Sexual and Reproductive Health Issue Brief, October 2016

October 2016

IN THIS ISSUE BRIEF Factors Influencing Health Sexual & Reproductive Health Trends and Rates MOVING TOWARDS EQUITY & A COMMON VISION TO IMPROVE HEALTH Ways to Achieve Health

WHAT IS SEXUAL & REPRODUCTIVE HEALTH? Sexual and reproductive health is an important part of our physical, emotional, mental, and social well-being throughout our lives.1,2,3 It means we are able to have a responsible and safe sex life free of coercion, discrimination, disease, and violence and that we have the capability to reproduce and the freedom to decide if, when, and how often to do so.1,2,3 Implicit in this is our right to be informed of and have access to safe, effective, and affordable methods of family planning, STI testing, and appropriate health care services that will enable us and our partners to be healthy.1,2

WHAT INFLUENCES SEXUAL & REPRODUCTIVE HEALTH? Sexual and reproductive health is influenced by many  Social and cultural factors, such as stigma associated complex factors across one’s lifespan and across with seeking assistance, gender roles, intimate partner generations.4 These factors can include: violence, economic dependence that reinforces power structures, or sexual behavior and  Structural and political conditions, including attitudes8,9,10 health policies, discrimination, availability of education, and access to culturally competent  Biological and genetic factors10,11 holistic health services5,6,7  Physical illnesses (including mental illness), disability, and emotional trauma9,12,13,14

TRENDS AND RATES IN DANE COUNTY An “indicator” is a way to tell what is going on in a community at one point in time, over a given period of time, or compared to other groups or populations. The following indicators were selected because they are priority areas referenced in Healthy People 202015 (10-year national objectives for improving the health of all Americans) and because Dane County or Wisconsin data were available. Many important indicators of sexual and reproductive health (i.e. number of Dane County schools offering comprehensive sexual health education, condom usage rates, etc.) were left out of this report due to lack of data.

INDICATOR MEASURE MADISON & DANE COUNTY SUMMARY

SEXUALLY Chlamydia, gonorrhea, syphilis, In 2015, Dane County was among seven counties in TRANSMITTED and HIV rates per 100,000 Wisconsin with the highest chlamydia, gonorrhea, INFECTIONS people syphilis rates. Significant racial/ethnic disparities exist.

The birth rate among 15-19 year olds in Dane County has TEEN BIRTH Number of births per 1,000 decreased 20% over the past 5 years. A decrease in the RATE females, ages 15-19 years teen birth rate has been seen nationally and in Wisconsin.

During 2012-2013, an estimated 29% of Wisconsin births were unintended, with significant disparities in PREGNANCY Percentage of unintended unintended births by race/ethnicity, age, education, births INTENTION marital status, health insurance before pregnancy, and poverty status.

Rate of reported forcible rapes The rate of reported forcible rapes in Dane County per 100,000 people during 2011-2015 was 24 per 100,000 people. SEXUAL Percent of men and women In Wisconsin, it is estimated that approximately a third VIOLENCE with a history of sexual of women and a fourth of men had a history of sexual violence, stalking, and intimate violence, stalking, and intimate partner violence in 2010. partner violence Sexual violence statistics are very underreported.

PREGNANCY Percentage of pregnancies Nearly 1/3 of non-first time births in Dane County were conceived less than 18 months conceived less than 18 months from the previous live SPACING from a previous live birth birth.

SEXUALLY TRANSMITTED INFECTIONS (STIs)

Dane County STI prevalence is high

 Dane County ranked in the top seven Wisconsin counties with the highest STI rates in 2015.17  7th in Chlamydia Rankings based on STI rates per  5th in Syphilis 100,000 people  4th in Gonorrhea

 Chlamydia is Dane County’s most commonly reported infection.18,19,20  15-24 years old have the highest rates of STIs.18

The rate of STIs in Blacks is approximately ten times the rate of Whites, a disparity seen throughout the US and not due to individual behavior.21

Number of STI reports per 100,000 people by race/ethnicity 18

In the United States, the estimated lifetime medical cost of WHY? Individual behavior does not explain racial/ethnic disparities. treating eight of the National research indicates that Whites have more unsafe sex than most common STIs Blacks. However, a Black person who has unsafe sex is much more $ likely to get an STI than a White person because of the high prevalence contracted in just one of infection within their social network.22 year is approximately Another major factor is the skewed ratio of available men to women in $15.6 billion (2010 the Black community due to the high rate of incarceration and early 16 death for Black men.22 dollars). Other factors include Blacks being more likely to be tested for STIs than Whites, relationship patterns, and poorer access to health care.22

