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The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior

July 9, 2001

III. The Public Health Problem

The United States faces a significant challenge related to the sexual health of its citizens. Concerns include: STDs; infertility and cancer resulting from STDs; HIV/AIDS; sexual abuse, coercion and prejudice; unintended pregnancy; and abortion.

Five of the ten most commonly reported infectious diseases in the U.S. are STDs; and, in 1995, STDs accounted for 87 percent of cases reported among those ten (Institute of Medicine [IOM], 1997). Nevertheless, public awareness regarding STDs is not widespread, nor is their disproportionate impact on women, adolescents, and racial and ethnic minorities well known:

  • Chlamydia infection is the most commonly reported STD. While reported rates of infection in women greatly exceed those in men, largely because screening programs have been primarily directed toward women, the rates for both women and men are probably similar. Chlamydia rates for women are highest among those aged 15-19 years and rates for Black and Hispanic women are also considerably higher than those for White women (IOM, 1997).

  • Rates for gonorrhea are highest among women aged 15-19 years and Blacks (IOM, 1997).


  • It is estimated that 45 million persons in the U.S. are infected with genital herpes and that one million new cases occur per year (Fleming et al., 1997).

  • Sexually transmitted infections in both women and men contribute to infertility, which affects approximately 14 percent of all couples in the United States at some time (Sciarra, 1991). For example, chlamydia and gonorrhea infections account for 15 percent of cases of infertility in women (IOM, 1997).

  • Human Papillomavirus (HPV) is a sexually transmissible virus that causes genital warts. An estimated 5.5 million persons become infected with HPV each year in the U.S. and an estimated 20 million are currently infected. There are many different types of HPV. While most women who have HPV do not develop cervical cancer, four HPV subtypes are responsible for an estimated 80 percent of cervical cancer cases, with approximately 14,000 new cervical cancer cases occurring per year (Centers for Disease Control and Prevention [CDC], 1999a).

Currently, there are an estimated 800,000 to 900,000 persons living with HIV in the United States, with approximately 40,000 new HIV infections occurring every year. Among those who are currently positive for HIV, an estimated one-third are aware of their status and in treatment, one-third are aware of their status but not in treatment, and one-third have not been tested and are unaware of their status (CDC, 2000a; CDC, 2001a).

Since 1981, a total of more than 774,467 AIDS cases had been reported to the U.S. Centers for Disease Control and Prevention (CDC). The disease has disproportionately affected men who have sex with men -- 47 percent of reported cases -- and minority men who have sex with men have now emerged as the population most affected (CDC, 2001b). A recently released seven city survey indicates that new HIV infection was substantially higher for young Black gay and bisexual men than for their White or Hispanic counterparts (CDC, 2001c). During the 1990s, the epidemic also shifted toward women. While women account for 28 percent of HIV cases reported since 1981, they accounted for 32 percent of those reported between July 1999 and June 2000. Similarly, women account for 17 percent of AIDS cases reported since 1981, but 24 percent of those reported between July 1999 and June 2000 (CDC, 2000b).

Sexual abuse contributes to sexual dysfunction and other public health problems such as substance abuse and mental health problems. There are an estimated 104,000 child victims of sexual abuse per year (U.S. Department of Health and Human Services [USDHHS], 2000a), and the proportion of women in current relationships who are subject to sexual violence is estimated at eight percent (Coker et al., 2000). While it is estimated that only a relatively small proportion of rapes are reported (Koss et al., 1988), a major national study found that 22 percent of women and approximately two percent of men had been victims of a forced sexual act (Laumann et al., 1994).

Sexual orientation is usually determined by adolescence, if not earlier (Bell et al., 1981), and there is no valid scientific evidence that sexual orientation can be changed (Haldeman, 1994; APA, 2000). Nonetheless, our culture often stigmatizes homosexual behavior, identity and relationships (Herek, 1993). These anti-homosexual attitudes are associated with psychological distress for homosexual persons and may have a negative impact on mental health, including a greater incidence of depression and suicide, lower self-acceptance and a greater likelihood of hiding sexual orientation (Gonsiorek, 1982; Ross, 1985; Ross, 1990; Greene, 1997; Remafedi, 1998). Although the research is limited, transgendered persons are reported to experience similar problems. In their extreme form, these negative attitudes lead to antigay violence. Averaged over two dozen studies, 80 percent of gay men and lesbians had experienced verbal or physical harassment on the basis of their orientation, 45 percent had been threatened with violence, and 17 percent had experienced a physical attack (Berrill, 1992).

There are also persons who are challenged with developmental, physical or mental disabilities whose sexuality and sexual needs have often been ignored, or at worst, exploited and abused (Schover and Jensen, 1988; Hingsburger and Harber, 1998). Although appropriate assistance has been developed for these vulnerable populations, it is seriously underutilized (Acton, 1992; Sipski and Alexander, 1997). Additional materials and programs, as well as further research, are needed.

It is estimated that nearly one-half of all pregnancies in the U.S. are unintended (US.DHHS, 2000b). While women in all age, income, race and ethnicity categories experience unintended pregnancies, the highest rates occur among adolescents, lower-income women and Black women (IOM, 1995). Unintended pregnancy is medically costly in terms of the precluded opportunity for preconception care and counseling, as well as increased likelihood of late or no prenatal care, increased risk for low birthweight, and increased risk for infant mortality. It is also socially costly in terms of out-of-wedlock births, reduced educational attainment and employment opportunity, increased welfare dependency, and later child abuse and neglect -- and economically in terms of health care costs (IOM, 1995).

An estimated 1,366,000 induced abortions occurred in the U.S. in 1996, a slight increase from the 1,364,000 in 1995, but a 15 percent decrease from the 1,609,000 in 1990. A similar pattern of decrease has been observed in abortion rates with 22.9 abortions per 1000 women aged 15-44 years in 1996 compared to 27.4 in 1990 (Ventura, 2000). Moreover, surveillance data indicate that for those States that report previous induced abortions, nearly 45 percent of abortions reported in 1996 were obtained by women who had already had at least one abortion (CDC, 1999b).

The belief that adolescents obtain the majority of abortions in the U.S. is inaccurate. Abortion rates are substantially higher for women in their twenties than for adolescents. Rates in 1996 were 50.7 abortions per 1,000 for women aged 20-24 years and 33.6 per 1,000 for women aged 25-29 years, compared with a rate of 29.2 abortions per 1000 women aged 15-19 years. Moreover, women over 20 years of age account for 80 percent of total induced abortions. Nonetheless, a higher proportion of adolescent pregnancies end in abortion (29 percent) than do pregnancies for women over 20 years of age (21 percent) (Ventura, 2000).

Significant differences of opinion exist regarding the morality of abortion. In general, U.S. courts have ruled that the procedure is legal and health care technology has made abortion relatively safe. However, there is broad accord that abortion should be a rare procedure and that improvements in sexual health and an emphasis on a reduction in the number of unintended pregnancies will clearly move this objective forward. The underpinning of the public health approach to this issue is to apply a variety of interventions at key points to prevent unintended pregnancy from occurring, and thus, ensure that all pregnancies are welcomed.

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This article was provided by U.S. Department of Health and Human Services.