Oral Sex Among Adolescents:Is It Sex or Is It Abstinence?

Over the past few decades, nationally representative surveys have accumulated a wealth of data on levels of adolescent sexual activity. Thanks to such surveys, we know how the proportion of 15-19-year-olds who have ever had intercourse has changed over the years. Similar data exist on age at first intercourse, most recent sexual intercourse and current contraceptive use.

Yet all of these measures focus on—or relate to the possible results of—vaginal intercourse. This is natural, given that attention to adolescent sexual activity arose initially out of concerns over the far-reaching problems associated with teenage pregnancy and childbearing. More recently, infection with sexually transmitted diseases (STDs), particularly with HIV, has fueled further public and scientific interest in teenage sexual behavior.

But to what extent does adolescent sexual activity consist of noncoital behaviors—that is, mutual masturbation, oral sex and anal intercourse—that are not linked to pregnancy but involve the risk of STDs? Some of these activities may also be precursors to vaginal intercourse. Yet, health professionals and policymakers know very little about their prevalence among teenagers.

There are several explanations for this dearth of information. One is the perceived difficulty of getting parents to consent to surveys on the sexual activity of their minor children (generally aged 17 and younger). Another is a generalized fear that asking young people about sex will somehow lead them to choose to have sex. The conflicts and passions usually surrounding the appropriateness of asking young people about sex, especially in public settings such as schools as compared with private households, become even more inflamed when the questions go into behaviors "beyond" intercourse.

Another reason is the federal government's reluctance to sponsor such controversial research into the full range of noncoital behaviors among adolescents.* For example, the highly charged political debate in 1992 over federal financing of comprehensive sexuality studies had a chilling effect on adolescent sexuality research.¹ The Senate's decision, prompted by pressure from a small group of conservative senators, to deny funding for the American Teenage Study of adolescent sexual behavior still reverberates in the scope of research on teenagers. (An amendment sponsored by Sen. Jesse Helms [R.-NC] prohibited the funding of that survey, along with one of adults, "in fiscal year 1992 or any subsequent fiscal year."² Despite warnings that ideology was dictating science, the conservative leadership succeeded in casting these endeavors as "reprehensible sex surveys" only undertaken "to legitimize homosexuality and other sexually promiscuous lifestyles."³)

It has become increasingly clear, however, that the narrow focus on sexual intercourse in research that does get funded is missing a major component of early sexual activity. There is growing evidence, although still anecdotal and amassed largely by journalists, not researchers, that adolescents might be turning to behaviors that avoid pregnancy risk but leave them vulnerable to acquisition of many STDs, including HIV.

The reports in the popular press that oral sex has become widespread among adolescents cannot be confirmed or refuted because the data to do so have never been collected. Moreover, adults do not really know what behaviors teenagers consider to be "sex" and, by the same token, what they consider to be its opposite, abstinence. All of this leaves health professionals and policymakers without the means to effectively address these issues.

The tendency to equate "sex" with intercourse alone represents long-standing cultural norms of acceptable sexual behavior and certainly applies to adults as well as to adolescents. It also reflects a deeply rooted ambivalence about talking about sex. Recent press reports, however, are forcing a reappraisal of the implications of this exclusive focus on coitus for research and data collection efforts, for STD prevention and treatment, and for the framing and interpretation of abstinence and risk-reduction messages.

This special report draws on interviews and correspondence with roughly two dozen adolescent and health professionals, including researchers, psychologists, abstinence program coordinators and evaluators, sexuality educators and epidemiologists, to explore some of these consequences. The report concentrates on oral sex, as opposed to other noncoital behaviors, because it is currently the subject of public debate in the media and in many schools. It reviews the limited information on adolescents' experience with oral sex, and looks at the even smaller body of evidence on what young people consider to be sex or abstinence.

