Public Health Reports Webinar on Understanding Sexual Health: Overview

1. Public Health Reports Webinar on Understanding Sexual Health: Overview March 12, 2013 1:00 PM - 2:00 PM EDT

2. Public Health Reports Webinar on Understanding Sexual Health: Overview Mary Beth Bigley, Dr.P.H., M.S.N., A.N.P. Acting Editor, Public Health Reports Office of the Surgeon General

3. Public Health Reports Webinar on Understanding Sexual Health: Overview John M. Douglas, Jr, M.D.. Chief Medical Officer National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention

4. Sexual Health: Surgeon General’s Call to Action • Focused on the need to promote sexual health and responsible sexual behavior across the lifespan • Essential component of overall individual health • Has major impact on overall health of communities • National dialogue at all levels critical in improving population health • Primary goal to stimulate respectful, thoughtful, and mature discussion in our communities and in our home about sexuality.

5. Sexual Health in the U.S.: Why Now? • High population burden of adverse outcomes related to sexual behavior • HIV/STD • Estimated 1.1 million living with HIV, 50,000 new infections/year • 19.7 million STI each year—almost half among persons 15-24 • 25% adolescent F infected with at least one STD • Unintended/teen pregnancy • Nearly 50% of all pregnancies in the U.S. are unintended • U.S. with one of highest teen birth rates of industrialized nations • Sexual violence • Annual estimates: 1. 3 million F raped, 6.7 m F and 6 m M with other sexual violence victimization • Health equity/ disparities concern • African–Americans: HIV rates 8 to 20x Whites • MSM: 40-50x higher HIV rates than other males • High economic burden—estimated annual costs • STD/HIV: $17 billion • Teen childbearing: $11 billion • Rape/other sexual assault $12 billion

7. What is Sexual Health? • WHO definition (2006) • state of physical, emotional, mental, and social well-being related to sexuality • not merely absence of disease, dysfunction, or infirmity. • requires a positive and respectful approach to sexual relationships, as well as possibility of having pleasurable & safe sexual experiences, free of coercion, discrimination, and violence. • for sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled.

8. CDC/HRSA Advisory Committee Definition of Sexual Health: A Public Health Perspective Douglas JM, Fenton K. Understanding sexual health and its role in more effective prevention programs. Public Health Reports 2013 Recommended by the CDC-HRSA Advisory Committee on HIV, STD, and Viral Hepatitis Prevention and Treatment, May 2012 (CHAC Minutes: http://www.cdc.gov/maso/facm/pdfs/CHACHSPT/20120508_CHAC.pdf) • Sexual health is a state of wellbeing in relation to sexuality across the lifespan that involves physical, emotional, mental, social, and spiritual dimensions. • Sexual health is an inextricable element of human health and is based on a positive, equitable, and respectful approach to sexuality, relationships, and reproduction, that is free of coercion, fear, discrimination, stigma, shame, and violence.  • It includes the ability to understand the benefits, risks, and responsibilities of sexual behavior; the prevention of disease and other adverse outcomes; and the possibility of fulfilling sexual relationships.  • Sexual health is impacted by socioeconomic and cultural contexts–including policies, practices, and services–that support healthy outcomes for individuals, families, and their communities.

9. Addressing Sexual Health Douglas JM, Fenton K. Understanding sexual health and its role in more effective prevention programs. Public Health Reports 2013 • Over past decade, increasing attention to addressing the concept of sexual health • Public health premise: sexual health promotion • great potential to complement traditional disease control and prevention efforts for a range of conditions (eg, HIV, STD, viral hepatitis, unintended pregnancy, sexual violence) • not to replace traditional efforts but to improve their acceptance and population impact

10. Sexual Health Framework: Emphasizing Health Promotion to Enhance Disease Control and Prevention Potential Benefits • Engage new and diverse partners • Normalize conversations • Reduce stigma, fear, and discrimination • Enhance the efficiency and effectiveness of prevention messaging and services Ivankovich et al. Considerations for national public health leadership in advancing sexual health. Public Health Reports 2013

