What Teenagers Might Be Doing
Some believe the level of participation in oral sex and other noncoital behaviors is probably higher now than it was in the past, while others have a "hunch" that oral sex is no more common, just much more talked about.
For example, according to Kathleen Toomey, director of the Division of Public Health in Georgia's Department of Human Resources, "anecdotal evidence and some recent data suggest that teenagers are engaging in oral sex to a greater degree than we had previously thought, but whether this represents a true increase is difficult to say, since we have no baseline data for comparison." Susan Rosenthal, a professor of pediatrics and a pediatric psychologist at Cincinnati Children's Hospital Medical Center, notes that in her clinical practice, "girls are clearly talking about oral sex and masturbation (of their partners or by their partners) more frequently than I used to hear about, but whether this is because they talk more openly about it or are doing it more is unclear." Deborah Haffner, a sexuality educator and former president of the Sexuality Information and Education Council of the United States (SIECUS), dismisses the press reports of oral sex among middle-school-aged adolescents as largely media hype, saying that only a very small number of young people are probably involved.
Experts believe that the type of oral sex practiced by young teenagers is overwhelmingly fellatio, not cunnilingus. According to Deborah Tolman, senior research scientist at the Wellesley Center for Research on Women, that distinction is paramount: "We are not fainting in the street because boys are giving girls cunnilingus. Which is not to say that girls and boys never have that experience. They probably do, and just rarely do it again for a really long time, because of how girls feel about themselves and their bodies, how boys feel about girls' bodies, and the misinformation they have about each other's bodies."
Many STDs can be transmitted by either fellatio or cunnilingus, although some are more easily passed than others. According to Penelope Hitchcock, chief of the Sexually Transmitted Diseases Branch of the National Institute of Allergy and Infectious Diseases, saliva tends to inactivate the HIV virus, so while transmission through oral intercourse is not impossible, it is relatively rare. Other viral STDs that can be transmitted orally include human papillomavirus, herpes simplex virus and hepatitis B, while gonorrhea, syphilis, chlamydia and chancroid are among the bacterial infections that can be passed through oral sex.
In the absence of survey data on the frequency of oral sex, the question arises as to whether clinicians are seeing evidence of a rise in STDs that have been acquired orally. The answer depends upon the per son asked. Some say they have seen no change in STDs acquired noncoitally, while others report that they are seeing both new types of infections and new types of patients--i.e., teenagers who have not yet initiated coitus but who come in with fears and anxiety over having acquired in infection orally.
Linda Dominguez, assistant medical director of Planned Parenthood of New Mexico and a nurse practitioner with a private practice, reports that at patients' requests, she is performing more oral swabs and throat inspections now than in the past. She affirms that "I have more patients who are virgins who report to me that they are worried about STDs they may have gotten by having oral sex. There are a lot of questions and concerns about herpes, since they seem to know that there is some risk of 'top and bottom' herpes, as one of my patients put it."
Sharon Schnare, a family planning clinician and consultant in Seattle, remarks that she now sees many teenagers with oral herpes. She adds that "I have also found, though rarely, oral Condylomata acuminata [a sexually transmitted condition caused by the human papillomavirus] in teenagers." Moreover, Hitchcock states that "several studies have shown that one-third of the isolates from genital herpes cases in kids right now are HSV1 [herpes simplex virus 1, the oral strain], which suggests a significant amount of oral intercourse is going on." This suggestion is impossible to verify, however, because of the extensive crossover between the two strains. Moreover, trends are especially hard to detect because of past and current problems in the reliability of type-specific testing.
Pharyngeal gonorrhea is one STD that is definitely acquired through oral sex. A few cases of pharyngeal gonorrhea have been diagnosed in adolescent girls in Dominguez's family planning clinic in New Mexico and in one region of Georgia through a community screening project among middle-school students to detect certain strains of meningitis bacteria carried in the throat. In Georgia, the cases caught everyone off guard, according to Kathleen Toomey. The infections were found only because throat swabs were being done for meningitis in a population that would not be considered "sexually active" in the traditional sense of the word.
