Rethinking How to Teach People About Healthy Sex

Conventional wisdom says cutting resources for sexually transmitted diseases (STD) testing and treatment is the wrong position to take—especially when cases of syphilis and antibiotic-resistant gonorrhea are on the rise, but recent evidence suggests that the alternatives to traditional clinics may be more effective.

As the country's laboratory of systemic health care reform, Massachusetts is where sexual health care providers can look to see how its public health services for sexually transmitted diseases are faring. And one year after the state closed the last of its STD clinics due to budget cuts, testing for major STDs is actually up by 12 percent.

Kevin Cranston, director of the Massachusetts Bureau of Infectious Disease, says that he would not "recommend clinic closure as a first response" to limited financial resources, but public health officials are using this as an opportunity to integrate sexual health services into primary care.

And in fact, the clinic closings are part of a larger trend that has been happening over the last decade, which has seen a 10 percent decline in these kinds of STD-specific facilities.

Follow the money

Even before state funding for sexual health care became as tight as it is today, the Center for Disease Control’s (CDC) STD prevention unit developed an initiative called Program Collaboration and Service Integration, or PCSI (pronounced, charmingly, “pixie”). PCSI’s focus is to treat patients with multiple conditions through a coordinated approach. This also happens to be a perfect response to what the CDC calls “limited and dwindling federal resources for core program activities.”

PCSI targets “syndemics,” which are diseases with associated risk factors like shared needles or sex with multiple partners. The idea is to retreat from the siloed clinic system, which has led to a division of services. For example, going for HIV screenings every 6 months doesn't mean that a patient would ever be tested for chlamydia, even though the latter increases susceptibility to the former. Nor would a patient necessarily receive counseling information on contraceptive options that don’t also serve as STD barriers.

But Massachusetts has managed the decline of its STD clinics gracefully, combining STD with HIV and hepatitis services in fourteen Integrated Counseling, Testing, and Referral sites. And with coordinated services comes eligibility for additional funding: Title X funds, the federal allocation to family planning clinics initiated by the Reagan administration, are not available to clinics that offer strictly STD care, but they are granted to comprehensive family planning clinics.

Title X accounts for about 12 percent of public expenditures for family planning, and combined with Medicaid, about 85 percent. If STD services are rolled into family planning facilities, they become eligible to receive federal support. In turn, Title X requires that clinics offer the full range of STD tests.

Funding is also limited by gender. A 2002 paper found that "government funding may be earmarked for or otherwise limited to female services," citing a case where Medicaid refused to cover partner antibiotics for women with chlamydia if their partners were not also covered by Medicaid—but treating both partners is an essential part of avoiding repeat infections.

Shortcomings of coordinated care

Although tuberculosis is only “syndemically” related to STDs—HIV patients are at the highest risk for tuberculosis, and other STDs can increase the risk of contracting HIV—it’s covered in coordinated care, while unintended pregnancy remains conspicuously absent from PCSI's scope.

This is a problem because while studies have found that women who use hormonal birth control are less likely to use condoms, the need for “dual protection” against STDS and pregnancy is still a reality.

Dr. Shobha S. Krishnan, a family physician and gynecologist at Columbia University and founder and president of the Global Initiative Against HPV and Cervical Cancer (HPV stands for human papillomavirus, an extremely common STD that can cause cervical cancer in women), explains the dual protection dilemma, saying that a variety of contraceptives, some of which are more effective than condoms, are available, while “condoms are the only thing we have to prevent STDs, and even that is not 100 percent.”

Krishnan advocates for improved education and condom negotiating skills for women who have sex with men. She adds that despite assumptions people make about condoms reducing sexual pleasure, a major study found that adults using condoms are “just as likely to rate the sexual experience positively” as those who do not use condoms.

The specialized clinic system might become a casualty of health care reform (if it survives the 112th Congress), or of tight budgets even if reform stays afloat. “The relevant role of dedicated clinics is a hot issue on the table,” Cranston says, and even if the clinic system has grown archaic in a primary care-focused era, “A clinician who works in an STD clinic really knows how to diagnose STDs.”

Confidence that doctors can recognize syphilis, for example, which can be asymptomatic for long periods of time, is low; with 300 cases in Massachusetts annually, years may go by in which a primary care doctor never sees a case of infection. To prepare for more patients with STDs in the primary care setting, the Massachusetts public health department trained more than 3,000 providers in an advanced STD class, and the least squeamish participated in a 3-day hands-on session. Ultimately, Cranston says, there is a “balancing act between preserving specialized care and making sure that these sometimes uncommon infections are identified.”

