Oral Versus Vaginal Sex Among Adolescents: Perceptions, Attitudes, and Behavior Bonnie L. Halpern-Felsher, PhD*; Jodi L. Cornell, MSW, MA*; Rhonda Y. Kropp, BScN, MPH*; and Jeanne M. Tschann, PhD‡ ABSTRACT. Objective. Despite studies indicating ABBREVIATIONS. STI, sexually transmitted infection; ANOVA, that a significant proportion of adolescents are having analysis of variance. oral sex, the focus of most empirical studies and inter- vention efforts concerning adolescent sexuality have focused on vaginal intercourse. This narrow focus has lthough the past several decades have pro- created a void in our understanding of adolescents’ per- duced a host of research on adolescent sexu- ceptions of oral sex. This study is the first to investigate ality as well as numerous prevention and adolescents’ perceptions of the health, social, and emo- A intervention efforts aimed at reducing adolescents’ tional consequences associated with having oral sex as engagement in risky sexual behaviors, the majority compared with vaginal sex, as well as whether adoles- of these efforts have focused solely on vaginal inter- cents view oral sex as more acceptable and more preva- lent than vaginal sex. course. This concentration has occurred despite stud- Methods. Participants were 580 ethnically diverse ies indicating that a significant proportion of adoles- ninth-grade adolescents (mean age: 14.54; 58% female) cents are engaging in noncoital sexual activities, who participated in a longitudinal study on the relation- including oral sex.1–5 Studies indicate that between ship between risk and benefit perceptions and sexual 14% and 50% of adolescents have had oral sex before activity. Participants completed a self-administered ques- their first experience with sexual intercourse,3,5–8 that tionnaire that inquired about their sexual experiences more adolescents have had oral sex than vaginal and percent chance of experiencing outcomes from, atti- sex,5,8,9 and that few adolescents who engage in oral tudes toward, and perceived prevalence of oral versus sex are using barrier protection.1,6,9 The emphasis on vaginal sex among adolescents. Results. More study participants reported having had vaginal sex has resulted in intervention efforts pro- oral sex (19.6%) than vaginal sex (13.5%), and more par- viding limited education and guidance about oral ticipants intended to have oral sex in the next 6 months sex, including the potential risk of sexually transmit- (31.5%) than vaginal sex (26.3%). Adolescents evaluated ted infections (STIs), including HIV.1,10 Most clinical oral sex as significantly less risky than vaginal sex on preventive service guidelines provide specific guide- health, social, and emotional consequences. Adolescents lines concerning only screening or education about also believed that oral sex is more acceptable than vagi- vaginal sex or sex in more general terms.11–14 To the nal sex for adolescents their own age in both dating and extent that adolescents perceive oral sex as less risky nondating situations, oral sex is less of a threat to their and more acceptable and that these perceptions in- values and beliefs, and more of their peers will have oral fluence their decisions to engage in oral sex, it is sex than vaginal sex in the near future. Conclusions. Given that adolescents perceive oral sex critical that health care providers include screening as less risky, more prevalent, and more acceptable than and education about oral sex into their practice. vaginal sex, it stands to reason that adolescents are more Although it is true that oral sex negates the risk of likely to engage in oral sex. It is important that health pregnancy and entails significantly less risk of STI care providers and others who work with youths recog- transmission, various studies and case reports sug- nize adolescents’ views about oral sex and broaden their gest that oral sex is still a potential transmission clinical preventive services to include screening, coun- route for oral, respiratory, and genital patho- seling, and education about oral sex. Pediatrics 2005;115: gens,6,15–18 including STIs such as herpes, hepatitis, 845–851; adolescent sexual behavior, risk perception, gonorrhea, chlamydia, syphilis, and HIV.15 Although STDs, oral sex. HIV transmission rates are lower for oral sex than vaginal and anal sex,17 HIV and STI transmission is still possible through oral sex,6,16–18 with 1 estimate From the *Division of Adolescent Medicine, Department of Pediatrics, for HIV transmission through oral sex of 0.04% com- University of California, San Francisco, California; and ‡Department of pared with 0.06% for anal sex,17 and another estimate Psychiatry, University of California, San Francisco, California. of 1% (range: 0.85–2.3%) for oral sex with a single Accepted for publication Dec 3, 2004. doi:10.1542/peds.2004-2108 partner, as compared with 10% (range: 4.2–12%) for 18 No conflict of interest declared. anal sex. There is a concern about the potential for Address correspondence to Bonnie L. Halpern-Felsher, PhD, Division of a rise in STI transmission rates