Many researchers and clinicians believe that young adolescents who are having oral sex before they start coitus might be especially reluctant to seek clinical care. Moreover, adolescents virtually never use condoms or dental dams to protect against STD infection during oral sex, even those who know about the risk and worry that they might become infected.
However little is known about teenagers' experiences with oral sex, even less information is available on their involvement with anal sex, which also carries risks of STD infection, particularly of HIV. While teenage patients now seem much more comfortable talking about oral sex than they were in the past, the taboo against bringing up anal sex is still very much in place.
Attitudes and Motivations
Experts say there are multiple, interrelated reasons for why adolescents might be turning to oral sex. Deborah Roffman, a sexuality educator at The Park School in Baltimore, asserts that "middle-school girls sometimes look at oral sex as an absolute bargain--you don't get pregnant, they think you don't get diseases, you're still a virgin and you're in control since it's something that they can do to boys (whereas sex is almost always described as something boys do to girls)."
This sense of control is illusory, according to Roffman, because engaging in fellatio out of peer pressure or to gain popularity is clearly exploitative of girls who lack the maturity to realize it. The issue of just how voluntary oral sex is for many girls came up repeatedly, especially when the act is performed "to make boys happy" or when alcohol is involved. Roffman relates the experience of a guidance counselor who, after bringing up the topic of rape in this context of coerced oral sex, was told by female students that the term did not apply to their situation, because fellatio "is not really sex."
Teenagers seem to be especially misinformed about the STD risks of oral sex. Experts repeatedly mentioned their concerns over adolescents' perceptions of oral sex as less risky than intercourse,[C] especially in the context of teenagers' tendency to have very short-term relationships. Several observers mentioned the trap of AIDS education, which often teaches that HIV is transmitted through sexual intercourse, so adolescents think they are avoiding risk by avoiding sexual intercourse. Sarah Brown, director of the National Campaign to Prevent Teen Pregnancy, suggests what some adolescents might be thinking: "Okay, we get it. You adults really don't want us to have sexual intercourse, and you're probably right because of AIDS and pregnancy. But we're still sexual and we're going to do other things."
Haffner's interviews with 11th and 12th graders reveal that they view oral sex as "something you can do with someone you're not as intimate with, while intercourse is, by and large, reserved for that special person." This emotional differential between oral sex and vaginal sex--the assertion that oral sex carries few or no emotional ties--is acknowledged by many professionals who work with adolescents. Linda Dominguez quotes her adolescent patients as thinking "if you're going to avoid intercourse, you're going to resort to oral sex. You're going to do something that is sexual, but in some ways emotionally safer, before you give the big one away."
Adolescent health professionals reinforced the view reported in the popular press that today's adolescents consider oral sex to be less consequential and less intimate than intercourse. "Oral sex is clearly seen as something very different than intercourse, as something other than sex," according to Susan Rosenthal. She also mentions a generational shift in thinking, noting that "if you were to query older women, oral sex might be perceived as something more intimate or equally intimate to vaginal sex (and which frequently happened later on in a relationship); for the teens, oral sex appears to be much less intimate or serious than vaginal intercourse."
Insights from Formal Research
How does the limited published research conducted on oral sex inform the current situation? Because of the difficulties in obtaining funding and consent for conducting this type of research among minors, many of these studies have necessarily relied on small, nonrepresentative samples of college-age students enrolled in human sexuality or psychology classes, which are hardly generalizable to the overall population. Perhaps the best, though still limited, dataset that includes adolescents dates from the early 1980s: In 1982, a marketing research firm collected data from a national panel of households in 49 states. Douglas Kirby, currently of ETR Associates, directed this early research project; he recalls that "we were surprised that there was much more oral sex than we had anticipated."
