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There is a lot to like about a more positive approach towards sexuality, but a causal link between better sexual health and lower pregnancy and STI rates ultimately requires scientific evidence that goes beyond intuitive reasoning.

Written by Kees Rietjmeijer for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Editor's Note: This article is part of a series developed by the American Social Health Association (ASHA) in celebration of Sexual Health Month 2012 during September. RHRC will be publishing articles by ASHA all month, see all the articles here and visit ASHA online throughout September for updates.

Cross-posted with permission from the American Social Health Association (ASHA).

One evening, during the week of the 2001 International Society for STD Research meeting in Berlin, I met with a couple of colleagues for beers after the day's proceedings. We lamented the the narrow focus of many conferences was on disease and the lack of a broader sexuality framework. "It is time to put sex into STD prevention," one of my colleagues said. The comment was a bit wistful at the time and I don't think any of us could have foreseen that a decade later our field would be expressing so much more interest in sexuality and sexual health.

This has been accentuated by the Center for Disease Control's (CDC) recent efforts in developing a sexual health framework signalling an overall shift from disease prevention to health promotion. Credit goes to Dr. John Douglas, the Chief Medical Officer in the National Center for HIV, Hepatitis, STD and TB Prevention, who spearheaded this effort in the past three years and has created a broad coalition of stakeholders across the political and cultural spectrum to endorse a national strategy for sexual health.

Of course, the CDC's efforts did not arise in a vacuum and there have been a number of developments in the past decade that have fostered a broad-based discussion of sexual health. For me, one of the heralding events in the sexual health discourse was Dr. Amy Schalet's presentation on teen sexuality at the Jacksonville STD Prevention Conference in 2006. I have always been taken by Dr. Schalet's work  --  perhaps because as a chauvinist Dutchman (born and raised in Amsterdam) I liked her findings that a more liberal attitude towards sexuality among Dutch teens and their parents is associated with much lower rates of teen pregnancy and sexually transmitted infections (STIs) in the Netherlands compared to the U.S.  Her book: "Not Under My Roof" was published last year (a podcast interview with Dr. Schalet is available at this link).

However, association does not causation make. There is a lot to like about a more positive approach towards sexuality, but a causal link between better sexual health and lower pregnancy and STI rates ultimately requires scientific evidence that goes beyond intuitive reasoning. For example, it has been said that prevention messages that use a positive "gain" frame (i.e., focus on health) are more effective than messages that use a negative "loss" frame (i.e., focus on disease). Intuitively, this sounds good but what's the evidence? Not much, at least not in the field of prevention. The only study that analyzed the use of negative versus positive approaches for ongoing prevention with patients, actually found greater efficacy of the loss frame (or negative) messaging. This study formed the basis of the Partnership for Prevention intervention, which has been widely disseminated by the Diffusion of Effective Behavioral Interventions (DEBI) program. 

The point is that for a sexual health strategy to work, we must develop a sexual health science. For starters, we must determine what parameters best measure a person's sexual health. How are these parameters assessed and how are they related to the outcomes we are interested in: unintended pregnancy, STIs, sexual violence? Finally, can interventions be designed to influence these parameters that can be shown to improve sexual health and reduce negative outcomes?

If our forays into sexual health do not yield something more than what we are already doing now (i.e., testing and treating for STIs (including HIV), counsel our patients to reduce numbers of partners and increase condom use), our journey may have been interesting, but ultimately proven to be a detour.  

There is some good research at the interface of sexuality and STI/HIV/pregnancy prevention. One of the leaders in that field is Dr. Dennis Fortenberry (indeed: he of the "wistful" comment cited above) at Indiana University School of Medicine. He has become a frequent speaker at national and international STI conferences on sexual health topics. In one such presentation, he proposed a sexual health research paradigm that encompasses and links the full spectrum of sexual expression, including sexual abstinence, masturbation, and partnered sex. For example, he presented very interesting data on the linkage of masturbation and condom use (click here for a copy of this presentation). He has also proposed that in the context of sexual health, a much greater focus must be placed on pleasure and desire. Go read his blog entitled: "What is Sexual Health" posted at this link.

At the end of the day, I am still an STD prevention guy. And, while I am a strong believer in sexual health promotion, we need science not just good will to show that this approach is working.       

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