Personal Reflections on Sexual Health: From Aspiration to Emerging Reality in U.S. STD Control

I will be attending my 50th college reunion a few weeks after submission of this article, and I am pleased to realize that the celebration of the 50th anniversary of Sexually Transmitted Diseases has a parallel in my own life, with the launching of my medical education and subsequent career. Following medical school and residency, I pursued training in Infectious Diseases at the University of Washington. Partly because my fellowship started in July 1981, a month after the first reports of AIDS-related illness in the United States, and partly because Seattle had such great expertise in STDs, the latter became my fellowship and subsequent career focus. Subsequently, as an ID-trained STD controller at Denver Public Health in Colorado for 19 years, my orientation was completely focused on the growing range of microbes considered to be sexually transmitted. Similarly, the focus of the Denver STD Prevention Training Center that I directed for over 15 years was education about microbes and diseases and how to treat and prevent them. However, during the following 10 years of my career at the Centers for Disease Control and Prevention (CDC) in Atlanta—first as Director of the Division of STD Prevention (DSTDP) and subsequently as Chief Medical Officer for the National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)—my orientation shifted. It became more and more clear to me that while basic laboratory, clinical, epidemiological, and prevention research on microbes and diseases remained essential, framing our larger prevention and control effort as an infection/disease-focused enterprise was too fragmented for something as complex and potentially politically fraught as sexual behavior. During my years at DSTDP, we worked hard on Syphilis Elimination (though sadly, less successfully each year), controlling gonorrhea (despite growing antimicrobial resistance), preventing pelvic inflammatory disease and infertility (through chlamydia screening), and preventing HPV-related cancers (through roll-out of the exciting new HPV vaccine), but with controversies over pathogen-specific condom effectiveness and abstinence-only sex education, it became increasingly evident that public health needed a unified health-based framework to coordinate prevention, not just of STD, but also other topics of public health importance related to sexual behavior, including HIV, unintended pregnancy, and sexual violence. Fortunately, we had inspiring collaborators able to help CDC and our field address this effort. In 2001, Dr. David Satcher published the first Surgeon General's report on this topic: The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior (https://www.ncbi.nlm.nih.gov/books/NBK44216/). Published during a time of great controversy over sex education programs, it called for advancing a national dialogue on issues of sexuality, sexual health, and responsible sexual behavior and provided a number of important recommendations for promoting sexual health. NCHHSTP began to work with Dr. Satcher and colleagues across the country who similarly recognized the importance of a health-based framework for public health programs.1 We kicked off efforts to develop a new sexual health approach for CDC's programs with a meeting of experts in 2010 which developed recommendations for CDC in six strategic areas: promoting national leadership; developing effective policy actions; expanding communication, awareness, and education; strengthening surveillance, evaluation, and research; enhancing strategic partnerships; and strengthening sexual health service infrastructure (https://www.cdc.gov/sexualhealth/docs/sexualhealthreport-2011-508s.pdf). Although CDC chose not to adopt an overarching framework to promote sexual health across its programs addressing sexual behavior, a number of supportive follow-up steps occurred. These included the first development of a definition of sexual health for the United States context by the CDC/HRSA Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment,2 the elaboration of a social-ecological model of sexual behavior and a sexual health promotion/public health framework,3 the creation by a broad range of stakeholders of a National Coalition for Sexual Health (https://nationalcoalitionforsexualhealth.org/about), and the initiation of a biannual National Sexual Health Conference (https://www.taicfcp.org/SexualHealthConference2024). So what does the above summary have to do with celebrating the 50th birthday of what many would consider the world's preeminent STD journal? Actually quite a bit. My own initial foray into health promotion-based prevention was the HIV/STD prevention study, Project Respect, and while overall trial results were published elsewhere, most of the secondary analyses from the trial, as well as the results of the large follow-up study Project Respect-2 study4 were published in Sexually Transmitted Diseases. Fast forward to 2017: when it became apparent that a many-years-in-the-works white paper intended as a follow-up to the 2010 meeting would not be published by CDC, this journal agreed to publish an updated version describing a new vision for public health action through promotion of sexual health.5 Indeed, promoting the nomenclature and concept of sexual health has been increasingly normalized by the journal: of the over 3000 articles that show up with the search term “sexual health,” almost a quarter were published in the last 5 years. The trajectory of normalization of sexual health seen in articles in Sexually Transmitted Diseases has been occurring broadly and particularly notable was the 2021 report by the National Academy of Sciences, Engineering, and Medicine: Sexually Transmitted Infections: Adopting a Sexual Health Paradigm (https://www.nationalacademies.org/our-work/prevention-and-control-of-sexually-transmitted-infections-in-the-united-states). This report is not the final chapter in the journey toward using the framework of sexual health promotion as a public health tool, of course, and much remains to be done to achieve the vision of the 2001 Surgeon General's Report, as evidenced by recent controversies over access to reproductive health services and care for transgender persons. Dr. Satcher often described the quest for achieving sexual health in the United States as a relay race, carried on by many contributors and extending over years and decades. Much progress has occurred in this race over the last 25 years, in no small part due to Sexually Transmitted Diseases, and it will undoubtedly play a prominent role in the progress to be made in the years and decades to come.