Sexual health is a state of physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.
-- World Health Organization
In the field of public health, there has been an important shift away from blaming people for any negative health outcomes they may experience. Instead, the field acknowledges the ways in which different influences (social, political, and economic) contribute to individual and community health.
Sexual health outcomes, including unintended pregnancy, HIV, and other STIs, are very much included in this shift, for many reasons. First, high-quality, comprehensive sexuality education goes beyond helping students learn how to use condoms correctly or gain access to reliable contraception (though these remain critical components of the work). Truly comprehensive sexuality education is sexpositive, includes all gender identities and sexual orientations, and empowers youth to build their knowledge and skills.
The research is clear: youth experience negative sexual health outcomes at rates higher than adults. One in four adolescents will contract a viral or bacterial sexually transmitted infection (STI). The number rises to one in two by age 25. According to the 2011 Youth Risk Behavior Survey (YRBS):
- 61% of New York State high school students reported they had sexual intercourse by 12th grade. Over 20% had sexual intercourse by 9th grade.
- 13% of students did not use any method to prevent pregnancy during their last sexual intercourse.
- Only 11% of sexually active students used both a condom plus another birth control method (recommended to address both pregnancy and STI/HIV prevention) during their last sexual intercourse.
- Youth with special circumstances, such as youth in foster care, have significantly higher rates of sexual activity and pregnancy. Nearly a third of young women in foster care reported that they had been pregnant at least once by age 17.
Reproductive and sexual health issues are key for adolescents and young adults, and the one-sized-fits-all approach is missing the mark -- especially for those who are most vulnerable, namely youth of color and those who identify as lesbian, gay, bisexual, transgender, or questioning (LGBTQ). Love Heals, Inc. believes that young people who are provided age-appropriate, medically accurate information will develop the knowledge and skills they need to stay healthy, while learning the advocacy skills they need to tackle the larger systemic issues that contribute to their sexual health.
Social Drivers, Youth and HIV
Systemic factors are major drivers of the HIV epidemic. When risk-taking behaviors are otherwise equal, factors such as poverty, poor health care, systemic inequality, and location elevate risk for HIV transmission. As a result, youth of color and young men who have sex with men continue to have a higher risk for HIV infection than their peers.
Living in poverty increases the likelihood that a young person has limited or no access to quality health care. As a result, they may delay HIV and STI testing, or not be tested at all, increasing their time without treatment if they are infected. Improving access to youth-friendly clinical care could increase the number of young people who have access to condoms, HIV and STI testing, and treatment. This could help decrease transmission in two ways: through the consistent use of condoms, and by adherence to HIV medications, which reduces viral load.
Systemic inequality perpetuates HIV transmission in numerous ways. First, racist and discriminatory police practices, such as Stop-And-Frisk and increased surveillance in schools (part of the "School-to-Prison Pipeline"), target youth of color and those who identify as LGBTQ. These are the same young people who are more likely to live in unstable housing or poor neighborhoods, to experience homelessness, or to be victims of harassment and bullying. They are more likely to be arrested, subjected to frequent and harsher disciplinary action, and experience overall marginalization at rates much higher than youth who are white and/or heterosexual.
Stop-and-Frisk policies target youth of color and LGBTQ youth, resulting in arrests for prostitution if condoms are found. By criminalizing condom possession, law enforcement actually increases the risk of HIV transmission in those who are trying to prevent it. Youth exposed to the criminal justice system often experience social isolation due to homophobia and transphobia, and often receive little support from adults. This increases their risk for HIV infection by maintaining the status quo of unjust school rules and law enforcement practices.
In order to combat these practices and decrease HIV transmission, larger strides need to be taken so that social systems promote fairness rather than impeding it. Enacting legislation can help spark systemic change. By working to change NYC police leadership and enacting an anti-racial-profiling bill, Mayor Bill de Blasio's administration is attempting to dismantle the School-to-Prison Pipeline, end Stop-and-Frisk, and decriminalize condom possession, which collectively can shift the impact those policies have on HIV transmission.
Bolster HIV Prevention Education in Schools
The National HIV/AIDS Strategy (NHAS) states that everyone needs to be educated about how to prevent HIV. It follows that HIV education should be a part of health education nationwide. Aligned with the NHAS, New York State mandates that HIV prevention be taught in grades K-12. As a result, the NYC Department of Education recommends that young people receive sexual health education for one semester in both middle and high school.
However, this sex ed requirement is neither funded nor enforced during curriculum design and planning for middle and high school students. For those reasons, more could be done to bolster prevention efforts across the state and to help meet the objectives outlined in Governor Cuomo's End the Epidemic (ETE) Blueprint.
Of all age groups, young adults aged 20 to 29 had the most HIV diagnoses (36%) in 2014. The Northeastern U.S. had the second highest HIV rate: 14.2 per 100,000 people. The only region experiencing higher HIV rates was the South, at 18.5 per 100,000 people.