11. Sexual Health: A National Priority • 2010—National HIV/AIDS Strategy • “Provides an opportunity for working together to advance a public health approach to sexual health that includes HIV prevention as one component” • 2011—Healthy People 2020 • “Reproductive and Sexual Health” is a leading health indicator • 2011—National Prevention Strategy • Vision: Working together to improve health and quality of life by moving from a focus on sickness and disease to one based on prevention & wellness • “Reproductive and Sexual Health” is one of seven priority areas

12. Public Health Reports Supplement on Sexual Health • Priority topics • Research • Surveillance • Program • Perspectives

13. Public Health Reports Supplement on Sexual Health • Research • Susan Kirby: Beginning a conversation on sexual health • Programs • Robert Nystrom: Shifting the paradigm in Oregon from teen pregnancy prevention to youth sexual health • Perspectives • Edward Hook: Sexual health education—frame-shifting and its challenges

14. Public Health ReportsMeet the Author! Live Webcast A Communication Framework for Sexual Health Susan D. Kirby, Dr.PH, MPH President, Kirby Marketing Solutions

15. Finding Common Communication Ground CDC recognizes the need to work with a wide variety of partners who hold differing viewpoints Communicating about sexual health may be difficult when you don’t share same values Communication is important and we need everyone to participate in the conversation Finding common communication ground is a starting place …

16. A set of beliefs and values developed over a lifetime of experiences Mental maps we use to navigate the world We fit new information into our frames We typically reject information that doesn’t fit our frame, not the frame Understanding is frame-based, not fact-based Effective communication can reframe understanding

17. Robert Wood Johnson Foundation’sSocial Determinants Research Republicans’ Frame • Life and health are journeys through unpredictable paths • People need opportunity to make good choices Your opportunity for health starts long before you need medical care. Health starts—long before illness—in our homes, schools and jobs. Democrats’ Frame Complex, interdependent social systems influence the health of people

18. Methodology • Environmental scan • Media • Frame development • Diverse external and internal stakeholders • Developed 4 frames, 30 messages • Interviews • 26 diverse community and health professionals • Revised messages • Online surveys • 240 public • 70 health professionals

19. Four Frames & Example Messages • Navigating a Journey/Choices Life is a series of choices, including sexual choices. Throughout their lives, all people need information and skills to make healthy sexual choices that reflect their own values and deeply held beliefs. • Health Promotion/Wellness Living a healthy lifestyle is important to good health, and this includes sexual health, too. It’s time we focused on promoting and encouraging the behaviors that improve the emotional, social, spiritual, and physical aspects of sexuality. • Working Together As a society, we have the responsibility to help all Americans make healthy sexual choices. • Fair Chance/Fair Opportunity All people need to have a fair chance to make informed choices about their sexual health.

20. Focus on Framing Results 46% Most accepted frames by general public and professional respondents

21. Making Messages Fit a Shared Frame Wellness Frame Messages • Moderates, Conservatives, Professionals • Liberals • Visit the article at Public Health Reports for the full message set on p.50 Journey/Choices Frame Messages • Public: Throughout life, we all make choices, including sexual choices. Along the way, all of us need the information, knowledge, and skills that will help us make sexual choices that protect us from the risks and dangers of unhealthy sexual activity. • All Professionals: Throughout life, we all make choices, including sexual choices. Along the way, Americans need the information, knowledge, and skills that will help them make sexual choices that protect their health and future partners.

22. What’s Next? • Findings developed in a positive direction, but there’s more we need to know • Needs replication in more contexts and in more real life “campaigns” • The field needs to know more about how specific health or social issues interact with frame preferences • We need to understand how to use framing to build broad consensus movements

23. Public Health ReportsMeet the Author! Live Webcast Shifting the Paradigm in Oregon from Teen Pregnancy Prevention to Youth Sexual Health Robert Nystrom Section Manager Adolescent, Genetics & Reproductive Health Oregon Public Health Division

24. History Oregon Youth Sexual Health Plan • 3rd decade of plans • 1994-2002 • Policy & systems • Minor consent • Sexuality education • School-Based Health Centers • Governor’s directive 2005 • Oregon Youth Sexual Health Partnership • Plan released in 2009

