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SPECIAL REPORT

Oral Sex Among Adolescents: Is It Sex or Is It ? By Lisa Remez

ver the past few decades, nation- p a red with private households, become stinence. All of this leaves health profes- ally re p resentative surveys have even more inflamed when the questions sionals and policymakers without the Oaccumulated a wealth of data on go into behaviors “beyond” intercourse. means to effectively address these issues. levels of adolescent sexual activity. Thanks Another reason is the federal govern- The tendency to equate “sex” with in- to such surveys, we know how the pro- ment’s reluctance to sponsor such con- te r course alone rep r esents long-standing portion of 15–19-year-olds who have ever t roversial re s e a rch into the full range of cultural norms of acceptable sexual be- had intercourse has changed over the noncoital behaviors among adolescents.* havior and certainly applies to adults as years. Similar data exist on age at first in- For example, the highly charged political well as to adolescents. It also reflects a te r course, most recent sexual interco u r s e debate in 1992 over federal financing of deeply rooted ambivalence about talking and current contraceptive use. c o m p rehensive sexuality studies had a about sex. Recent press reports, however, Yet all of these measures focus on—or chilling effect on adolescent sexuality re- a re forcing a reappraisal of the implica- relate to the possible results of—vaginal se a rc h . 1 The Senate’s decision, prom p t e d tions of this exclusive focus on coitus for in t e r course. This is natural, given that at- by pre s s u re from a small group of con- re s e a rch and data collection efforts, for tention to adolescent sexual activity aros e servative senators, to deny funding for the STD prevention and treatment, and for the initially out of concerns over the far-re a c h - American Teenage Study of adolescent framing and interpretation of abstinence ing problems associated with teenage sexual behavior still reverberates in the and risk-reduction messages. p regnancy and childbearing. More re- scope of re s e a rch on teenagers. (An This special report draws on interviews c e n t l y, infection with sexually transmit- amendment sponsored by Sen. Jesse and correspondence with roughly two ted diseases (STDs), particularly with HIV, Helms [R.-NC] prohibited the funding of dozen adolescent and health profession- has fueled further public and scientific in- that survey, along with one of adults, “in als, including res e a r chers, psychologists, terest in teenage sexual behavior. fiscal year 1992 or any subsequent fis c a l abstinence program coordinators and But to what extent does adolescent sex- ye a r. ” 2 Despite warnings that ideology evaluators, sexuality educators and epi- ual activity consist of noncoital behav- was dictating science, the conservative demiologists, to explore some of these iors—that is, mutual , oral leadership succeeded in casting these en- consequences. The report concentrates on sex and anal intercourse—that are not deavors as “re p rehensible sex surveys” oral sex, as opposed to other noncoital be- linked to but involve the risk only undertaken “to legitimize homosex- haviors, because it is currently the subject of STDs? Some of these activities may also uality and other sexually pro m i s c u o u s of public debate in the media and in many be precursors to vaginal intercourse. Yet, lifestyles.”3) schools. It reviews the limited information health professionals and policymakers It has become increasingly clear, how- on adolescents’ experience with oral sex, know very little about their pre v a l e n c e e v e r, that the narrow focus on sexual in- and looks at the even smaller body of ev- among teenagers. t e rcourse in re s e a rch that does get fund- idence on what young people consider to There are several explanations for this ed is missing a major component of early be sex or abstinence. dearth of information. One is the per- sexual activity. There is growing evidence, ceived difficulty of getting parents to con- although still anecdotal and amassed Anecdotal Reports in the Media sent to surveys on the sexual activity of la r gely by journalists, not res e a r chers, that The first hint in the popular press of a new their minor children (generally aged 17 adolescents might be turning to behaviors “ t rend” in sexual activity among young and younger). Another is a generalized that avoid pregnancy risk but leave them people appeared in an April 1997 article fear that asking young people about sex vulnerable to acquisition of many STDs, in The New York Ti m e s.4 That article as- will somehow lead them to choose to have including HIV. serted that high school students who had sex. The conflicts and passions usually The reports in the popular press that come of age with AIDS education con- surrounding the appropriateness of ask- oral sex has become widespread among si d e r ed oral sex to be a far less dangerou s ing young people about sex, especially in adolescents cannot be confirmed or re- alternative, in both physical and emo- public settings such as schools as com- futed because the data to do so have never tional terms, than vaginal intercourse. By been collected. Moreo v e r , adults do not re- Lisa Remez is associate editor of Per - ally know what behaviors teenagers con- *The exceptions are the National Survey of Adolescent sp e c t i v e s . The preparation of this special report was made Males, which asked 15–19-year-old males about their ex- possible by a grant from the Marion Cohen Memorial sider to be “sex” and, by the same token, perience with oral and , and other studies that Foundation. what they consider to be its opposite, ab- were not national in scope.

