The many, even competing, agendas in the culturally loaded definitions of the term "sex" make sexuality research exceptionally challenging to conduct.[E] In early fall of 1998, the American public was riveted by President Bill Clinton's claim that he had not perjured himself because he "did not have sexual relations with that woman [White House intern Monica Lewinsky]"; he had, in fact, had something else oral sex. At the time, according to a Gallup Poll, roughly 20% of adults also believed that oral sex did not constitute "sexual relations." No one knows how many adolescents feel the same way. As Robert Blum, director of the Adolescent Health Program at the University of Minnesota puts it, "we know that there are many sexual practices other than intercourse that predispose young people to negative health outcomes. What we really don't know is, in an age of a focus on abstinence, how young people have come to understand what is meant by being sexually active."
Limited data are available on college undergraduates' perceptions of what is meant by sexual activity. Among roughly 600 students enrolled at a Midwestern university surveyed in 1991, 59% did not believe that oral sex would qualify as sex and only 19% thought the same about anal sex. Females (62%) were more likely than males (56%) to assert that cunnilingus and fellatio were not "sex."
What young adults consider to be "sex" also varies by contextual and situational factors, such as who is doing what to whom and whether it leads to orgasm. In data collected in early 1998 among a sample of college undergraduates who were read hypothetical scenarios and were asked to comment on them, 54% considered that a man would say fellatio did not qualify as sex and 59% that a woman would not consider cunnilingus to be sex; these proportions were even higher once it was specified that oral sex had not resulted in orgasm. Correspondingly, in another study in which these students were asked which acts would define a sexual partner, they were less likely to say that a couple would consider one another as "sexual partners" if they had had oral sex than if they had had vaginal or anal intercourse.
In the face of limited rigorous research in this area, magazines for teenagers serve as an important source of information on what adolescents think about oral sex. Impressions of oral sex are necessarily bound up with views on sexual intercourse, since one is usually cited as either a precursor or substitute for the other. According to a fall 1999 survey conducted by Seventeen magazine in which 723 15-19-year-old males and females were approached in malls, 49% considered oral sex to be "not as big a deal as sexual intercourse," and 40% said it did not count as "sex." A summer 2000 Internet survey conducted by Twist magazine received 10,000 on-line responses from 13-19-year-old girls, 18% of whom said that oral sex was something that you did with your boyfriend before you are ready to have sex; the same proportion stated that oral sex was a substitute for intercourse.
Adults and adolescents do not necessarily agree on what activities are now inferred by the word "sex." Individuals from across the ideological spectrum who were interviewed for this report acknowledged that the assumption of what "sex" encompasses has changed. As Tom Klaus, president of Legacy Resource Group in Iowa, which produces comprehensive pregnancy prevention and abstinence resources for educators, observes, "we thought we were on the same page as our kids when we talked about 'it.' The new emerging paradigm is that we can't be so certain that we are really talking about the same thing."
What Is Abstinence?
If adolescents perceive oral sex as something different from sex, do they view it as abstinence? Research conducted in 1999 with 282 12-17-year-olds in rural areas in the Midwest probed how adolescents who received abstinence education interpreted the term. Students struggled to come up with a coherent definition, although older adolescents had less difficulty than younger ones. The wide-ranging responses covered ground from "kissing is probably okay" to "just no intercourse."
Some of the students brought marriage into their definition of abstinence, and others asserted that it means going only as far sexually as one wanted to or felt comfortable with. The list of behaviors encompassed within virginity was long, and typically ended in statements such as "To me, the only thing that would take away my virginity is having sex. Everything else is permitted." (The very few recent abstinence program evaluations that assessed whether adolescents had engaged in sexual activities other than intercourse did not ask whether they did so under the assumption that they were being abstinent.)
In 1994-1995 data from 1,101 college freshman and sophomores in the South, 61% considered mutual masturbation (to orgasm) to be abstinent behavior, 37% described oral intercourse as abstinence and 24% thought the same about anal intercourse. The authors surmised that pregnancy prevention came first in these students' perceptions, so behaviors unlinked to pregnancy then counted as abstinence. On the other hand, nearly one-quarter labeled kissing and bathing or showering together as "not abstinent."
Health educators themselves might be unclear about precisely what the term "abstinence" means. In a 1999 e-mail survey of 72 health educators, for example, nearly one-third (30%) responded that oral sex was abstinent behavior. A similar proportion (29%), however, asserted that mutual masturbation would not qualify as abstinence.
Experts interviewed for this report acknowledged that defining what is meant by abstinence--and accurately communicating that definition to students--has become a crucial issue. While everyone agrees that the implicit meaning of the term is abstaining from vaginal-penile intercourse, especially since the concept is often taught as a "method" of avoiding pregnancy, the consensus stops there. What is the specific behavior that signals the end of abstinence and the beginning of sex?
Given the amount of federal and state money going into abstinence education, the lack of a consensus on whether and how to specify the behaviors to be abstained from warrants close examination. In 1996, Congress established a new abstinence-education program as part of its overhaul of welfare. Title V of the Maternal and Child Health Services Block Grant guarantees $50 million annually in federal support for five years (1998-2004) for abstinence-only education; since state and local governments are obligated to supply $3 for every $4 in federal funds, the total annual expenditure for government-supported abstinence education--which must promote abstinence until marriage could reach almost $90 million each year.
Although Title V does not specify an age-range for these activities, the majority of the states that have received funding have targeted teenagers aged 17 and younger. The eight-point official definition in Title V specifies that programs teach "abstinence from sexual activity outside marriage as the expected standard for all school-age children," but the law does not delineate "sexual activity."
