The World Health Organization’s working definition of sexual health is “a state of physical, mental, and social well-being in relation to sexuality. It 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.”[1]
Three aspects of sexual health — sexually transmitted diseases (STDs), dating violence, and unintended pregnancies — are each important indicators for the state of sexual health in San Francisco. Additionally, dating violence, among other risk factors, is associated with an increase in risk-taking sexual behaviors, an STD diagnosis, and unintended pregnancy.[2], [3]
Chlamydia, gonorrhea, HIV, and syphilis are all examples of STDs. All STDs are preventable, and bacterial STDs such as chlamydia, gonorrhea, and syphilis are curable. Syphilis occurs in distinct stages, with early syphilis being subdivided into primary, secondary, and early latent syphilis. Early latent syphilis is when the STD is most contagious. Risk factors for acquiring an STD include being sexually active in communities with high rates of STDs, poverty and marginalization, limited access to health care, limited health care – seeking behavior, abuse of drugs and alcohol, stigma and secrecy around talking about sex and STDs, and early initiation of sexual intercourse.[3]
Dating violence is defined as physical, sexual, psychological, or emotional violence within a dating relationship.[4] In addition to lethal violence, abuse includes the intentional sabotaging of contraception, deliberately exposing someone to STDs, and forcing a woman into having unwanted pregnancies or abortions.[5] Risk factors for dating violence include the belief that dating violence is normal and acceptable, depression and other symptoms of trauma, aggression in other relationships, drug and alcohol abuse, engaging in early sexual activity and having multiple partners, having friends involved in dating violence, having conflicts with a partner, and experiencing violence in the home.
Unintended pregnancies are those that are mistimed, unplanned, or unwanted at the time of conception.[6] The rate of occurrence for unintended pregnancies varies according to a variety of factors, including maternal age, race/ethnicity, poverty, and education.[7] Some risk factors for unintended pregnancies are unavailability of contraception, failure to use contraception appropriately, and reproductive and sexual coercion.[8] The American Academy of Pediatrics (AAP) recommends long-acting reversible contraceptives (intrauterine devices (IUDs) or subdermal implants) as the first-line contraceptive choice for adolescents who do not choose abstinence.[9]
Untreated STDs can lead to serious long-term health consequences, including reproductive health problems, fetal and perinatal health problems, cancer, and facilitated transmission of HIV. For example, chlamydia can damage a woman’s reproductive system and create pregnancy complications or even infertility.
Dating violence can have a negative effect on health throughout life. Victims of dating violence are more likely to experience symptoms of depression and anxiety. They might also engage in unhealthy behaviors, such as using tobacco, drugs, and alcohol, or inconsistent use of condoms and hormonal contraceptives. Dating violence is associated with unwanted pregnancy.[3] Teens who are victims of dating violence in high school are at higher risk for victimization later in life.[10], [11]
Unintended pregnancies are associated with many negative health and economic consequences. Negative outcomes that may occur for women during the unwanted pregnancy include delays in initiating prenatal care, reduced likelihood of breastfeeding, maternal depression, and increased risk of physical violence during pregnancy. Babies born under these circumstances often suffer from birth defects and low birth weight, as well as poor mental and physical health during childhood, and tend to have lower educational attainment and more behavioral issues in their teen years. The consequences are augmented for teen parents, who are less likely to graduate from high school and will over a lifetime earn significantly less income than those who delayed childbearing.[12] Unintended pregnancies also result in significant costs to the health system.[13]
Sexually transmitted diseases/HIV In 2013-2017, there had been steady declines in new HIV diagnoses. The annual rates of newly diagnosed HIV cases in San Francisco decreased from 46.68 per 100,000 in 2013 to 25.10 per 100,000 in 2017(Figure 1A). HIV cases were decreasing while STDs were increasing because biomedical HIV prevention—antiretroviral treatment for persons living with HIV and HIV pre-exposure prophylaxis for those at risk for HIV—sharply reduces transmission of HIV, but not STDs. Between 2012 and 2016, annual rates of newly reported chlamydia, gonorrhea, and early syphilis increased by 60%, 107%, and 13% respectively (Figure 2A).
The rates of new HIV and each STD cases were higher among men; men contracted HIV, chlamydia, gonorrhea and early syphilis up to 35 times more often than women (Figure 1B, 2B). In San Francisco, Black/African Americans were disproportionately affected by STDs and HIV . In 2016, rates of chlamydia, gonorrhea, and early syphilis were 4.7, 7.3, and 5.2 times higher among Black/African Americans, respectively, than among Asians and Pacific Islanders, who experience the lowest rates of STDs and HIV in San Francisco (Figure 1B, 2C). HIV transmission was the highest among men who have sex with men (MSM) with a rate of 131 per 100,000 (Figure 1C).
Generally, youth are more likely to contract STDs. Incidence rates decrease with age as people become less sexually active and/or have fewer sexual partners. In 2016, the peak age range for individuals to contract gonorrhea or chlamydia was 20 to 24 years old and 25 to 29 years old; middle-aged persons, between 45 and 54 years old, had the highest rates of early syphilis (Figure 2D). An increase in early syphilis indicates that people are not identifying it in its earliest stages or are not getting treated fast enough, so the infection progresses.