298 Family Planning Perspectives 1999, the press reports started attributing For example, according to Kathleen son asked. Some say they have seen no this behavior to even younger students. Too m e y , director of the Division of Public change in STDs acquired noncoitally, A July Washington Post article described Health in Georgia’s Department of Human while others report that they are seeing an “unsettling new fad” in which subur- Re s o u r ces, “anecdotal evidence and some both new types of infections and new ban middle-school students were re g u- recent data suggest that teenagers are en- types of patients—i.e., teenagers who have larly engaging in oral sex at one another’s gaging in oral sex to a greater degree than not yet initiated coitus but who come in homes, in parks and even on school we had previously thought, but whether with fears and anxiety over having ac- g rounds; this piece reported an oral sex this re p resents a true increase is diffic u l t quired an infection orally. p revalence estimate, attributed to un- to say, since we have no baseline data for Linda Dominguez, assistant medical di- named counselors and sexual behavior re- co m p a r i s o n . ” 9 Susan Rosenthal, a prof e s - rector of Planned Parenthood of New s e a rchers of “about half by the time stu- sor of pediatrics and a pediatric psychol- Mexico and a nurse practitioner with a pri- dents are in high school.”5* ogist at Cincinnati Children’s Hospital vate practice, reports that at patients’ re- Other stories followed, such as a piece Medical Center, notes that in her clinical quests, she is performing more oral swabs in Tal k magazine in February 2000 that re- practice, “girls are clearly talking about and throat inspections now than in the ported on interviews with 12–16-year- oral sex and masturbation (of their part- p a s t .1 6 She affirms that “I have more pa- olds. These students set seventh grade as ners or by their partners) more freq u e n t - tients who are virgins who report to me the starting point for oral sex, which they ly than I used to hear about, but whether that they are worried about STDs they claimed begins considerably earlier than this is because they talk more openly about may have gotten by having oral sex. There i n t e rcourse. By 10th grade, according to it or are doing it more is unclear.” 10 De b o - are a lot of questions and concerns about the rep o r t e r , “well over half of their class- rah Haffn e r , a sexuality educator and for- herpes, since they seem to know that there mates were involved.”6 This article laid mer president of the Sexuality Information is some risk of ‘top and bottom’ herpes, as part of the blame on dual-care e r, over- and Education Council of the one of my patients put it.” worked “parents who were afraid to par- (SIECUS), dismisses the press reports of Sharon Schnare, a family planning cli- ent,” and also mentioned that young ado- oral sex among middle-school–aged ado- nician and consultant in Seattle, remarks lescents were caught between messages lescents as largely media hype, saying that that she now sees many teenagers with about AIDS and abstinence on the one only a very small number of young peo- oral herpes. She adds that “I have also hand and the saturation of the culture ple are probably involved.11 found, though rare l y, oral C o n d y l o m a t a with sexual imagery on the other. In April Experts believe that the type of oral sex a c u m i n a t a [a sexually transmitted condi- 2000, another New York Ti m e s article on practiced by young teenagers is over- tion caused by the human papillomavirus ] pr ecocious sexuality quoted a Manhattan whelmingly , not cunnilingus. Ac- in teenagers.”1 7 M o re o v e r, Hitchcock psychologist as saying “it’s like a good- co r ding to Deborah Tolman, senior res e a rc h states that “several studies have shown night kiss to them” in a description of how scientist at the Wellesley Center for Re- that one-third of the isolates from genital seventh- and eighth-grade virgins who se a r ch on Women, that distinction is para- herpes cases in kids right now are HSV1 we r e saving themselves for were mount: “We are not fainting in the street be- [ 1, the oral strain], having oral sex in the meantime because cause boys are giving girls cunnilingus. which suggests a significant amount of they perceived it to be safe and risk-free . 7 Which is not to say that girls and boys oral intercourse is going on.”18 This sug- In a July 2000 Washington Post Magazine never have that experience. They prob a b l y gestion is impossible to verify, however, cover story, eighth graders described do, and just rarely do it again for a rea l l y because of the extensive crossover be- being regularly propositioned for oral sex long time, because of how girls feel about tween the two strains. More o v e r, tre n d s in school. The reporter echoed the asser- themselves and their bodies, how boys feel a re especially hard to detect because of tion made in earlier articles that although about girls’ bodies, and the misinformation past and current problems in the rel i a b i l - overall sexual activity among older, high they have about each other’s bodies.”12 ity of type-specific testing. school–aged adolescents—as measured by Many STDs can be transmitted by either Pharyngeal is one STD that the proportion who have ever had penile- fellatio