Who is affected?

Disparities in access to health care are based on more than insurance. Language barriers and transportation to doctor’s offices are among the many factors that impede care. The Deparment of Health & Human Services reports that “some ethnic minorities, as well as low-income families of whatever race or ethnicity, tend to be in poorer health than other Americans.”

Julia Hurley, media relations manager for the MA Department of Public Health, explains that even with an overall increase for STD testing, it remains “difficult to determine if certain populations are not being served as well.” Whether the people in most need of public testing services are receiving testing at other facilities is unknown, but the statewide 12 percent increase is encouraging nonetheless. And more than 70 percent of state residents now have private insurance, which means that private doctors have likely picked up much of the slack the stressed clinic system has left.

An integrated care approach is in keeping with the Obama administration’s funding emphasis on science-based sex education in lieu of abstinence-only education, and can also play out on college campuses. A survey conducted by condom manufacturer Trojan found that 93 percent of college campuses offered STD testing, and 24 percent offered free testing.  Yale University, which Trojan ranked number one, offers free testing to all students, whether or not they opt in to the school’s health plan.

Another demographic that needs a place to go: men. Family planning has historically focused on women’s needs, and men account for only 8 percent of patients at such clinics. Men also make up more than half of STD clinic clients, which means that they stand to lose the most in a post-clinic world. Even with a “growing proportion of men at family planning services,” the number of women clients is rising faster than the number of men, explains Cranston.

Effective outreach to men to keep them getting tested is key. Krishnan says men “shouldn’t think that if the STD clinic is closed there is no place left to go,” and adds, “Men who are accustomed to visiting STD clinics for their sexual health needs should be made aware that family planning clinics (particularly those that receive Title X funding) also offer similar services.”

There is also, of course, a sexually active population for which contraception is not a concern, including gay men, lesbians, and seniors. The average 25 percent rate on condom use in the United States declines steadily with age, and only 6 percent of individuals over 60 use condoms.

Men who have sex with men account for more than half of new HIV infections in the United States, and 63 percent of new syphilis cases, according to CDC data. In staggering disproportion, gay men are 44 times more likely than other men and 40 times more likely than women to become infected with HIV, and 46 times more likely than other men and 71 times more likely than women to become infected with syphilis. The CDC explains part of this disparity as resulting from homophobia that discourages testing and treatment, and also “limited access to prevention services.” Improving outreach and the “condom negotiation skills” Krishnan recommends are part of the CDC’s plan to reduce infection rates among gay men.

Meanwhile, evidence that women who have sex with women are at risk for STDs is relatively new. A Guttmacher Institute study surveyed lesbian and bisexual women and found that their responses “reflected woeful misinformation about the risk of STDs, particularly the perception that same-sex behavior carries no risk.” When pregnancy prevention is not of concern, the risks of sex are sometimes unknown or dismissed altogether.

Globally, about half of new HIV infections occur in young people ages 15 to 24. Outreach to young people is essential.

College campuses pose a special case, and health advocates are working to create culture-changing programs. Emily Skinner, Health Education Coordinator at Bowdoin, points to several prevalent misconceptions on the liberal arts campus. “There is misinformation in terms of STDs,” she explains, noting that some people look for “big bumps” as an indicator that their partners may have an infection, but this is an ineffective substitute for open and honest communication.

“Because we’re in what feels like a closed bubble in a small town in Maine, it doesn’t mean that people here at Bowdoin aren’t having sex with people outside of this community.” Particularly for gay men and women, she says, the student body is limited in terms of dating, so people’s sex lives aren’t always as obvious—or safe—as they may seem.

Skinner, who coordinates a group of 25 students, is optimistic about the ability to implement safer, healthier practices at colleges. “College campuses are a specific kind of environment, so the overall culture can really shift. Change is really possible,” she said. The primary objective is getting accurate information out to students, and getting them to recognize that STDs are a real problem—even for those on birth control, who Skinner says often fail to grasp the significance of the need for dual protection—and then moving from intellectual understanding to social practices, which is more easily achieved in a small student body than a larger population.

Sara Rubin is a staff writer at Campus Progress.

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