SEXUALLY TRANSMITTED INFECTIONS (STIs)

HIV continues to affect individuals living in Dane County HIV TRENDS  The new HIV diagnosis rate in Dane County decreased from 4.8 to 3.9 (per 100,000 people) from 2011-2015.23 In 2015, Dane County and Wisconsin rates of new HIV diagnoses were the same.23  In 2015, there were 822 people living with HIV in Dane County which is 12% of the total number of individuals living with HIV in Wisconsin (9% of Wisconsin’s population lives in Dane County).23  In Dane County, men accounted for 85% of the new HIV diagnoses in 2015.23

HIV COST  The lifetime treatment cost of an HIV infection is estimated at $379,668 (in 2010 dollars).24 Therefore, in Dane County (with approximately 30 cases per year) this totals approximately $11,390,000 in lifetime treatment costs if all cases are treated.

POPULATIONS AT RISK FOR HIV 68%  From 2010-2014, the population at highest risk for HIV was men who have sex with men (MSM).25 WHY? A variety of factors put MSM at higher risk for HIV including high prevalence in the population, socioeconomic factors, sexual risk behaviors, homophobia, stigma, and 20% discrimination.26, 27 8% 2% 2%  Rates of new diagnoses are highest in Blacks, as is true with STIs in general.25 MSM Other/ Hetero- Injection Injection Unknown sexual Drug Use Drug Use & MSM

WAYS TO REDUCE THE IMPACT OF HIV TESTING Approximately one in seven Americans living with HIV do not know they are infected.28 ACCESS TO CARE It is vital to ensure that those infected have access to care and remain in treatment in order to achieve and maintain low levels of HIV in the body (virally suppressed).28 Only about 64% of Dane County residents living with HIV in 2015 were virally suppressed.29 Maintaining low levels of HIV in the body can help individuals live a longer, healthier life and reduce risk of HIV transmission.30 Pre-Exposure Prophylaxis (PrEP) is another effective way to reduce the impact of HIV. It is a medication that can be taken by people without HIV to prevent HIV infection.31

TEEN BIRTH RATE

The teen birth rate in Dane County has decreased 20% from 2010-201432

US—29% decrease

WI—31% decrease Dane County —20% decrease

2010 2014

In 2014, there were 195 births (estimated pregnancy rate of 12.6 per 1,000) to mothers 15-19 years old in Dane County.32

ABOUT THE DECLINE  This decrease has occurred in all racial/ethnic groups and is also seen nationally and in Wisconsin.33  This decline is thought to be primarily due to improvement in teens’ contraceptive use.34, 35 There have been increases in the use of hormonal contraceptives, dual methods (i.e., condoms and hormonal methods simultaneously) and long-acting reversible contraceptive methods (i.e. IUD and implant).35

Teen pregnancy has substantial consequences and costs Teen pregnancy and childbearing can lead to large social and economic costs, resulting in long-term impacts on teen parents and children.36 For example, only about half of teen mothers receive a high school diploma by age 22 (compared to 90% for women who did not give birth during adolescence).36 In 2010, teen pregnancy and childbirth accounted for approximately $9.4 billion in costs to United States tax payers. This includes costs from:36  Increased health care and foster care  Increased incarceration rates among children of teen parents  Lost tax revenue because of lower educational attainment and income among teen mothers.

PREGNANCY INTENTION

Over one-quarter of Wisconsin births are unintended37 An unintended pregnancy is when a pregnancy is mistimed or unwanted at the time of conception, and it is associated with an increased risk for poor health outcomes for both the mother and baby.38 During 2012-2013, it is estimated that 29% of Wisconsin births were unintended.37 There are currently no county-level estimates for unintended pregnancies in Dane County. The abortion rate in Dane County from 2011-2015 has been decreasing,39, 40, 41, 42, 43 while the number of births has remained relatively stable.33

There are disparities in CHARACTERISTIC PERCENT unintended birth rates by race/ ethnicity, age, education, health All Mothers 28.6 insurance before pregnancy, and 37 Race/Ethnicity poverty status White 24.5

