Experiences of Other Countries

An examination of the social policies and experiences of other developed countries regarding sexuality underscores the adverse impact of the secrecy surrounding sexuality on STD prevention in the United States. For example, the Scandinavian countries have comparable levels of sexual activity, but their rates of many STDs and unintended pregnancy are much lower than in the United States (Piot and Islam, 1994; IOM, 1995). These differences may be largely a result of differences in how sexuality issues are dealt with in these countries. For example, lower rates of STDs and unintended pregnancies in northern and western European countries compared to the United States have been attributed to the pragmatic, rather than moralistic, approach to sexuality issues in these countries. In Denmark, for example, information regarding sexuality and STDs is provided freely in the media and sex education is mandated for all students beginning no later than third grade (age 9) (David et al., 1990). Because school-based sexual health education, mass media interventions, and public discussion regarding sexual health issues are much more common in many other developed countries, it follows that private communication regarding these issues—between parents and children, and between couples—is also more common in those societies than in the United States.

Another major factor that may explain the observed differences in STD rates is universal access to health services in other developed countries. As mentioned previously, a substantial proportion of young people at high risk for STDs in the United States do not have health insurance coverage. The positive impact of better access to clinical services for STDs on STD rates is supported by the observation that the differences in viral STD rates between the United States and other developed countries are much smaller than for curable STDs. In addition, the higher rates of drug use, such as crack cocaine use, in the U.S. population compared to some other developed countries contribute to the higher rates of STDs in the U.S. It is also possible that structural or policy differences play a role. For example, in some developed countries sex workers are licensed and screened and treated for STDs to prevent transmission to others. Another potential contributing factor is the higher level of "conforming" health behaviors (e.g., health-care-seeking behavior for STDs) in many other developed countries compared to the United States. While many factors may be responsible for the observed differences in rates of STDs between the United States and other developed countries, it seems that more appropriate social norms around discussion and education regarding sexual health issues and universal access to health care in other developed countries are major factors.

Research and Training Issues in Sexuality

For the past decade, behavioral research regarding sexuality has been driven



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