from oral sex as a Adolescent Medicine, Department of Pediatrics, University of California, result of a general misperception that oral sex entails 3333 California St, Suite 245, Box 0503, San Francisco, CA 94118. E-mail: [email protected] no risk at all or very little risk as compared with PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad- vaginal or anal sex, and therefore it is engaged in emy of Pediatrics. more frequently and with no use of barrier protec- Downloaded from www.aappublications.org/news by guestPEDIATRICS on October 2, Vol.2021 115 No. 4 April 2005 845 tion.1,6,10,15,16 Such concern has resulted in the need ipants’ reports, 9% of their mothers had a professional degree, for research on why adolescents are engaging in oral 2.4% had some education after college, 16.4% had a 4-year college 1,4,6,8,15,16,18,19 degree, 28.8% had at least some college education, 18.6% of the sex and how they view oral sex. Never- mothers had a high school degree, 12.5% did not graduate from theless, surprisingly few empirical studies have as- high school, and 12.0% of the participants reported that they did sessed adolescents’ attitudes toward or perceptions not know their mother’s educational level. of oral sex, especially as compared with vaginal sex. Only 1 study6 has investigated adolescent oral sex Procedures experience and risk perceptions, finding that al- Participants were recruited from mandatory ninth-grade though 96% of the sample acknowledged HIV trans- classes in 2 California public high schools. Researchers came to mission risk for vaginal and anal sex, significantly each class, introduced the study to the students, and invited all fewer (68%) acknowledged the risk for oral sex. That ninth-grade students to participate. Students received study infor- mation and consent forms during class time and were asked to study was limited in that it asked only about HIV bring the materials home to share with their parents. Interested risk and not other risks, such as other STIs or social participants signed the adolescent assent form, and parents signed and emotional risks that are pertinent to adolescent the parental consent form. Of the 1180 students who received decision making, and it did not analyze the potential consent packets, 665 (56.36%) returned completed consent forms. Of these, 637 (95.79%) completed the first survey, for an overall effect that experience with oral sex may have on the participation rate of 53.98%. The 580 participants included in this perceptions of risk. Furthermore, although there is study completed the second wave of data collection, representing evidence that adolescents are more likely to have 91% of the original 637 participants. Participants did not signifi- vaginal intercourse if they believe that they will ben- cantly differ from the overall population of students in their efit from the experience,20,21 no study has extended schools on ethnicity or socioeconomic status. Participants completed the self-administered questionnaire this research to oral sex. during regular class periods at their school. Before beginning the Adolescents’ perceptions of the extent to which survey, the researchers explained the instructions for completing peers are engaging in oral sex are also important, the surveys and remained available to answer questions that arose because studies have shown that adolescents are during the survey. Refreshments were provided for all partici- pants. In addition, schools were reimbursed for their assistance. more likely to have vaginal sex when they perceive This money was used for school supplies for the students. The 22–25 that it is more prevalent among their peers. One Institutional Review Board at the University of California, San study9 investigated the influence of adolescent per- Francisco, approved the study. ceptions of best friends’ oral sex behavior on engage- ment in oral sex, finding that perceptions of friends’ Measures behavior were significantly associated with engage- Demographics ment in oral but not vaginal sex. Although these Participants provided information about their age, grade, gen- results provide support for the relationship between der, ethnicity, and mother’s level of education. perceptions of best friends’ behavior and adoles- cents’ own behavior, previous studies have not in- Engagement in and Intentions to Have Oral and Vaginal Sex vestigated perceived prevalence of oral sex among Participants were asked about the number of times they had adolescents’ peer group in general. had oral sex and vaginal sex in their entire life, with the following The goals of this study were to fill these gaps in 6 response choices: never, 1 time, 2 times, 3 times, 4 times, and 5 our understanding of adolescents’ engagement in or more times. Participants were also asked whether they intended oral sex by determining whether adolescents per- to have vaginal sex and oral sex in the next 6 months, with responses provided on a 5-point scale ranging from “definitely ceive oral sex as less risky, more beneficial, more will not” (1) to “definitely will” (5) (Table 1).