adolescents and young adults. April is STD Awareness Month and a good time to talk about this uncomfortable but important issue.
Each year, one of every four sexually active teens will get a sexually transmitted infection. By age 25, half of all youth will have acquired one or more infections. The number of new cases of sexually transmitted infections is more than 9 million in people under the age of 25 each year.
Even worse, many of these are silent infections without clinical symptoms. Despite the absence of symptoms, long-term damage such as infertility can occur if infections are not diagnosed and treated. And many youth (and adults) assume that they would know if they or their partner had an infection.
The best way to be diagnosed with a sexually transmitted infection is to be tested for it. Great strides have been made in recent years in development of reliable tests for many STIs using patient specimens that can be obtained easily.
Most youth assume they are being tested for “all” STIs when they go to their doctor. In fact, testing rarely occurs even for the more common infections, even though health care guidelines and medical associations recommend testing be done routinely.
Communication is an important issue in obtaining testing. Just as adults are reluctant to discuss sexual health issues with youth, youth are also reluctant to discuss this with adults, including health care providers. Young people need the necessary information to know what and how to ask for tests for STIs.
Testing, treatment and communication are all important in addressing the STI epidemic. But they are not sufficient. Knowledge and prevention are essential also.
Of great concern is the politicization of sexual health information, which makes it difficult to be certain about the accuracy and context of messages. Groups that attack the effectiveness of condoms for preventing STIs, for example, hope this will encourage abstinence. Instead, it leaves our young people at risk.
The simple fact is that condoms, used correctly and consistently, provide substantial protection against many STIs, including HIV infection. They do not protect against all STIs or under all circumstances, but for a person who chooses to be sexually active, using a condom is much better than not using one.
The stigma attached to many diseases such as cancer a generation ago has disappeared. But sexual behaviors and STIs remain highly stigmatized in our country. This stigma inhibits discussion with parents, partners, and health care providers and discourages youth from seeking needed health care. Stigma is a significant barrier to prevention. Social attitudes that reinforce this shame do not reduce frequency of sexual contact but they do reduce prevention behaviors and increase risk of infection.
It is biologically certain that our children will grow up and become sexually mature. STIs have been with humans for centuries. Information, education, supportive social environments, and sound, well-funded public health programs are effective at reducing risks of infection. Our failure to address these issues leaves our youth vulnerable. We as a nation need to review the lessons of the past and make effective control of STIs a high priority.
James Allen, MD, MPH
Former President and CEO, ASHA
Therefore, we are particularly concerned by the business practices and the current working conditions in the adult film industry and the lack of government oversight to protect workers. Workers are required in the course of their employment to engage in oral, vaginal and anal sex acts, often with multiple partners, within short periods of time, and without barrier protection. Workers may be regularly exposed to sexually transmitted infections (STIs) including HIV and the subsequent life-threatening and serious adverse reproductive health sequelae.
The very nature of the adult film industry exposes workers to great risk of infectious diseases. Abstinence, limiting the number of sex partners, condoms and education which are traditionally considered central to reducing the risk of STIs including HIV are not options available to workers in this industry. An HIV outbreak that occurred in 2004 demonstrates the serious health risk to workers in this industry. A performer who had tested regularly for HIV but who was working without condoms transmitted HIV to three others in the workplace.
It is essential that workers in the adult film industry use condoms and that those who produce adult films are held accountable, as are employers in any other industry, for maintaining a safe workplace that ensures the health and safety of those they employ. Just as personal protective equipment such as gloves for health care workers or goggles or masks are used to reduce the risk of injury or acquiring an infectious disease, condoms should be mandatory to protect workers in this industry.
The Occupational Safety and Health Administration (OSHA) is responsible for setting workplace standards and the enforcement of those standards. California OSHA has created standards specific to protecting adult film workers. Unfortunately, the standards have been ignored by the industry and enforcement is inadequate.
Increased regulation of the adult film industry has broad public health benefits that can not be overstated. Protecting workers from STIs also reduces harm to their families and limits spread to others in the community. Mandatory use of condoms, routine HIV and STI testing, and hepatitis and HPV vaccination would greatly enhance the health and safety of those who work in this industry.
This is not an inconsequential industry. It is estimated that the adult film industry earns an estimated $13 billion in gross revenues each year. It is appropriate and imperative that health and safety standards are applied and fully enforced to protect workers in this industry.
The Centers for Disease Control and Prevention (CDC) currently estimates that about 250,000 – 300,000 people in the United States are infected yet unaware of their human immunodeficiency virus (HIV) status. Since HIV infection often takes a decade to develop into acquired immunodeficiency syndrome (AIDS), people living with HIV who remain undiagnosed risk spreading HIV without their knowledge for many years.
For two decades, ASHA has been an advocate of broader availability and use of HIV tests to facilitate more rapid diagnosis and treatment for those infected and to prevent further transmission in the community. Unfortunately, many people avoid or are unable to get tested in clinics or a physician’s office for a variety of reasons, including lack of access to health care services, distrust of the healthcare system, and the stigma of discovery.
We support CDC’s goals to implement new models for diagnosing HIV infection outside medical settings and to prevent new infections by working with persons diagnosed with HIV and their partners. A greater set of options, including over-the-counter, home-use, rapid HIV tests, may increase the number of people willing to be tested.
Clearly, it would be preferable for all individuals seeking HIV testing to receive pre- and post-test counseling in a supportive environment. However, the availability of these home-use tests could be a very powerful strategy to reduce barriers to testing and increase early detection of HIV infection.
