Methods

Sexual Health Rankings is based on a holistic, positive concept of sexual health, first advanced by the World Health Organization (WHO), that is widely accepted by authorities in the health and social sciences.

WHO defines sexual health as:

"... a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled."

WHO, 2006 Defining Sexual Health: Report of a Technical Consultation on Sexual Health, 28–31 January 2002, Geneva

WHO further defines the terms "sexuality" and "sexual rights" as follows:

SEXUALITY is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors.

SEXUAL RIGHTS embrace human rights that are already recognized in national laws, international human rights documents and other consensus statements. They include the right of all persons, free of coercion, discrimination and violence, to:

• the highest attainable standard of sexual health, including access to sexual and reproductive health care services; seek, receive and impart information related to sexuality;
• sexuality education;
• respect for bodily integrity;
• choose their partner;
• decide to be sexually active or not;
• consensual sexual relations;
• consensual marriage;
• decide whether or not, and when, to have children; and
• pursue a satisfying, safe and pleasurable sexual life.

The responsible exercise of human rights requires that all persons respect the rights of others.

WHO, 2006

Elements of Sexual Health

For the purpose of constructing this composite index, we have condensed the WHO definition into five fundamental elements:

1. Ability of individuals to have control over, and freely decide on, their own sexual behavior and experiences
2. Ability of individuals to decide freely on whether, and when, to procreate
3. Freedom from discrimination and violence related to sexuality and gender
4. Experience of sexual pleasure and satisfaction
5. Freedom from sexual morbidity, including HIV/AIDS and other sexually transmitted infections.

Indicator Categories

We identified indicator categories that measure these elements of sexual health. Adapted from WHO recommendations on country-level indicators of sexual health,¹ these categories were broadly classified as "outcomes" and "factors." We defined outcomes as measures of health status and impact. Factors are conditions, or social determinants, that influence sexual health.

We grouped sexual health factors into the following subcategories, corresponding to five "key domains" of sexual health, as defined in a 2010 WHO framework for sexual health programs.²

1. Laws, policies, and human rights
2. Education
3. Society and culture
4. Economics
5. Health systems.

This theoretical framework provided the basis for selecting individual indicators to include in the composite index.

Indicator Selection Criteria

We evaluated potential indicators systematically, using predetermined criteria based on standards developed for the International Monetary Fund General Data Dissemination System.³ These standards are not specific to health indicators, but are considered broadly applicable to health-related data collection and dissemination. The three main criteria are relevance, availability, and data quality.

Relevance

An indicator had to be relevant to the concept of sexual health as defined in the theoretical framework and relevance had to be supported by scientific evidence. Relevance was determined by mapping an indicator's relation to the 5 elements of sexual health, with literature reviews conducted to document evidence supporting these relationships.

Availability

Selection is limited to indicators for which state-level analyses of data are available in published reports or public datasets. All indicator data used in the analysis are publicly available secondary data.

Data quality

We adapted the International Monetary Fund Data Quality Assessment Framework to establish criteria for evaluating the quality of indicator data.⁴

We considered four aspects of data quality: integrity, accuracy, timeliness, and consistency.

Integrity

Indicator data collection, analysis, and reporting practices must be objective, transparent, and adherent to professional and ethical principles.

Accuracy

Data must be collected and analyzed using sound statistical techniques, and must sufficiently portray reality. Data must have been evaluated for accuracy by the organization responsible for their collection, analysis, and dissemination. Detailed documentation of metadata must be readily available. Indicators should include complete data for all 50 states. We avoided imputation of missing values if it was possible to use older data within the allowed time frame, if multiyear data could be combined to obtain a state value when single-year data were suppressed due to small sample sizes, or if another comparable indicator with complete data could be used.

Timeliness

Timeliness refers to the time frame that an indicator covered and the frequency with which data were reported. The limits imposed on timeliness are influenced by data availability for some indicators. We limited selection to indicators with available single-year data no earlier than 2010, and chose the latest available single-year data. Combining multiple years of data is sometimes necessary to increase sample sizes for small populations and uncommon outcomes. Multiple consecutive years of data may be combined for a pooled analysis, which estimates the average value of the indicator over that time period. We included indicators based on multiyear data for which the latest available year was 2010 or later, and the earliest year in the pooled analysis was 2006 or later. We prefer data published on an annual basis.

Consistency

Data must be consistent within the dataset, over time, and with major datasets. The organization producing the data must have addressed geographic differences in the way variables were defined and recorded, as well as other issues that could affect comparisons between states.

We used an analytical technique called "factor analysis for mixed data"¹ to reduce the full set of 26 sexual health indicators to a smaller set of composite variables (dimensions).² The analysis shows that two dimensions account for most of the variance in sexual health among the 50 states. The first dimension (social & policy) accounts for 33%, and second dimension (health status) accounts for 19%.

The 15 indicators that are significantly associated with each dimension contribute to a state's composite score on that dimension. Indicators that are not significantly associated with either dimension do not contribute to the composite scores, and do not influence the rankings.

The first and second dimension scores are added together to produce an overall sexual health score for each state. The 50 states are ranked from best to worst by their overall score, with the no. 1 rank going to the state with the highest score.

The highest-ranking states score highly on both dimensions. The lowest-ranking states have low scores for both dimensions.