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Risk

Risk

Healthy, Sexual Beings

By Robert Wm. Blum

Sex is not a public health "problem." Sex is a gift, a mystery, an expression of warmth and affection. Sex is a means of procreation, a way of meeting physiological and emotional needs.

Sex, however, is not without risks. Unwanted and mistimed pregnancies, HIV/AIDS and a host of other sexually transmitted infections (STIs) like gonorrhea and chlamydia are just a few health risks that can result from sex. And these risks can be exacerbated by societal attitudes and customs. Consider female genital cutting, child marriage and prohibitions on comprehensive sex education. With heartbreaking frequency, the consequences are sterility, obstetric fistula, school failure or death.

Before we can improve sexual health, we first must understand how the very nature of sexual risk has changed in recent years. Step back in time to, say, the mid-19th century. In the U.S. and Europe, less than 10 percent of the population lived in cities. Most people made their living from farming. The average age of menarche (a girl's first menstrual period) was greater than 15 years. Both women and men in the U.S. married before their 20th birthdays. Very few women had any opportunity to attend university or obtain a professional job.

Today, all that has changed. The average age of menarche in the industrialized world is approximately 12.5 years and in much of the developing world it is rapidly declining to that level (due primarily to improved nutrition and sanitation). In the U.S., women now marry on average at age 25.5 and men two years later (in much of Europe, men and women are over 30 before they decide to wed). More than half of the population lives in cities, nearly 40 percent of the population graduates from colleges, and more than 80 percent of women are in the workforce. Similar trends are emerging throughout the developing world.

While most of these changes are welcome and create new opportunities, we must also recognize they have opened a much wider window of sexual risk. Young people today have more years to be sexually active before marriage and fewer social and family conventions to restrict their number of sexual partners, thus putting them at greater risk for STIs.

When schooling was relatively rare and an agricultural-based life more common, pregnancy was not especially socially disruptive. Today, the declining age of menarche coupled with the rising age of marriage means that more young people risk pregnancy before marriage than ever before. And globalization's rising premium placed on education only magnifies an early pregnancy's effects on a young person's life trajectory. In many countries, pregnant girls cannot remain in school, so abortion is increasingly seen as a viable option even in countries where it is illegal. (Worldwide, disruption to one's education is the primary reason for seeking abortion.) Where abortion is clandestine, it is a leading cause of death in women who are pregnant or delivering.

So, what are we in public health to do? The answer is to do what we have always done: Work at the interface of behavior and society to minimize risk and negative outcomes. We help sex workers to decrease the risk of STIs and their consequences. We work with men who have sex with men to increase condom use and diminish the risk of HIV/AIDS. We work with schools and policymakers to institute evidence-based sex education to give young people lifesaving knowledge.

What shouldn't we do? We should not stigmatize sex. We should not make sex the "problem." That's counterintuitive. That's counter to reality. After all, we are sexual beings. We just need to make sure we stay healthy, sexual beings.

Robert Wm. Blum, PhD, MD, MPH, is the William H. Gates Sr. Chair and Professor of Population, Family and Reproductive Health.

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