or cunnilingus, although some are is definitely acquired through oral sex. A vaginal intercourse—seemed to have re- m o re easily passed than others. Accord- few cases of pharyngeal gonorrhea have cently leveled off or slightly declined, mid- ing to Penelope Hitchcock, chief of the been diagnosed in adolescent girls in dle-school–aged students (aged 12–14) Sexually Transmitted Diseases Branch of Dominguez’s family planning clinic in a p p e a red to be experimenting with a the National Institute of Allergy and In- New Mexico19 and in one region of Geor- wider range of behaviors at progressive- fectious Diseases, saliva tends to inactivate gia through a community screening proj - ly younger ages.8 the HIV virus, so while ect among middle-school students to de- t h rough oral intercourse is not impossi- tect certain strains of meningitis What Teenagers Might Be Doing ble, it is relatively rare. 13 Other viral STDs carried in the throa t . 20 In Georgia, the cases How valid are these anecdotal re p o r t s ? that can be transmitted orally include caught everyone off guard, according to Unless and until data to verify them be- human papillomavirus, herpes simplex Kathleen To o m e y.2 1 The infections were come available, we have only impres s i o n s virus and B,14 while gonorrhea, found only because throat swabs were to go on, and there is by no means a con- , c h l a m y d i a and chancroid are being done for meningitis in a population sensus among adolescent health pro f e s- among the bacterial infections that can be that would not be considered “sexually ac- sionals. Some believe the level of partici- passed through oral sex.15 tive” in the traditional sense of the word. pation in oral sex and other noncoital In the absence of survey data on the fre- behaviors is probably higher now than it quency of oral sex, the question arises as * A round the same time, an Irish Ti m e s article re p o r t e d was in the past, while others have a to whether clinicians are seeing evidence on 14- and 15-year-old Dubliners who, after getting drunk on hard cider, gathered in local parks and paired “hunch” that oral sex is no more common, of a rise in STDs that have been acquired of f for oral sex. (See: Sheridan K, Our children and their just much more talked about. or a l l y . The answer depends upon the per- sex games, Irish Times, July 17, 1999, p. 12.)

Volume 32, Number 6, November/December 2000 299 Oral Sex Among Adolescents

Many res e a r chers and clinicians believe “ O k a y, we get it. You adults really don’t young women who had performed fella- that young adolescents who are having want us to have , and tio had never had vaginal interc o u r s e .2 9 oral sex before they start coitus might be y o u ’ re probably right because of AIDS To many adolescents, safer-sex in the pre- especially reluctant to seek clinical care . and preg n a n c y . But we’re still sexual and AIDS era presumably meant avoiding Mo re o v e r , adolescents virtually never use we’re going to do other things.”23 pre g n a n c y . The practice of “outerco u r s e , ” or dental dams to protect against Ha ff n e r ’s interviews with 11th and 12th in fact, was suggested by at least one STD infection during oral sex, even those graders reveal that they view oral sex as physician as early as 1972† as an alterna- who know about the risk and worry that “something you can do with someone tive contraceptive method for young teen- they might become infected. y o u ’ re not as intimate with, while inter- a g e r s .3 0 That physician, John Cobb, as- However little is known about teen- course is, by and large, reserved for that serted that loosening the aro u n d agers’ experiences with oral sex, even less special person.”24 This emotional diff e r- noncoital activity might “help signifi- information is available on their involve- ential between oral sex and vaginal sex— cantly in the prevention of unwanted teen- ment with anal sex, which also carries the assertion that oral sex carries few or no age pregnancy and of venereal disease.” risks of STD infection, particularly of HIV. emotional ties—is acknowledged by many Other nonrep r esentative res e a r ch done While teenage patients now seem much pr ofessionals who work with adolescents. in the early 1980s focused on adolescents’ m o re comfortable talking about oral sex Linda Dominguez quotes her adolescent sexual experimentation as a precursor or than they were in the past, the patients as thinking “if you’re going to pr edictor of coitus. One longitudinal against bringing up anal sex is still very avoid intercourse, you’re going to resort to pr ospective study conducted in a southern much in place. oral sex. You ’ r e going to do something that city in 1980 and 1982 found that among a is sexual, but in some ways emotionally sample of black and white 12–17-year-o l d s , Attitudes and Motivations sa f e r , before you give the big one away.” 25 blacks proceeded more quickly to inter- Experts say there are multiple, interrel a t - Adolescent health professionals re i n- course, while whites followed a pred i c t a b l e ed reasons for why adolescents might be f o rced the view reported in the popular scenario of noncoital activities as substitutes turning to oral sex. Deborah Roffman, a p ress that today’s adolescents consider or delay mechanisms.31 Another study sexuality educator at