Creating a Sexually Healthy NationThroughout the month of September, we will be posting a series of essays on sexual health topics in recognition of World Sexual Health Day. This essay on the sex health and rights comes from William (Bill) Smith, the Executive Director of the National Coalition of STD Directors (NCSD) and a Senior Faculty Fellow at the Robert Wood Johnson Center for Health Policy at the University of New Mexico. He is also a PhD Candidate in Politics with a focus on political philosophy and the American Founding. This essay is featured in Creating a Sexually Healthy Nation, a volume of essays published in honor of ASHA’s 100th anniversary.

To be sure, the politics of sex in this country isn’t just a practical narrative in which one policy or program dominates or obliterates another. Rather, it tells the protracted tale of two diverse worldviews that were with us at the very founding of the nation and persist to this day. One, a view that looks over the shoulder, lamenting how wonderful everything once looked, and attempts to slow or even reverse the “decay.” The second, a stern stare back into that same past that finds injustice, inhumanity, and inequity, and ultimately tries to set a course for determining a “better” future. In between those two poles is where most Americans live and breathe and it’s where we have been debating sexual and reproductive health and rights for the last century if not longer. To capture all of the struggles in the last 100 years is the feet of a tome, not a short essay. So let me, instead, choose a few issues that seem timeless as “great good work,” in Abraham Lincoln’s noble words, and review efforts to secure our sexual and reproductive health and rights.

First, the issues of privacy and confidentiality remain as relevant as ever. In 1965, the U.S. Supreme Court issued its landmark decision of Griswold v. Connecticut which allowed married couples to access contraception and has since become the foundation for much of our sexual and reproductive rights. It’s the basis for extending the right of privacy in contraceptive use to unmarried couples (Eisenstadt v. Baird) and for the Roe v. Wade decision legalizing abortion. It also lay the groundwork for granting rights to gays and lesbians first through the Supreme Court’s 2003 ruling in Lawrence v. Texas which overturned discriminatory laws banning same-sex sexual behaviors and more recently through the decision to strike down parts of DOMA (the Defense of Marriage Act). The courts have helped pave the way for a true culture shift that has opened the door to marriage equality in many states, something I honestly never dreamt of as being possible as a gay kid growing up in rural Pennsylvania.

Yet today, there are new challenges to the right to privacy that threaten access to reproductive and sexual health care services. Not the least of these is the transforming nature of the healthcare delivery system, and more specifically, the technology that maintains our healthcare records and the insurance companies and government agencies that handle our claims. Less legalistic and more practical, the issues are who has access to your health records and their contents. Does a dermatologist’s office get to see your STD test results from the public health clinic? Does your gastroenterologist get to see your family planning consultation records? If your health insurance company is sending an explanation of benefits statement, will it disclose sensitive information—for example, an HIV test? Should parents have access to medical records for minor children or for older children remaining on their parent’s health plans? And if so, what contents are kept confidential and how do we create and manage those firewalls? These are solvable issues, but not without their own set of challenges.

While privacy in healthcare has always been of genuine concern, the expansion of health care in the United States brings new perils and challenges for advocates. The Affordable Care Act—Obamacare for those embracing the term—in its extension of health insurance coverage for millions of Americans, its elimination of discrimination on the basis of pre-existing conditions, and its mandate to cover certain preventive services without a copay or deductible is to be lauded. A number of the covered preventive services involve sexual health including birth control, Pap tests and cervical cancer screenings, and testing for STDs such as chlamydia and gonorrhea for certain populations. Again, these are good things especially when patients take advantage of them, but it means an ever-greater degree of vigilance must be maintained at all points where privacy and confidentiality could be compromised.

The second greatest political issue of our times is sex education, which seems as intractable in this country as abortion. It is a mini-stage on which the nation’s sexual dissonance plays itself out on the shoulders of young people whose very lives and livelihoods depend on getting the right information. One side going back to the “good old days” where they claim no one had premarital sex and everyone lived happily-married-everafter. The other hoping to address inequalities based on gender and sexual orientation and prepare young people for today’s world.

Worse still, under the guise of a truly historic and largely laudable effort to address the global HIV/AIDS threat, the George W. Bush Administration exported our home-grown abstinence-only-until-marriage nonsense in the humanitarian relief of the President’s Emergency Plan for AIDS Relief (PEPFAR). This has had generational consequences in countries that are most impacted by the pandemic. Sadly, too many years went by as billions of dollars in federal resources were squandered on a hypermoralistic “just say no to sex” approach.

Though it may seem like those days are in our country’s rearview mirror, the federal government still hands out 50 million dollars per year in abstinence-only-untilmarriage funding. And yes, while new teen pregnancy prevention funding outpaces what is spent on abstinence- only-until-marriage programs, policymakers have brokered a bitter deal that essentially allows both programs to exist side-by-side in an uneasy, irreconcilable truce. Further, as history has taught us, a complete turn of the tables is but an election away.

It is also disappointing to note that while advocates have long championed a truly comprehensive approach to sex education, the programs created under the Obama Administration, and as a counter balance to the abstinence- only approach of the previous Administration, are lamentably still stuck in disease- and pregnancyprevention paradigms. In many ways, the sex education debate is a place in which “political” policy makers always take the path of least resistance.

There is much that still needs to be done to further sexual and reproductive health and rights in this country, and indeed, given our diverse and vast republic and its citizenry, this may always be the case. Advocates will always be needed because it’s not just about making progress, but equally about holding back assaults on things once considered secure. As the one side seeks to correct the social injustices it sees in the past, the other will continue to argue that things were better then. That in 2014 we continue to fight for the right of women to access contraception is but one example to illuminate the never-ending pattern of political pushing and pulling. Again, to quote Lincoln, we need to continue the “great good work.”