biological, psychological, and cultural factors that must be considered when delivering effective health services and information to individuals. Sexuality is an integral part of how people define themselves. It influences how, with whom, and with what level of safety people engage in sexual behaviors. However, sexuality is a value-laden subject that makes people—including health care professionals, researchers, educators, and the public—feel anxious and uncomfortable talking about it. The resulting inability to address issues of sexuality places individuals at risk of STDs. The discomfort that many Americans feel discussing sexual behavior is reflected in a recent nationwide survey that showed that, including married couples, approximately one of four women and one of five men surveyed had no knowledge of their partner's sexual history (EDK Associates, 1995).

Sexuality has been described in many ways. The common denominator in all definitions is the recognition that sexuality is an intrinsic part of one's being. It is much more than the sexual act and encompasses more than the anatomy, physiology, and biochemistry of the sexual response system. It is the quality of being human—all that we are as men and women (Hogan, 1980). Sexuality is also an energy, a life force, that is an important aspect of individual behavior and includes personal roles, identity, thoughts, feelings and emotions, and relationships. In addition, sex is entwined with ethical, spiritual, and moral issues and is influenced by sociocultural values and norms, religion, family, and economic status (Chilman, 1978).

It is helpful to examine the origins of secrecy regarding sexuality to understand why it has had such a significant impact on STDs in the United States. STDs were considered to be a threat to the late Victorian social system, which valued discipline, restraint, and homogeneity (Brandt, 1988). Advocates of repressive sexuality perceived that social structure and traditional morality were in danger and wanted to restore order and morality to American society (Sokolow, 1983). During this time, societal sexual mores dictated that sexual intercourse was only acceptable within the context of marriage. The Victorian code of ethics considered all discussion of sexuality and STDs to be inappropriate. According to these ethics, sexuality should be disciplined, not only by law but also by shame, and then concealed by silence (Kosovich, 1978). This code was upheld by key groups and opinion leaders in the community. For example, some physicians hid diagnoses of STDs from their patients and families and did not talk about the "medical secret" (Brandt, 1988). The press also contributed to this code of secrecy by refusing to print any explicit articles regarding STDs. When public health officials were finally able to conduct educational campaigns regarding STDs during the first few decades of the twentieth century, these campaigns emphasized the dangers of sexual activity rather than disease prevention. By focusing on the "loathsome" and disfiguring aspects of STDs, these early campaigns may have contributed to the stigma associated with STDs and encouraged discrimination against persons with STDs (Brandt, 1988). The historical phenomenon of secrecy surrounding sexuality and STDs in the United States offers



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