The Park School in oral sex to be less consequential and less using the 1982 follow-up data set only (545 B a l t i m o re, asserts that “middle-school intimate than intercourse. “Oral sex is 10th–12th graders) concluded that 24% of girls sometimes look at oral sex as an ab- clearly seen as something very diff e re n t the virgins in the sample had had oral sex.32 solute bargain—you don’t get pre g n a n t , than intercourse, as something other than The corresponding proportion among they think you don’t get diseases, you’re sex,” according to Susan Rosenthal. She those who had initiated coitus was 82%. In still a virgin and you’re in control since it’s also mentions a generational shift in think- 1994–1995, a survey of 291 college under- something that they can do to boys ing, noting that “if you were to query graduates indicated that among those who (whereas sex is almost always described older women, oral sex might be perce i v e d we r e in a serious relationship, virgins were as something boys do to girls).”22 as something more intimate or equally as likely as nonvirgins to have ever had oral This sense of control is illusory, ac- intimate to vaginal sex (and which fre- sex (although nonvirgins were more like- co r ding to Roffman, because engaging in quently happened later on in a re l a t i o n- ly to have had mutual oral sex).33 fellatio out of peer pre s s u re or to gain ship); for the teens, oral sex appears to be popularity is clearly exploitative of girls much less intimate or serious than vagi- *For example, in a fall 1999 mall-intercept survey con- who lack the maturity to realize it. The nal intercourse.”26 ducted by S e v e n t e e n magazine and the Henry J. Kaiser Family Foundation, 16% of 15–19-year-old males and fe- issue of just how voluntary oral sex is for males asserted that oral sex was “safe” because it pro- many girls came up repeatedly, especial- Insights from Formal Research tected against infection with an STD, while 48% labeled ly when the act is performed “to make How does the limited published res e a rc h the practice as “safe” because it protected against preg- boys happy” or when alcohol is involved. conducted on oral sex inform the current n a n c y. Incidentally, 55% thought that oral sex was Ro f fman relates the experience of a guid- situation? Because of the difficulties in ob- “ g ross,” the same proportion who said they had ever done it. (See re f e rence 45.) More o v e r, in the S e v e n - ance counselor who, after bringing up the taining funding and consent for conduct- t e e n/Kaiser collaborative special section “Sex Smarts,” topic of in this context of coerced oral ing this type of re s e a rch among minors, the number-one sex myth listed in the “10 Sex Myths sex, was told by female students that the many of these studies have necessarily re- Exposed” was “oral sex is no big thing.” (Forman G, 10 term did not apply to their situation, be- lied on small, nonrep r esentative samples sex myths exposed, Sex Smarts Special Section, tearout cause fellatio “is not really sex.” of college-age students enrolled in human in Seventeen, June 2000.) Teenagers seem to be especially misin- sexuality or psychology classes, which are †Tw e n t y - fi ve years later, this physician, in a letter to the formed about the STD risks of oral sex. Ex- ha r dly generalizable to the overall popu- ed i t o r , again advocated encouraging adolescents to prac- tice outercourse (or heavy petting to without pen- perts repeatedly mentioned their concerns lation. Perhaps the best, though still lim- etration) as a “cost-free, natural and effective way to pre- over adolescents’ perceptions of oral sex ited, dataset that includes adolescents vent unwanted pregnancy and STDs while making love.” as less risky than intercourse,* especially dates from the early 1980s: In 1982, a mar- This time, the message was updated with the warning in the context of teenagers’ tendency to keting re s e a rch firm collected data fro m that the advent of HIV meant that “of course, anal or oral have very short-term relationships. Sev- a national panel of households in 49 in t e r course is to be avoided.” (See: Cobb JC, Outerco u r s e 27 as a safe and sensible alternative to contraceptives, let- eral observers mentioned the trap of AIDS states. Douglas Kirby, currently of ETR ter to the editor, American Journal of Public Health, 1997, education, which often teaches that HIV Associates, directed this early re s e a rc h 87(8):1380–1381.) Critics of this strategy, however, point is transmitted through sexual interco u r s e , pr oject; he recalls that “we were surprised to the fact that it has never been adequately evaluated so adolescents think they are avoiding risk that there was much more oral sex than we and that since it involves promoting behaviors that are by avoiding sexual intercourse. Sarah had anticipated.”28 c o n s i d e red themselves predisposing factors for coitus, it may lead to intermittent, unprotected intercourse. (See: Br own, director of the National Campaign Roughly one-fifth of the 1,067 13–18- Genius SJ and Genius SK, Orgasm without org a n i s m s : to Prevent Teen Preg n a n c y , suggests what ye a r -olds surveyed in the early 1980s said science or propaganda? Clinical Pediatrics, 1996, some adolescents might be thinking: they had ever had oral sex, and 16% of 35(1):10–17.)

