Surgeon General Issues Call to Promote Sexual Health and Responsible Behavior

In late June, Surgeon General David Satcher released a report describing the "serious public health challenge regarding the sexual health of our nation" and outlining strategies to increase awareness, implement and strengthen interventions, and expand the research base relating to sexual health matters. Satcher called the report "only a first step—a call to begin a mature, thoughtful, and respectful discussion nationwide about sexuality."

In releasing the report, Satcher described "a conspiracy of silence" about sex and sexuality and framed the issue of access to information about sexual health as one of equal opportunity. A key objective outlined in the report is to target socioeconomically vulnerable communities, in which people have less access to health education and services and are thus likely to suffer most from sexual health problems.

The Call to Action to Promote Sexual Health and Responsible Sexual Behavior cites a number of sexually related public health problems.

• Twelve million Americans a year contract sexually transmitted diseases.

• An estimated 45 million persons are infected with genital herpes, and one million new cases are reported each year.

• Four subtypes of human papillomavirus, a sexually transmissible virus that causes genital warts, are responsible for an estimated 93 percent of cervical cancer cases; 5.5 million new cases of cervical cancer are reported annually.

• Nearly half of all pregnancies in the United States are unintended.

• An estimated 1.36 million abortions were performed in 1996.

• Some 800,000 to 900,000 Americans are living with HIV, and a third of them are unaware that they are infected.

• An estimated 104,000 children are victims of sexual abuse each year.

• About 8 percent of women are subject to sexual violence in their relationships.

• Eighty percent of gay men and lesbians have experienced verbal or physical harassment, 45 percent have been threatened with violence, and 17 percent have experienced a physical attack.

• Twenty-two percent of American women and 2 percent of American men have been victims of rape.

Strategies geared toward increasing awareness include a recognition that parents are a child's primary educators and should guide the child's education about sexuality in a way that is consistent with their values and beliefs. The report acknowledges that families differ in their level of knowledge of and comfort in discussing such issues, making school education a vital component of equity of access to information. In releasing the report, Satcher described schools as "the great equalizers in assuring that all children have a basic understanding of essential sexual health matters." The report also notes that churches and other community entities can play a role in providing such education.

The report emphasizes that information about sexuality and sexual health should be thorough and wide ranging, should begin early, and should continue throughout life. Education should recognize the special place that sexuality has in everyday life; stress the value and benefits of remaining abstinent until one is involved in a committed, enduring, and monogamous relationship; and ensure awareness of optimal protection from sexually transmitted diseases and unintended pregnancy, while also stressing that there are no infallible methods of contraception aside from abstinence and that condoms cannot protect against some forms of sexually transmitted diseases.

Strategies to implement and enhance interventions call for the strengthening of families by encouraging stable, committed, and enduring adult relationships, particularly marriage; adequate training in sexual health for all professionals who deal with sexual issues in their work; improved access to related health care services; and the elimination of disparities in health status that arise from social and economic disadvantage.

Research-oriented strategies promote further study of human sexual development and reproductive health that covers the entire life span, improve evaluation efforts for interventions, and help in the development of educational materials.

The Call to Action to Promote Sexual Health and Responsible Sexual Behavior is the result of a two-year effort to find ways to promote responsible sexual behavior, one of Satcher's top public health priorities. The report's conceptual framework was developed at a July 2000 conference attended by more than 130 representatives of 90 organizations. The final report was drafted by a team of experts in the fields of public health, sexuality, and sexual health, and drafts were reviewed by a committee representing the conference participants and other experts.

The 33-page report is available on the Surgeon General's Web site at www.surgeongeneral.gov.

CSAT Releases Report Detailing National Expenditures for Substance Abuse Treatment

Alcohol and drug abuse cost the American public a total of $294 billion in 1997. Less than $12 billion—4 percent of that total—was spent on substance abuse treatment. These figures are reported in National Estimates of Expenditures for Substance Abuse Treatment, 1997, which was released by the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Administration (SAMHSA).

In releasing the report, SAMHSA Acting Administrator Joseph H. Autry III, M.D., noted that two-thirds of individuals with serious needs for substance abuse treatment are not being treated. CSAT director H. Westley Clark, M.D., J.D., pointed out that "there is no other medical condition for which the American public would tolerate only $11.9 billion in treatment expenditures while enduring over $294 billion in total social costs." Dr. Clark suggested that increasing funds for treatment should be viewed not as additional spending but as a reallocation of funds, given the fact that the nation is already paying the social costs of substance abuse.

The objective of the study was to provide 10-year estimates of substance abuse expenditures that could be compared with spending on mental health and all health care services in the United States. Although the report contains dollar estimates that are identical to those of a larger study that was released last year (see Psychiatric Services, September 2000, page 1195), it focuses to a greater extent on the differences between these types of expenditures and provides more detail on substance abuse spending.

Of the $11.9 billion spent on substance abuse treatment in 1997, almost 80 percent ($9.3 billion) went to specialty providers. Specialty providers are defined as those that focus exclusively on substance abuse treatment; they include specialty hospitals, specialty dependency units of general hospitals, psychiatrists, other substance abuse professionals, and specialty substance abuse centers. General providers—those that treat physical health problems and may also treat mild or moderately severe substance use disorders—received 17.4 percent of treatment expenditures ($2.1 billion). Over half of substance abuse expenditures were for care in freestanding outpatient and residential settings, as opposed to hospital-based services, which was also the case for all health care expenditures in 1997.