Roughly one-fifth of the 1,067 13--18-year-olds surveyed in the early 1980s said they had ever had oral sex, and 16% of young women who had performed fellatio had never had vaginal intercourse. To many adolescents, safer-sex in the pre-AIDS era presumably meant avoiding pregnancy. The practice of "outercourse," in fact, was suggested by at least one physician as early as 1972[D] as an alternative contraceptive method for young teenagers. That physician, John Cobb, asserted that loosening the taboos around noncoital activity might "help significantly in the prevention of unwanted teenage pregnancy and of venereal disease."
Other nonrepresentative research done in the early 1980s focused on adolescents' sexual experimentation as a precursor or predictor of coitus. One longitudinal prospective study conducted in a southern city in 1980 and 1982 found that among a sample of black and white 12-17-year-olds, blacks proceeded more quickly to intercourse, while whites followed a predictable scenario of noncoital activities as substitutes or delay mechanisms. Another study using the 1982 follow-up data set only (545 10th-12th graders) concluded that 24% of the virgins in the sample had had oral sex. The corresponding proportion among those who had initiated coitus was 82%. In 1994-1995, a survey of 291 college undergraduates indicated that among those who were in a serious relationship, virgins were as likely as nonvirgins to have ever had oral sex (although nonvirgins were more likely to have had mutual oral sex).
Few studies focus exclusively on individuals before they are "sexually active." One such effort assessed the range of precoital sexual activities among a volunteer sample of 311 nonvirgin college undergraduates who were surveyed retrospectively, in the 1995-1996 academic year, about their experiences before their first coitus. Seventy percent of the males and 57% of the females reported having performed oral sex at least once before their first intercourse; the proportion ever receiving oral sex was the same for both genders ( 57-58%).
Two early-1990s surveys based on total high school enrollment, instead of single-subject college classes, came out of efforts to evaluate condom availability programs for HIV prevention. In 1992, baseline data collected for such a program in Los Angeles among 2,026 ninth-12th graders indicated that 29-31% of the virgins in this sample had engaged in masturbation with a partner, and 9-10% of those who had not yet had coitus had nonetheless had oral sex. Very few (1% of noncoitally experienced students) revealed that they had ever engaged in anal intercourse.
Another study from 1992, also designed to collect baseline data for a condom program evaluation, was conducted in suburban high schools in the New York City metropolitan area. The director of that study said it unexpectedly uncovered considerably higher rates of oral intercourse than of vaginal intercourse.
Finally, one nationally representative survey--the National Survey of Adolescent Males--asked about a full range of heterosexual genital activities in both 1988 and 1995. Although the overall proportion of 15-19-year-old males who had ever received oral sex did not change significantly from 1988 to 1995 (44% vs. 50%), this proportion more than doubled among blacks (from 25% to 57%). Moreover, among virgin young men, the proportion ever having received oral sex increased from 10% to 17%, although this difference was not statistically significant. [Editors' note: For further details on these data, see pp. 295-297 & 304.]
Data collected in small-scale evaluations of abstinence education programs are an unexpected source of information on adolescents' current experience with oral sex. A few evaluation sites recently used questionnaires that asked about a variety of sexual activities in assessing how middle-school students interpret messages about behaviors to be abstained from. Thus, those who had had oral sex but not coitus could be distinguished from other groups. According to Stan Weed, director of the Institute for Research and Evaluation in Salt Lake City, the responses to these items indicate that "there is a percentage of kids for whom oral sex seems to be a substitute for intercourse; I'm guessing that, although it varies with the sample, for around 25% of the kids who have had any kind of intimate sexual activity, that activity is oral sex, not intercourse."
- Remez, Lisa; Oral sex among adolescents: is it sex or is it abstinence?; Family Planning Perspectives; Nov/Dec 2000; Vol. 32; Issue 6.
Reflection Exercise #9
The preceding section contained information about the attitudes and motivations of teens regarding oral sex. Write three case study examples
regarding how you might use the content of this section in your practice.
According to Roffman, why do adolescent girls turn to oral sex?
Record the letter of the correct answer the