300 Family Planning Perspectives Few studies focus exclusively on indi- other groups. According to Stan Weed, di- we r e less likely to say that a couple would viduals before they are “sexually active.” rector of the Institute for Research and consider one another as “sexual partners” One such effort assessed the range of pre- Evaluation in Salt Lake City, the res p o n s - if they had had oral sex than if they had had coital sexual activities among a volunteer es to these items indicate that “there is a vaginal or anal interco u r s e . 44 sample of 311 nonvirgin college under- p e rcentage of kids for whom oral sex In the face of limited rigorous research graduates who were surveyed ret ro s p e c - seems to be a substitute for interc o u r s e ; in this area, magazines for teenagers serve t i v e l y, in the 1995–1996 academic year, I’m guessing that, although it varies with as an important source of information on about their experiences before their fir s t the sample, for around 25% of the kids what adolescents think about oral sex. Im- coitus. Seventy percent of the males and who have had any kind of intimate sexu- pr essions of oral sex are necessarily bound 57% of the females reported having per- al activity, that activity is oral sex, not up with views on sexual intercourse, since formed oral sex at least once before their intercourse.”39 one is usually cited as either a pre c u r s o r first intercourse; the proportion ever re- or substitute for the other. According to a ceiving oral sex was the same for both gen- What Is Sex? fall 1999 survey conducted by S e v e n t e e n ders (57–58%).34 The many, even competing, agendas in the magazine in which 723 15–19-year- o l d Two early-1990s surveys based on total culturally loaded definitions of the term males and females were approached in high school enrollment, instead of single- “sex” make sexuality res e a r ch exception- malls, 49% considered oral sex to be “not subject college classes, came out of effo r t s ally challenging to conduct.* In early fall as big a deal as sexual intercourse,” and to evaluate availability prog r a m s of 1998, the American public was riveted 40% said it did not count as “sex.”4 5 A for HIV pre v e n t i o n .3 5 In 1992, baseline by President Bill Clinton’s claim that he summer 2000 Internet survey conducted data collected for such a program in Los had not perjured himself because he “did by Twi s t magazine received 10,000 on-line Angeles among 2,026 ninth–12th graders not have sexual relations with that woman responses from 13–19-year-old girls, 18% indicated that 29–31% of the virgins in this [White House intern Monica Lewinsky]”; of whom said that oral sex was something sample had engaged in masturbation with he had, in fact, had something else—oral that you did with your boyfriend before a partner, and 9–10% of those who had not sex. At the time, according to a Gallup Poll, you are ready to have sex; the same pro- yet had coitus had nonetheless had oral roughly 20% of adults also believed that portion stated that oral sex was a substi- sex. Very few (1% of noncoitally experi- oral sex did not constitute “sexual re l a- tute for intercourse.46 enced students) revealed that they had t i o n s . ”4 0 No one knows how many ado- Adults and adolescents do not neces- ever engaged in anal interc o u r s e .3 6 A n- lescents feel the same way. As Robert Blum, sarily agree on what activities are now in- other study from 1992, also designed to di r ector of the Adolescent Health Prog r a m f e r red by the word “sex.” Individuals collect baseline data for a condom pro- at the University of Minnesota puts it, “we fr om across the ideological spectrum who gram evaluation, was conducted in sub- know that there are many sexual practices w e re interviewed for this report ac- urban high schools in the New York City other than intercourse that pre d i s p o s e knowledged that the assumption of what m e t ropolitan area. The director of that young people to negative health outcomes. “sex” encompasses has changed. As Tom study said it unexpectedly uncovered con- What we really don’t know is, in an age of Klaus, president of Legacy Resourc e siderably higher rates of oral intercourse a focus on abstinence, how young people Group in Iowa, which produces compre- than of vaginal intercourse.37 have come to understand what is meant by hensive pregnancy prevention and absti- F i n a l l y, one nationally re p re s e n t a t i v e being sexually active.”41 nence re s o u rces for educators, observes, survey—the National Survey of Adoles- Limited data are available on college “we thought we were on the same page cent Males—asked about a full range of u n d e rgraduates’ perceptions of what is as our kids when we talked about ‘it.’ The he t e r osexual genital activities in both 1988 meant by sexual activity. Among ro u g h- new emerging paradigm is that we can’t and 1995. Although the overall prop o r t i o n ly 600 students enrolled at a Midwestern be so certain that we are really talking of 15–19-year-old males who had ever re- university surveyed in 1991, 59% did not about the same thing.”47 ceived oral sex did not change signifi- believe that oral sex would qualify as sex cantly from 1988 to 1995 (44% vs. 50%), and only 19% thought the same about anal What Is Abstinence? this proportion more than doubled among se x . 42 Females (62%) were more likely than If adolescents perceive oral sex as some- blacks (from 25% to 57%).3 8 M o re o v e r, males (56%) to assert that cunnilingus and thing diff e rent from sex, do they view it among virgin young men, the prop o r t i o n fellatio were not “sex.” as abstinence? Research conducted in 1999 ever having received oral sex incre a s e d What young adults consider to be “sex” with 282 12–17-year-olds in rural areas in fr om 10% to 17%, although this diffe re n c e also varies by contextual and situational the Midwest probed how adolescents who was not statistically significant. [Editors’ factors, such as who is doing what to received abstinence education interpre t- note: For further details on these data, see whom and whether it leads to orgasm. In ed the term. Students struggled to come pp. 295–297 & 304.] data collected in early 1998 among a sam- Data collected in small-scale evalua- ple of college undergraduates who were *For and women, for example, the narrow pe- tions of abstinence education pro g r a m s read hypothetical scenarios and were asked nile-vaginal intercourse definition is clearly irre l e v a n t . In data recently collected from an Internet sample, adult are an unexpected source of information to comment on them, 54% considered that homosexuals and bisexuals tended to label a greater num- on adolescents’ current experience with a man would say fellatio did not qualify as ber of activities as “sex” than did a comparable sample oral sex. A few evaluation sites re c e n t l y sex and 59% that a woman would not con- of heterosexuals. The researcher concluded that the im- used questionnaires that asked about a va- sider cunnilingus to be sex;4 3 these pro- plications of such semantic diversity “cannot be under- riety of sexual activities in assessing how portions were even higher once it was spec- estimated in conducting sexuality survey res e a r ch, clin- middle-school students interpret mes- i fied that oral sex had not resulted in ical sexual history taking or .” (See: Mustanski B, Semantic heterogeneity in the definition of sages about behaviors to be abstained or gasm. Corres p o n d i n g l y , in another study “having sex” for homosexuals, unpublished manuscript, f rom. Thus, those who had had oral sex in which these students were asked which Department of Psychology, Indiana University, Bloom- but not coitus could be distinguished from acts would define a , they ington, IN, 2000.)