Several experts noted that the different purpose or intent of the teaching of abstinence i.e., for public health reasons or for moral or religious reasons--will naturally produce a different set of activities to be abstained from. The lack of a consensus definition of abstinence is also a relatively new issue that current events are forcing to the forefront. As Barbara Devaney of Mathematica, a research agency conducting a national evaluation of Title V programs, points out, "at the time that the legislation was written, there was not much public controversy over what abstinence was; this was not yet on the radar screen."
This issue is especially thorny because some abstinence-only programs are committed to being as specific as possible so adolescents do not take away the wrong message about what abstinence is, while others insist that specifying those behaviors violates a child's innocence and amounts to providing a "how-to" manual. Tom Klaus affirms that the inability to specify what activities youth should abstain from is forcing a Catch 22--adolescents cannot practice abstinence until they know what abstinence is, but in order to teach them what abstinence is, they have to be taught what sex is. According to Stan Weed, "there's no settled consensus in the abstinence movement. Some programs are willing to take it head on and say [oral sex] is not an appropriate activity, if you think this is a substitute, you're wrong; others are not even dealing with it."
Amy Stephens of Focus on the Family, a Colorado Springs-based conservative religious organization, asserts that in its curriculum, Sex, Lies and...the Truth, "our definition is refraining from all sexual activity, which includes intercourse, oral sex, anal sex and mutual masturbation--the only 100% effective means of preventing pregnancy and the spread of STDs." Stephens notes that the different faith communities will use language specific to their congregations (i.e., "chastity" in Catholic circles and "purity" in Christian Evangelical communities). In the official definition of abstinence used by the Chicago-based Project Reality, the "sexual activity" to be avoided until marriage "refers to any type of genital contact or sexual stimulation including, but not limited to, sexual intercourse."
Consequences and Implications Sexuality and Abstinence Education
Some adolescent health professionals believe that although the revelation of early oral sex has been shocking, it has had the positive effect of forcing a dialogue with adolescents about the full meaning of sexuality and of the importance of defining sex not as a single act, but as a whole range of behaviors. There is widespread agreement among educators from all along the ideological spectrum that the continuing lack of adult guidance about what sex really means contributes to the desensitized, "body-part" sex talked about in the press, whatever the real prevalence might be. They stress that teachers and parents need to do a better job at helping children interpret the context-free messages of sexuality they are bombarded with in the media, which now includes the still-evolving Internet. Some experts believe that programs are moving in the right direction by teaching adolescents how to identify bad or abusive relationships, but that there is still much work to be done to help them with intimacy and how to recognize good relationships.
The lack of guidelines on what activity is appropriate when is a common concern among professionals who work with adolescents. Educators who endorse comprehensive sexuality education support giving adolescents the criteria they need to decide when to abstain or when to participate across the full continuum of sexual behaviors. Abstinence proponents are wrestling with how to handle an evolving dilemma that pits those who stress the need to be as precise as possible in specifying the range of behaviors to be abstained from against others who insist that such specificity violates the core of abstinence-only education.
What are some of the health consequences of continuing to define sex so narrowly and to lack data on a wider range of behaviors? "As public health people, we need to think about how we can address prevention and education, when we don't even know which are the behaviors we are trying to 'prevent,'" Kathleen Toomey says. She notes that the cases of pharyngeal gonorrhea were only uncovered among middle schoolers, who had not sought care otherwise, through a screening project for meningitis, adding "we're probably missing this because we are not routinely doing throat swabs and because we are not asking the right questions."
There is widespread agreement that oral STD risk in adolescent populations has yet to be adequately measured and screened for. This situation is exacerbated by the fact that many of the adolescent patients involved have not yet initiated coitus and thus are unlikely to visit a family planning or STD clinic. When they do, several practitioners assert, more detailed sexual histories, despite the extra time involved, are essential to prevent misdiagnosis and to understand what the patient, rather than the provider, means by "sexual activity.' In the absence of an adequate screening protocol, unknowing clinicians might automatically assume that the patient has strep and prescribe antibiotics. The fact that many infections are asymptomatic further complicates the diagnosis when the mode of infection is not easily talked about.
The deeply rooted tendency to define sex as intercourse might not necessarily be working any more in reaching many adolescent patients at risk. How to counsel adolescents about lowering that risk is especially problematic, since many young people consider oral sex itself to be a form of risk reduction and are probably already reluctant (as are many adults) to discuss oral sex openly or to use dental dams or condoms. Many practitioners feel they have gotten very good at talking about penetrative risk, but that they now need to hone their skills at communicating with their young clients about other types of sexual activities--and to do so they need more information.
Qualitative and quantitative data on sexual behaviors other than intercourse are clearly needed to close the gaps in knowledge about practices that may expose young people to emotional and physical harm. Surveys have not yet been undertaken that would yield more useful data on the broad range of sexual behaviors young people might be engaging in. If such surveys are conducted and reveal that only a small percentage of adolescents are involved, "then we need not be alarmed," according to Laura Stepp, the Washington Post reporter who wrote some of the first stories on oral sex. "But if it's a considerable proportion, then we need to get out there with megaphones."
- 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 #10
The preceding section contained information regarding defining sex and abstinence. Write three case study examples
regarding how you might use the content of this section in your practice.
What were the results of a study of 600 students enrolled at a Midwestern university regarding oral sex?
Record the letter of the correct answer the