Risky sexual behaviors Condoms are effective at preventing STDs. Among sexually active San Francisco youth, only 71% of middle school and 58% of high school students used a condom in 2017 (Figure 3A). Gay or lesbian high school students were less likely to report using a condom during their most recent sexual encounter than heterosexual or bisexual students were (Figure 3D). As this data only looks at condom usage, the older high school students could be using other forms of birth control. Surveillance has also found decreased condom use in San Francisco among gay adult men. [14]
Alcohol and drugs impair cognitive reasoning, which can lead to unwanted consequences if sexual behavior follows alcohol or drug use. From 2015 to 2017, alcohol or drug use before sex decreased among high school students but increased among middle school students (Figure 4A). Between 2013 and 2017, White and Black/African American students were more likely to use drugs or alcohol before sex than other races (Figure 4C). Similar to risky sexual behavior like less condom using, gay or lesbian high school students had the highest percent of using drugs or alcohol before sex (Figure 4E).
Sexual violence About 7.4% of San Francisco high school students said they had been forced to have sex and 9.4% said they had been forced to do sexual things by a boyfriend or girlfriend in 2017 (Figure 5A, Figure 6A). In 2015-2017, 26.74% of the gay or lesbian high school students said they had been physically forced to have sexual intercourse which is more than 4 times higher than heterosexual students (Figure 5B); they were also more likely to be forced to do sexual things by a boyfriend or girlfriend (Figure 6C).
Unwanted pregnanciesIn 2013-2015, 18% of women reported they had mistimed or unwanted pregnancies and 11.2% reported they were unsure about pregnancy intention (Figure 7A). The data suggests major disparities by race: Hispanic and Black women were more likely to have mistimed or unwanted pregnancy and the rates were 2 times higher than White women; As for unsure of pregnancy intentions, Black women had the highest percent 33.1% which was 3 times higher than all other races (Figure 7B).
SFDPH HIV and STD Surveillance, San Francisco Department of Public Health (SFDPH).
YRBSS Youth Risk Behavior Surveillance System (YRBSS), Centers for Disease Control and Prevention.
MIHA Maternal and Infant Health Assessment (MIHA), California Department of Public Health(CDPH).
HIV: The number of new HIV diagnoses per year was determined by summing persons who were diagnosed with HIV that year, persons initially diagnosed with HIV infection Stage 3 (AIDS), and persons initially diagnosed with any HIV stage below 3 who then developed Stage 3 later in the year. The numbers representing incidence and prevalence are an underestimate of true HIV status in San Francisco because the values do not account for people tested anonymously, unless they also tested confidentially or entered care in San Francisco.
Chlamydia, gonorrhea, and syphilis: The data includes San Francisco residents who contract chlamydia or gonorrhea, are tested, and have positive STD test results reported to the health department.
Rates: Incidence, prevalence, and case diagnosis rates were calculated using population estimates and projections from California Department of Finance. Annual rates are calculated as the number of cases diagnosed for a particular group during each year divided by the population for that group, multiplied by 100,000.
Condom and alcohol or drug usage: The denominator in rate calculations is based on youth ever reporting having sex. Due to the low number of responses collected from the YRBS survey, statistics may have decreased accuracy or large confidence ranges. Responses from separate years had to be pooled together to generate stable numbers.
Statistical instability: Statistically unstable estimates are not shown in this document. Statistical instability may arise from:
…few respondents to a survey,
…small population sizes, or
…small numbers of affected individuals.
Statistical instability indicates a lack of confidence in an estimates ability to accurately and reliably represent the population. Due to statistical instability, estimates are not available for all age, gender, ethnicity, or other groups.
1. World Health Organization, “Sexual Health.” http://www.who.int/topics/sexual_health/en/
2. National Women’s Health Network, “Violence Against Women and Unintended
Pregnancy: Building Connections.”
https://nwhn.org/violence-against-women-and-unintended-pregnancy-building-connections
3. A. L. Coker, “Does Physical Intimate Partner Violence Affect Sexual Health?: A Systematic Review,” Trauma, Violence, & Abuse (2007), no. 8, vol. 2: 149-177
4. Healthy People P2020, “Sexually Transmitted Diseases. Accessed August 2015.
http://www.healthypeople.gov/2020/topics-objectives/topic/sexually-transmitted-diseases
5. American Congress of Obstetricians and Gynecologists, “Contraceptive Sabotage Not
Uncommon,” Accessed August 2015.
http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/
Contraceptive-Sabotage-Not-Uncommon
6. Centers for Disease Control and Prevention, CDC features, “Teen Dating Violence.” Accessed August 2015. http://www.cdc.gov/features/datingviolence/
7. Centers for Disease Control and Prevention, “Unintended Pregnancy.” Accessed August 2015.
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/
8. Child Health USA 2013, “Unintended Pregnancy and Contraception Use.” Accessed August 2015. http://mchb.hrsa.gov/chusa13/perinatal-risk-factors-behaviors/p/unintended-pregnancy-
contraception-use.html
9. American Academy of Pediatrics, AAP Updates, “Recommendations on Teen Pregnancy.”
https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/
AAP-Updates-Recommendations-on-Teen-Pregnancy-Prevention.aspx#sthash.fqLUpPFE.dpuf
10. A. Furedi, 1997, “The Causes of Unplanned Pregnancy.” Accessed August 2015.
Contraception http://www.prochoiceforum.org.uk/ri1.php
11. Centers for Disease Control and Prevention, Injury Prevention and Control: Division of Violence Prevention, “Teen Dating Violence.” Accessed August 2015.
http://www.cdc.gov/violenceprevention/intimatepartnerviolence/teen_dating_violence.html
12. Healthy People 2020, “Family Planning.” Accessed August 2015.
http://www.healthypeople.gov/2020/topics-objectives/topic/family-planning
13. J. Trussell, A. M. Lalla, and Q. V. Doan, et al., “Cost-Effectiveness of Contraceptives in the United States,” Contraception 79 (2009), vol.1: 5–14.
14. Yea-Hung Chen, Jonathan Snowden, H. F. Raymond, CDC National HIV Behavioral Surveillance