Volume 32, Number 6, November/December 2000 301 Oral Sex Among Adolescents up with a coherent definition, although guarantees $50 million annually in feder- p regnancy and the spread of STDs.”5 7 older adolescents had less difficulty than al support for five years (1998–2004) for ab- Stephens notes that the diff e rent faith younger ones. The wide-ranging re- stinence-only education; since state and communities will use language specific to sponses covered ground from ”kissing is local governments are obligated to supply their congregations (i.e., “chastity” in pr obably okay” to “just no interco u r s e . ” 48 $3 for every $4 in federal funds, the total Catholic circles and “purity” in Christian Some of the students brought marriage annual expenditure for government-sup- Evangelical communities). In the official into their definition of abstinence, and oth- ported abstinence education—which must de fi nition of abstinence used by the Chica- ers asserted that it means going only as far pr omote abstinence until marriage—could go-based Project Reality, the “sexual ac- sexually as one wanted to or felt comfort- reach almost $90 million each year.52 * tivity” to be avoided until marriage “ref e r s able with. The list of behaviors encom- Although Title V does not specify an to any type of genital contact or sexual passed within was long, and typ- age-range for these activities, the majori- stimulation including, but not limited to, ically ended in statements such as “To me, ty of the states that have received funding sexual intercourse.”58 the only thing that would take away my have targeted teenagers aged 17 and vi r ginity is having sex. Everything else is yo u n g e r . The eight-point official defini t i o n Consequences and Implications permitted.” (The very few recent absti- in Title V specifies that programs teach Sexuality and Abstinence Education nence program evaluations that assessed “abstinence from sexual activity outside Some adolescent health professionals be- whether adolescents had engaged in sex- marriage as the expected standard for all lieve that although the revelation of early ual activities other than intercourse did not school-age childre n , ”5 3 but the law does oral sex has been shocking, it has had the ask whether they did so under the as- not delineate “sexual activity.” positive effect of forcing a dialogue with sumption that they were being abstinent.49 ) Several experts noted that the diffe re n t adolescents about the full meaning of sex- In 1994–1995 data from 1,101 college purpose or intent of the teaching of absti- uality and of the importance of defin i n g f reshman and sophomores in the South, nence—i.e., for public health reasons or for sex not as a single act, but as a whole range 61% considered mutual masturbation (to moral or religious reasons—will natural- of behaviors. There is widespread agree- or gasm) to be abstinent behavior, 37% de- ly produce a diffe r ent set of activities to be ment among educators from all along the scribed oral intercourse as abstinence and abstained from. The lack of a consensus de- ideological spectrum that the continuing 24% thought the same about anal inter- finition of abstinence is also a relatively new lack of adult guidance about what sex re- co u r s e . 50 The authors surmised that preg - issue that current events are forcing to the ally means contributes to the desensitized, nancy prevention came first in these stu- fo re f r ont. As Barbara Devaney of Mathe- “body-part” sex talked about in the pres s , dents’ perceptions, so behaviors unlinked matica, a res e a r ch agency conducting a na- whatever the real prevalence might be. to pregnancy then counted as abstinence. tional evaluation of Title V pro g r a m s , They stress that teachers and parents need On the other hand, nearly one-quarter la- points out, “at the time that the legislation to do a better job at helping children in- beled kissing and bathing or showering was written, there was not much public t e r p ret the context-free messages of sex- together as “not abstinent.” co n t r oversy over what abstinence was; this uality they are bombarded with in the Health educators themselves might be was not yet on the radar scree n . ” 54 media, which now includes the still-evolv- unclear about precisely what the term “ab- This issue is especially thorny because ing Internet. Some experts believe that stinence” means. In a 1999 e-mail survey some abstinence-only programs are com- p rograms are moving in the right dire c- of 72 health educators, for example, near- mitted to being as specific as possible so tion by teaching adolescents how to iden- ly one-third (30%) responded that oral sex adolescents do not take away the wro n g tify bad or abusive relationships, but that was abstinent behavior. A similar pro- message about what abstinence is, while th e r e is still much work to be done to help portion (29%), however, asserted that others insist that specifying those behav- them with intimacy and how to rec o g n i z e mutual masturbation would not qualify iors violates a child’s innocence and good relationships. as abstinence.51 amounts to providing a “how-to” manu- The lack of guidelines on what activity Experts interviewed for this report ac- al. Tom Klaus affirms that the inability to is appropriate when is a common concern knowledged that defining what is meant specify what activities youth should ab- among professionals who work with ado- by abstinence—and accurately communi- stain from is forcing a Catch 22—adoles- lescents. Educators