It is imperative that those who test negative fully understand the implications of their test results, and those who test positive to have immediate access to counseling services and referral to quality medical care.
ASHA urges states to adopt mandates requiring comprehensive, developmentally appropriate, and medically accurate sexuality education programs that:
- are based on rigorous, peer reviewed published research;
- show promise for delaying the onset of sexual activity and a reduction in sexual behavior that puts adolescents at risk for contracting sexually transmitted diseases, including HIV, and for becoming pregnant;
- include both factual information and skills building lessons related to reproductive biology, pregnancy, sexual transmission of diseases, sexual abstinence, sexual responsibility, communication, decision-making, and condom use;
- include ample involvement of parents, health professionals, and other concerned community members in the development of the program;
- include an ongoing evaluation component; and
- are part of an overall health education program.
The surest way to avoid transmission of sexually transmitted diseases (STDs) is to abstain from sexual intercourse or to be in a long-term mutually monogamous relationship with a partner who has been tested and is not infected with any sexually transmitted infections.
For millions of people who have previously acquired a viral sexually transmitted infection, however, effective measures must be taken to protect any future partners from infection. In the United States, there are 50 million people estimated to be infected with herpes simplex virus (HSV), 20 million people estimated to be infected with human papillomavirus (HPV), and 850,000-950,000 people estimated to be infected with human immunodeficiency virus (HIV), the virus that causes AIDS.
Non-viral STDs also remain important public health challenges. Two of these diseases, chlamydia and gonorrhea, are regularly among the leading reportable infectious diseases in the United States.
Many people engage in sexual behaviors that place them at risk for acquiring STDs. Sexually active people must have access to information and options to reduce their risk. The male latex condom effectively reduces the risk of STD transmission when used correctly and consistently.
Numerous studies have shown that latex condoms, when used consistently and correctly, are highly effective in preventing the transmission of HIV, the virus that causes AIDS. Latex condoms, when used consistently and correctly, have been shown to reduce the risk of transmission of gonorrhea, chlamydia, and trichomoniasis.
Correct and consistent use of male latex condoms can reduce the risk of transmitting genital herpes, syphilis, and chancroid only when the infected area or site of potential exposure is covered and protected.
While the effect of male latex condoms in preventing transmission of human papillomavirus is not known, studies have shown that condom use has been associated with lower rates of cervical cancer in women, an HPV-associated disease.
Therefore, correct and consistent use of male latex condoms can reduce, but not eliminate, the risk of transmission for these infections.
The complexity of this problem is exacerbated by our national discomfort in discussing both race and the stigma associated with STDs. Yet the data suggest action is needed: African American adolescents and young adults have STD rates that are more than 20 times higher than those in white adolescents.
Comprehensive chlamydia screening programs for women thus far show higher rates for minority women than for white women.
Non-white women are nearly three times as likely as white women to be hospitalized with acute Pelvic Inflammatory Disease (PID) and more than two times as likely to be hospitalized with chronic PID.
African American women are nearly three times more likely to die of cervical cancer than white women.
Reported cases of primary and secondary syphilis are about three times higher for Hispanics than for non-Hispanic whites.
- Involve all racial/ethnic communities in STD prevention. including planning, developing, implementing and evaluating programs.
- Develop culturally competent/sensitive and linguistically appropriate behavioral interventions for STD and HIV prevention in minority communities.
- Integrate STD prevention with other relevant programs through which the affected population has been successfully reached.
- Identify methods to overcome potential reporting bias, including increased and improved enforcement of mandatory reporting requirements by private providers to assist in alleviating reporting bias.
The American Sexual Health Association, recognizing that all people are sexual beings from birth to death, asserts that all members of society have certain rights and consequent responsibilities:
Adolescents have rights to balanced, accurate, and realistic sex education, access to confidential sexual health services, and a secure stake in the future. Respect and should be included in shaping programs and policies that affect their well-being.
Society has the responsibility to provide young people with the tools needed to safeguard their sexual health and protect them from unwanted and coerced sexual activity
Adolescents have the responsibility to protect themselves from bearing children too early and from acquiring sexually transmitted infections, including HIV.
In the area of childhood and adult immunization
Faith-based organizations and communities often serve as the primary caregivers of our nation’s youth as well as the elderly. Through pre-school, after-school and adult-care programs, they have a unique opportunity to ensure that families have access to information about vaccine-preventable diseases, as well as access to the vaccines themselves.
In the area of adolescent health
Faith-based organizations and communities have historically played a critical role in the socialization and development of their members. In an era where adolescents are increasingly more vulnerable to health-related threats and challenges, these organizations can play a critical role in educating their membership about the biological and social factors that place youth at greater risk than those in other age groups.
In the area of sexually transmitted infections (STIs)
Faith-based organizations and communities can be a powerful force in the prevention of sexually transmitted infections including HIV, by creating an atmosphere which reduces the stigma surrounding these infections and encourages the acquisition of information and skills necessary to prevent their transmission.
Public health officials should seek input from faith-based organizations when deciding health policy. Agencies responsible for public health should collaborate with faith-based organizations when conducting community needs assessments and implementing health education and prevention programs. Including clergy and representatives of faith-based organization on boards of directors, community planning initiatives and on governing bodies can be useful. Researchers should include faith-based organizations in efforts to promote and conduct health research.