Understanding high levels of sexually transmitted infections in the United States: A between- and within-country analysis

Despite tremendous expenditures on health care and average sexual behaviors in the United States (US) resembling those in many European countries, the US has among the highest levels of sexually transmitted infections (STIs) in the developed world. The literature argues that two factors are primarily to blame: cultural factors related to sexuality, namely a pervasive discomfort with sexuality, and reduced access to health care. However, little empirical research has tested these theories. Consequently, in this dissertation, I use nationally representative, individual-level data from the US, Britain, and Finland to explore associations between STI risk and indicators of sexual culture and access to health care. I also examine associations within the US, based on the premise that under most conditions, explanations for disparities that apply at the national level also should contribute to within-country differentials. Finally, since certain demographic characteristics are commonly associated with risk, I assess the contribution of these factors to risk differentials within and between countries. Due to dramatically higher STI rates among blacks than non-blacks in the US, I focus in particular on racial/ethnic differences. The first essay, a comparative analysis of self-reported STIs, provides support for the importance of sexual culture in accounting for cross-national STI differentials. Although differences in demographic factors-and especially, race/ethnicity-also are found to contribute to differentials, I find little support for the importance of health-care access in accounting for high STI rates in the US. The second and third essays use Add Health and NHANES data to analyze variation in risk within the US. Analyzing diagnosed and undiagnosed STIs among adolescents and young adults, I find that associations differ depending on the measure of risk used, and discomfort with sexuality at the individual and school levels is associated with some measures, but not others. In the final essay, which analyzes biomarker and self-reported data on genital herpes infections, I find that associations differ depending on whether infections are diagnosed. I also find limited support for the role of reduced access to care but little support for the importance of sexual culture in accounting for high STI levels in the US