who endorse com- cating that definition to students—has be- cents cannot practice abstinence until they p rehensive sexuality education support come a crucial issue. While everyone agree s know what abstinence is, but in order to giving adolescents the criteria they need that the implicit meaning of the term is ab- teach them what abstinence is, they have to decide when to abstain or when to par- staining from vaginal-penile interco u r s e , to be taught what sex is.55 Ac c o r ding to Stan ticipate across the full continuum of sex- especially since the concept is often taught Weed, “there’s no settled consensus in the ual behaviors. Abstinence proponents are as a “method” of avoiding preg n a n c y , the abstinence movement. Some programs are wr estling with how to handle an evolving consensus stops there. What is the specif- willing to take it head on and say [oral sex] dilemma that pits those who stress the ic behavior that signals the end of absti- is not an appropriate activity, if you think need to be as precise as possible in speci- nence and the beginning of sex? this is a substitute, you’re wrong; others fying the range of behaviors to be ab- Given the amount of federal and state ar e not even dealing with it.”56 stained from against others who insist that money going into abstinence education, Amy Stephens of Focus on the Family, such specificity violates the core of absti- the lack of a consensus on whether and a Colorado Springs–based conservative nence-only education. how to specify the behaviors to be ab- religious organization, asserts that in its stained from warrants close examination. curriculum, Sex, Lies and…the Tru t h , “our *The original Title V legislation had no provision for eval- In 1996, Congress established a new ab- de fi nition is refraining from all sexual ac- uation at the state level, but nearly every state has com- mitted some funds—an average of 5% of their abstinence stinence-education program as part of its ti v i t y , which includes intercourse, oral sex, education monies. At the federal level, Congress allot- ov e r haul of welfare. Title V of the Mater- anal sex and mutual masturbation—the ted $6 million for a national-level evaluation in the Bal- nal and Child Health Services Block Grant only 100% effective means of preventing anced Budget Act of 1997. (See: reference 52.)

302 Family Planning Perspectives Research and Evaluation these especially sensitive behaviors in the ing project for meningitis, adding “we’re What is to be gained by broadening the most private setting and mode of admin- pr obably missing this because we are not range of behaviors asked about in surveys istration possible (i.e., using audio com- routinely doing throat swabs and because of sexual behavior? The simplest public pu t e r -assisted self-interviews rather than we are not asking the right questions.” health argument is that doing so would personal interviews). Others say that T h e re is widespread agreement that enable res e a r chers to identify individuals should national-level studies prove im- oral STD risk in adolescent populations whose behaviors place them at risk, so that possible because of the constraints of has yet to be adequately measured and more appropriate programs and policies funding agencies, then small-area studies s c reened for. This situation is exacerbat- can be developed. Many of these youth would be of value, especially in higher ed by the fact that many of the adolescent a re now being missed by current survey p revalence areas where there might be patients involved have not yet initiated in s t r uments. By considering only adoles- gr eater receptivity to gathering such data. coitus and thus are unlikely to visit a fam- cents who have ever had coitus, or only Other professionals are clearly worried ily planning or STD clinic. When they do, dividing them by whether they had that about the prospect of gaining pare n t a l several practitioners assert, more detailed experience, “we don’t get a full under- consent—what Brown terms “the 800 sexual histories, despite the extra time in- standing of the range of adolescent activ- pound gorilla in the roo m ” 63 — e s p e c i a l l y volved, are essential to prevent misdiag- ity and of the developmental and emo- since many of the adolescents purported nosis and to understand what the patient, tional processes involved,” according to to be engaging in sexual activities other rather than the provider, means by “sex- Mark Schuster, dire c t o r, UCLA/RAND than intercourse are younger than 15, the ual activity.” In the absence of an adequate Center for Adolescent Health Prom o t i o n . 59 minimum age usually included in tradi- sc r eening protocol, unknowing clinicians It is also impossible to adequately assess tional surveys. Stan Weed, who has ex- might automatically assume that the pa- how changes in sexual activity or in con- perience drafting questionnaires in the tient has strep and prescribe antibiotics. traceptive behavior contributed to rec e n t new climate of ostensibly greater partici- The fact that many infections are asymp- declines in adolescent pregnancy rates as pation in oral sex, suggests that advance tomatic further complicates the diagno- long as information on sexual activity un- f o c u s - g roup re s e a rch can be helpful in sis when the mode of infection is not eas- linked to pregnancy remains unavailable. countering objections to questions fro m ily talked about. For example, while diffe r ent groups have pa r ents and school administrators. If