25. Plan Development Community Survey Youth Action Research Community Forums Use of Data Literature Reviews

26. Youth Action Research Youth Action Research Team

27. Five Overarching Goals • Youth use accurate information and well developed skills to make thoughtful choices about relationships • Sexual health inequities are eliminated • Rates of unintended teen pregnancy are reduced • Rates of sexually transmitted infection are reduced • Non-consensual sexual behaviors are reduced

28. Objectives 1. Infrastructure 2. Policy 3. Health Inequities 4. Youth Development 5. Education for Youth and Families 6. Services for Youth and Families 7. Data 8. Assurances

29. Accomplishments - Outputs • Expansion of clinical services • Revised/strengthened K-12 comprehensive sexuality education statute • Teacher training on LGBTQ inclusiveness • AMCHP/ASTHO learning collaborative • Research series on sexual health of disenfranchised youth • Implemented/expanded community interventions & programs program

30. Making it work for Oregon’s youth…

31. Implications - Going Forward National Oregon’s experience serves as a model for other states to shift from a risk-problem focused framework to a more PYD framework that promotes sexual health Importance of authentic community & youth engagement and interest-based problem solving Oregon Evaluating plans early efforts Expand state capacity to use Youth Action Research (YAR) or to apply it to other public health topics Expand focus on addressing disparities & inclusiveness

32. Public Health ReportsMeet the Author! Live Webcast Sexual Health Education: Frame Shifting and Its Challenges Edward W. Hook III M.D. Professor of Medicine, Epidemiology, and Microbiology University of Alabama at Birmingham, Alabama/North Carolina STD/HIV Prevention Training Center And Jefferson County Department of Health Birmingham Alabama

33. Historical Partners in U.S. STD Prevention Brandt, AM. No Magic Bullet, Oxford Univ Press, 1985. American Society for Sanitary and Moral Prophylaxis (1905) – (Coalition of physicians, social hygienists, charity groups, moral reformer churches) American Social Hygiene Association (1913) Armed Forces U.S. Public Health Services

34. Conventional Wisdom Regarding STIs STIs are the result of inappropriate behavior People with STIs will know they have them Efforts to control STIs should focus on women Sex (and STIs) is not an appropriate topic for conversation

35. Stigma Intolerance

36. Consequences of STI-Related Stigma Personal (Individual) • Delays in using or seeking preventative health care • Condoms • Vaccines • Screening • Delays in seeking care for perceived problems • Ineffective partner notification Provider • Hesitancy in seeking relevant information • Differential testing • Changes to provider-client interactions Population • Guilt by association • Differential Care • Profiling

37. Framing – influenced by context; anticipated to have selective influence on perception, encouraging certain interpretation, discouragement, others (Wikipedia) A sexual health framework shifts the approach from a more traditional loss frame approach to a gain frame • Gain frame – Emphasizes positives, benefits • Loss frame – Emphasizes risks, potential harm, potentially fueling shame and stigma

38. Self-Reflective Questions on Sexual Health • Have you ever hesitated to take a sexual history? • Have you ever hesitated to test for STIs because you worry that a client may find it troublesome or insulting? • Have you ever apologized for making a STI diagnosis?

39. Loss Frame/Gain Frame ExamplesSexual History Loss Frame Partner Type Have you ever had homosexual sex? Sites of exposure Have you had oral or rectal sex , or just regular sex? Gain Frame Partner Type Are your partners men, women or both? Sites of exposure When you have sex, what sites are exposed- oral, rectal or genital?

40. Health Education Opportunities Derived From a Sexual Health Approach Patients (Empowering) Life Course Perspective Reduces Consequences of Perceived Stigma Broadly Encourages Preventative Health Care (Women AND Men) Vaccines Screening Providers (Permissive) Life Course Perspective Reduces Consequences of Perceived Stigma Efficiency- Addresses Existing Redundancy

41. Questions?

42. Closing For more information about PHR: www.publichealthreports.org