Black/Afr. American 50.8 FACTORS INFLUENCING Hispanic/Latina 35.2 THESE DISPARITIES Other 28.5  Differences in the ability to receive family planning services for both men Age and women44 Under 20 years 71.8  20-24 49.2 Differences in contraceptive usage rates45, 46 25-34 20.4 35 and older 17.2  Differences in how providers treat patients based on their race/ethnicity/ Education 46 income Less than High School 47.0 POTENTIAL IMPACTS OF High School 37.3 UNINTENDED PREGNANCIES Some College 27.9 College Graduate 16.6  38, 44, 45 Delays in initiating prenatal care  44 Health Insurance Before Pregnancy Maternal depression Private or Employer Insurance 20.6  Increased risk of violence during Medicaid 43.4 pregnancy44 Uninsured 36.6  44 Reduced likelihood of breastfeeding

 Poverty Status Babies born with birth defects and low birth weight44 Poor 48.3 Near-poor 30.3  Increased risk of negative health and Not poor 13.1 educational outcomes for children44

SEXUAL VIOLENCE

Reports of sexual assaults increased from 2011-2015 in Dane County47 The economic and societal costs of rape and sexual assault are great, including decreased quality of life, medical and victim services costs, law enforcement resources, and loss of productivity.48

DATA SNAPSHOT

 There were 1,749 sexual assaults in Dane County reported to law enforcement 47 “Rape is a challenging crime agencies from 2011-2015. for law enforcement to track. There was an increase in reported sexual assaults over this time period. It is Reported forcible rape figures unknown if this is a true increase in the number of sexual assaults as this is a can be affected by victims’ severely underreported statistic. willingness to report offenses, victims’ comfort  The rate of reported forcible rapes in Dane County during 2011-2015 was 24 per level with local law 100,000 people,49 similar to rates nationally and in Wisconsin.51 enforcement, and other  In Wisconsin, it was estimated that 32% of women and 23% of men had a history of factors. This crime tends to be sexual violence, stalking, and intimate partner violence in 2010.52 underreported.”50  Many people who experience rape, physical violence, or stalking by an intimate In Wisconsin, only an partner, first experienced some form of partner violence between 11 and 17 years of estimated 27% of rapes or age.52, 53 sexual assaults are reported to police.50

PREGNANCY SPACING

Conceived less During 2010-2014, nearly a third of non-first time births than 18 29% in Dane County were conceived less than 18 months months after a 33 from the previous live birth. previous live 71% birth  Dane County levels of pregnancy spacing have remained consistent dur- Conceived more than ing 2010-2014, and remain slightly lower than the Wisconsin rate of 18 months after a 31%.33 previous live birth WHY IT MATTERS  The amount of time between a live birth and the beginning of the next pregnancy can affect the health of both mothers and infants.54  When pregnancy spacing is less than 18 months, the likelihood of adverse health outcomes for both the mother and child increases. For example, the risk of preterm birth and low birth weight increases.54

WAYS TO ACHIEVE SEXUAL AND REPRODUCTIVE HEALTH  All adolescents having the opportunity to participate in evidence-based, comprehensive education about sexual and reproductive health (build knowledge and resilience among young people).55, 56

 All women having access to accurate, informed choices for reproductive health planning and pregnancy spacing.38, 44, 57, 58

 Health professionals providing tailored, non-judgmental, and confidential sexual and reproductive health services to specific at risk populations including teens, men who have sex with men, and transgender individuals.58, 59

 Students feeling that adults and peers in the school care about them (social connectedness) and their academic success.60

 Parents and educators supporting and improving the learning, development, and health of children and adolescents (youth development).61

 All individuals having access to health care services that are culturally and linguistically appropriate.62, 63

 All individuals having access to educational, economic, and job opportunities.62, 63

 All individuals being able to live free of stigma, discrimination, and racism.62, 63

There are numerous opportunities that would help the Dane County community achieve sexual and reproductive health.

SOURCES

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ABOUT THIS PROFILE

Sexual and Reproductive Health in Dane County is part of an ongoing effort by Public Health Madison & Dane County to assess, document and identify local prevention priorities. Community health assessment is one statutory role performed by local health departments.

Using categories of the Surgeon General’s National Prevention Strategy, along with priorities identified locally, Public Health Madison & Dane County staff work with community partners to identify challenges and opportunities to improve population health, with a specific focus on improving health equity.

This report is based on an examination of the most recent available local, state and national data sources, interviews with staff from health care and the social sector, and interviews with community partners serving clients who navigate the health care system every day.

October 2016

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