find - The deeply rooted tendency to defin e attributed a greater or lesser share of the ings illustrate that the behavior is preva- sex as intercourse might not necessarily declines in pregnancy rates to incre a s e d lent, for example, then the evaluation team be working any more in reaching many a b s t i n e n c e ,6 0 how much of that “absti- can use that information to explain why adolescent patients at risk. How to coun- nence” corresponds to sexual activity other those questions need to be asked.64 sel adolescents about lowering that risk than intercourse is still unknown. Although the well-known technique of is especially problematic, since many Another advantage to using a broader asking 18-year-olds to report on their ear- young people consider oral sex itself to be me a s u r e of sexual activity is being able to lier experiences was also mentioned, some a form of risk reduction and are prob a b l y mo r e fully measure the impact of various experts point out that parents’ willingness already reluctant (as are many adults) to pr ograms and curricula that address ado- to grant consent might have re c e n t l y discuss oral sex openly or to use dental lescent sexuality. As Sarah Brown stress- changed. Joyce Abma, a demographer at dams or condoms. Many practitioners feel es, “if, for example, we found that there the National Center for Health Statistics, they have gotten very good at talking was a curriculum that delayed the age of for example, is hopeful that “maybe we’re about penetrative risk, but that they now first vaginal intercourse, but increased the in an era where people understand the need to hone their skills at communicat- p reponderance of oral sex, we should di r e nature of STD transmission and HIV. ing with their young clients about other know that.”61 So if the message is that this could possi- types of sexual activities—and to do so Cu r re n t l y , the principal outcome mea- bly contribute to both a better under- they need more information. su r es used in evaluations of both compre- standing of and eventual lessening of Qualitative and quantitative data on hensive sexuality and abstinence-based these serious health conditions, then there sexual behaviors other than interc o u r s e pr ograms are the standard ones of vaginal might be a greater possibility of coopera- a re clearly needed to close the gaps in in t e r course, pregnancy and contraceptive t i o n . ”6 5 This belief is echoed by others, knowledge about practices that may ex- use. That holds true for the Mathematica who talk of the need to engage parents di- pose young people to emotional and national evaluation of Title V abstinence ed- rectly and to not necessarily assume that physical harm. Surveys have not yet been ucation programs. The project dire c t o r, they would deny permission. undertaken that would yield more useful Rebecca Maynard, explains that after much data on the broad range of sexual behav- debate, the group that devised the ques- Clinical Care iors young people might be engaging in. t i o n na i re settled on the stable outcome What are some of the health consequences If such surveys are conducted and reveal me a s u r e of intercourse for the first wave of continuing to define sex so narro w l y that only a small percentage of adolescents of follow-up, to assure that the evaluation and to lack data on a wider range of be- a re involved, “then we need not be was not measuring diffe r ent definitions of haviors? “As public health people, we alarmed,” according to Laura Stepp, the sex, as opposed to diffe r ent behaviors.62 need to think about how we can address Washington Post reporter who wrote some Even if there is agreement on the need pr evention and education, when we don’t of the first stories on oral sex. “But if it’s a to expand the definition of sexual activi- even know which are the behaviors we are considerable proportion, then we need to ty to create more accurate re s e a rch and trying to ‘prevent,’ ” Kathleen To o m e y get out there with megaphones.”67 evaluation tools, getting those items onto s a y s .6 6 She notes that the cases of pha- survey instruments remains a concern. ryngeal gonorrhea were only uncovered References Some res e a r chers assert that surveys need among middle schoolers, who had not 1. Di Mauro D, Sexuality Research in the United States: An to be allowed to capture self-reports of sought care otherwise, through a screen- Assessment of the Social and Behavioral Sciences, New Yor k :

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Social Science Research Council, 1995. 27. Coles R and Stokes G, Sex and the American Teenager, ducted by Se v e n t e e n finds that more than half of teens ages New York: Harper and Row, 1985. 15–19 have engaged in oral sex, Feb. 28, 2000. 2. U.S. Congressional Record—Senate, Apr. 2, 1992, pp. S 4737 and S 4758. 28. Kirby D, ETR Associates,Santa Cruz,CA, personal 4 6 . Birnbaum C, The love & sex survey 2000, Tw i s t , communication, Sept. 12, 2000. Oct./Nov. 2000, pp. 54–56. 3. Ibid., p. 4737. 29 . Coles R and Stokes G, 1985, op. cit. (see ref e r ence 27). 47. Klaus T, Legacy Resource Group, Carlisle, IA, per- 4 . Lewin T, Teen-agers alter sexual practices, thinking sonal communication, Sept. 21, 2000. risks will be avoided, New York Times, Apr. 5, 1997. 30 . Cobb JC, Nonproc r eative sexuality as an alternative to contraception, in Advances in Planned Parenthood, 48. Bell HA, Just because you see their privates doesn’t 5 . 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