Spending on drugs accounted for .3 percent of 1997 substance abuse treatment funds. By contrast, 12.3 percent of spending for mental health treatment was for pharmacotherapy. This disparity may reflect the relative lack of medications to treat drug abuse. It may also reflect the types of providers who typically treat substance abuse rather than mental illness: independent psychiatrists and independent professionals other than physicians received only 2.4 percent each of 1997 substance abuse treatment dollars, compared with 9.7 percent and 13.4 percent, respectively, of mental health dollars.

Between 1987 and 1997, spending on substance abuse shifted more heavily from the private sector to the public sector. The public sector's share of expenditures increased 11 percentage points (from 53 percent to 64 percent), compared with an increase of 1 percentage point for mental health expenditures (from 56 to 57 percent) and 5 percentage points for all health care spending (from 41 to 46 percent).

Federal funding for drug abuse treatment increased an average of 9.6 percent each year between 1987 and 1997. The federal share of funding in 1997 was 36 percent, compared with 29 percent for mental health spending and 33 percent for all health care spending. State and local governments managed nearly half of all expenditures for substance abuse treatment but only 22 percent of all health care services dollars.

Over the ten-year period, out-of-pocket spending on drug abuse treatment increased by 4.9 percent, faster than for any other health condition. Although out-of-pocket expenditures for substance abuse treatment accounted for only 10.5 percent of total substance abuse spending in 1997, individuals with substance use disorders who paid for their own treatment faced much higher expenses for most services than did individuals with mental health disorders, who in turn had higher expenses than individuals with physical conditions that required treatment.

In 1997, more than two-thirds of spending for substance abuse treatment by allied professionals—psychologists, counselors, and social workers—came from out-of-pocket payments, compared with 41 percent of mental health spending. Thirty-two percent of the reimbursements for substance abuse treatment received by nonpsychiatric physicians were out-of-pocket payments, compared with 16 percent from mental health patients. These findings raise the concern that high out-of-pocket costs for substance abuse treatment may discourage many individuals who need care from seeking it.

The report, which contains detailed tables, is available from the National Clearinghouse for Alcohol and Drug Information. Call 800-729-6686 or 800-487-4889 (TTD) and ask for DHHS publication no. SMA 01-3511.

News Briefs

New name for HCFA: The Health Care Financing Administration, the federal agency that administers Medicaid, Medicare, and the State Children's Health Insurance Program (SCHIP), has been renamed the Center for Medicare and Medicaid Services (CMS). Thomas Scully, formerly the president and chief executive officer of the Federation of American Hospitals, was sworn in as the agency's new director on June 1. The agency has been restructured in response to calls for reform from Congress and health care providers. CMS will have three new service centers. The Medicare program will be managed by two centers. The Center for Medicare Management will oversee fee-for-service payment policy and management of Medicare carriers and fiscal intermediaries. The Center for Beneficiary Choices will focus on education of enrollees, the Medicare+Choice program, consumer research, and grievance and appeals. The third center is the Center for Medicaid and State Operations, which will focus on state-administered programs, including Medicaid, SCHIP, private insurance, survey and certification, and the Clinical Laboratory Improvement Amendments.

Applications for minority research training: The American Psychiatric Institute for Research and Education seeks applicants for its minority research training in psychiatry program, which is funded by the National Institute of Mental Health. The program provides medical students and psychiatric residents with funding for stipends, travel expenses, and tuition for an elective or summer experience at research-oriented departments of psychiatry in major U.S. medical schools and other sites nationwide. Stipends are also available for one- or two-year postresidency fellowships for minority psychiatrists. The deadline for applications is December 1 for residents seeking a year or more of training and for postresidency fellows. Deadlines for medical students are three months before training is to begin. Students who will start their training by June 30, 2002, should submit their applications by April 1. For more information, call the program's toll-free number, 800-852-1390, or call 202-682-6225. Information is also available from Ernesto Guerra at [email protected], or write to The American Psychiatric Institute for Research and Education, 1400 K Street, N.W., Washington, D.C. 20005.

Low-cost prescription drugs: The Cost Containment Research Institute in Washington, D.C., has published a 32-page booklet, "Free and Low Cost Prescription Drugs." The booklet lists 78 drug firms that offer discounts and free medication to people who have no insurance. To obtain a copy, send $5 to the Institute Fulfillment Center, Booklet PDM-370, P.O. Box 210, Dallas, Pennsylvania 18612-0210. For more information, visit the institute's Web site at www.institutedc.org or call 202-478-0481.

Access Project Web site: The Access Project, a national health care initiative, has redesigned its Web site (www.accessproject.org) to provide more information about how communities can launch initiatives to increase access to health care for the uninsured. Publications are available that may be ordered or downloaded. The Web site is sponsored by the Robert Wood Johnson Foundation and the Annie E. Carey Foundation.

Care guidelines for Alzheimer's disease: The American Academy of Neurology has issued new practice guidelines for early recognition, diagnosis, and treatment of Alzheimer's disease. The guidelines were condensed from the findings of more than 1,000 studies by a team of experts. They stress early diagnosis because current medications and care options are most effective for patients with mild to moderate Alzheimer's disease. The guidelines include recommendations for education and support to improve the well-being of caregivers. A summary of the guidelines is posted on the Web site of the American Academy of Neurology at www.aan.com. The guidelines were published in the May 8 issue of Neurology.