In addition to the steps described in the ETE, Love Heals suggests the following ways to help decrease HIV transmission rates in youth, which will in turn bring HIV diagnoses down to the goal of 750 per year in NYS.
Teach Sexual Health Education
There are many ways in which schools and youth-serving community-based organizations (CBOs) work around systems that perpetuate health inequality, including risk for HIV. One of the most important ways to prevent HIV transmission is to strengthen the methods by which young people develop the knowledge, skills, and abilities needed to navigate their schools, neighborhoods, and communities. Providing quality comprehensive sexuality education is one way to help bolster this skill set.
Quality sex education is age-appropriate, clear, concise, medically accurate, skills-based, includes all gender identities and sexual orientations, and teaches both consent and pleasure. The ETE recognizes that this is a cost-effective way to prevent HIV transmission. By mandating comprehensive sexuality education for all public school students in grades K-12, as outlined in the National Sexuality Education Standards (NSES), New York State could establish a strong foundation of health-based knowledge, skills, and behavior. This would set the stage for HIV prevention and sexuality education nationwide. Healthy sexual development is a lifelong process, so expanding sex education to the elementary level will position students in New York City to:
- Avoid unintended health outcomes, including reducing HIV, STIs, and unintended pregnancy.
- Learn to communicate effectively about sexuality and sexual health with family, friends, partners, and clinicians.
- Develop a sense of autonomy over their own bodies and learn to respect the autonomy of others.
- Understand and practice consent.
- Develop a sense of dignity and respect for all people, regardless of sexual orientation or gender identity, and speak and behave inclusively.
Quality comprehensive sexuality education should be taught by professionally trained, culturally similar sexuality health educators
In New York State, there are over 2.6 million public school students in grades K-12. Of these, 25% are Latino and 18% are African American. Culturally appropriate sex education is tailored to the students' values, beliefs, traditions, and lifestyles. Sexuality is inherently rooted in an individual's own culture. Therefore, an understanding of that culture -- its norms and expectations -- will help ensure that the teacher meets students where they are, and increases the chance that the skills being taught match their community values.
Engage Youth in Prevention Activities
Youth-Adult Partnerships, a team-based approach in which young people and adults collaborate as equal partners, is a driving force of youth development and civic engagement. The World Health Organization suggests that such partnerships are critical components of HIV education and reproductive health programs, stating "Youth should be involved from the start as full and active partners in all stages, from conceptualization, design, implementation, feedback, and follow-up." Partnerships that mobilize young people and adults in the fight against HIV need to be put into practice more widely, particularly when working to lower HIV infection rates in youth of color and LGBTQ youth.
Condom Distribution is Effective
Worldwide, community-based condom distribution efforts are recognized to be a cost-effective HIV prevention method. Youth-led condom projects, such as the one led annually since 2009 by alumni of Love Heals' Leadership Empowerment and Awareness Program (LEAP) for Girls, integrates a youth-adult partnership model with proven intervention approaches to make female and male condoms and lubricant widely available to youth and adults alike.
It's important to note that youth-led condom distribution efforts have a positive impact both on the youth doing the outreach and on the community they serve. The initiative makes condoms available and acceptable in the community, while helping young people develop health knowledge and leadership skills as they talk with community members of all ages. Youth in Love Heals' condom distribution projects say the experience had a positive impact in numerous ways: They grew as individuals, learning to initiate conversations about the importance of consistent condom use, while providing members of their community with HIV prevention tools they might otherwise have gone without.
Through youth-adult partnerships, Love Heals' Youth Advisory Council has developed a series of projects aimed at spreading awareness about PrEP. From handing out educational pamphlets and safer sex kits to performing at the Brooklyn Museum's LGBTQ Teen Night, YAC members have used their knowledge of historic social justice struggles and their public speaking skills to advocate for change.
Youth Are The Experts
In order to achieve the ETE's objectives, educators, policy makers, and researchers need to clearly embrace the notion that young people know best. Young people know best how to communicate with other young people -- including what language to use and which modes of social media to engage with. They know best the specific barriers young people face when using protection or getting tested. They know best the stigma facing young people who are LGBTQ or who have HIV.
Young people understand that they are cornerstones in their communities. With adult support and guidance, their efforts to make positive change will be successful. As Common says in his song, "Glory", "No one can win the war individually. It takes the wisdom of the elders, and young people's energy." By listening to youth, and giving them the opportunity to use their voices and implement their ideas, we will find new insights about how best to achieve Governor Cuomo's objectives and finally End the Epidemic.
Sara Flowers is director of Love Heals' Youth Initiative, Mia Ragozino is manager of its Youth Advisory Council, and Deborah Levine is executive director.