ANECDOTAL REPORTS IN THE MEDIA

The first hint in the popular press of a new "trend" in sexual activity among young people appeared in an April 1997 article in The New York Times.⁴ That article asserted that high school students who had come of age with AIDS education considered oral sex to be a far less dangerous alternative, in both physical and emotional terms, than vaginal intercourse. By 1999, the press reports started attributing this behavior to even younger students. A July Washington Post article described an "unsettling new fad" in which suburban middle-school students were regularly engaging in oral sex at one another's homes, in parks and even on school grounds; this piece reported an oral sex prevalence estimate, attributed to unnamed counselors and sexual behavior researchers of "about half by the time students are in high school."⁵†

Other stories followed, such as a piece in Talk magazine in February 2000 that reported on interviews with 12-16-year-olds. These students set seventh grade as the starting point for oral sex, which they claimed begins considerably earlier than intercourse. By 10th grade, according to the reporter, "well over half of their classmates were involved."⁶ This article laid part of the blame on dual-career, overworked "parents who were afraid to parent," and also mentioned that young adolescents were caught between messages about AIDS and abstinence on the one hand and the saturation of the culture with sexual imagery on the other. In April 2000, another New York Times article on precocious sexuality quoted a Manhattan psychologist as saying "it's like a goodnight kiss to them" in a description of how seventh- and eighth-grade virgins who were saving themselves for marriage were having oral sex in the meantime because they perceived it to be safe and risk-free.⁷

In a July 2000 Washington Post Magazine cover story, eighth graders described being regularly propositioned for oral sex in school. The reporter echoed the assertion made in earlier articles that although overall sexual activity among older, high school-aged adolescents—as measured by the proportion who have ever had penile-vaginal intercourse—seemed to have recently leveled off or slightly declined, middle-school-aged students (aged 12-14) appeared to be experimenting with a wider range of behaviors at progressively younger ages.⁸

WHAT TEENAGERS MIGHT BE DOING

How valid are these anecdotal reports? Unless and until data to verify them become available, we have only impressions to go on, and there is by no means a consensus among adolescent health professionals. 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."⁹ 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."¹⁰ 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.¹¹

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."¹²

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.¹³ Other viral STDs that can be transmitted orally include human papillomavirus, herpes simplex virus and hepatitis B,¹⁴ while gonorrhea, syphilis, chlamydia and chancroid are among the bacterial infections that can be passed through oral sex.¹⁵

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 person 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 an 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.¹⁶ 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."¹⁷ 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."¹⁸ 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 Mexico¹⁹ 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.²⁰ In Georgia, the cases caught everyone off guard, according to Kathleen Toomey.²¹ 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)."²²

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,^‡ 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."²³

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."²⁴ 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."²⁵

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."²⁶

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.²⁷ 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."²⁸

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.²⁹ 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^§ as an alternative contraceptive method for young teenagers.³⁰ 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.³¹ 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.³² 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).³³

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%).³⁴

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.³⁵ 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.³⁶ 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.³⁷

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%).³⁸ 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."³⁹

WHAT IS SEX?

The many, even competing, agendas in the culturally loaded definitions of the term "sex" make sexuality research exceptionally challenging to conduct.** 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."⁴⁰ 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."⁴¹

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.⁴² 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;⁴³ 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.⁴⁴

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."⁴⁵ 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.⁴⁶

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."⁴⁷

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."⁴⁸

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.⁴⁹)

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.⁵⁰ 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.⁵¹

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.⁵²††

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,"⁵³ 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."⁵⁴

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.⁵⁵ 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."⁵⁶

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."⁵⁷ 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."⁵⁸

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.

Research and Evaluation

What is to be gained by broadening the range of behaviors asked about in surveys of sexual behavior? The simplest public health argument is that doing so would enable researchers to identify individuals whose behaviors place them at risk, so that more appropriate programs and policies can be developed. Many of these youth are now being missed by current survey instruments. By considering only adolescents who have ever had coitus, or only dividing them by whether they had that experience, "we don't get a full understanding of the range of adolescent activity and of the developmental and emotional processes involved," according to Mark Schuster, director, UCLA/RAND Center for Adolescent Health Promotion.⁵⁹

It is also impossible to adequately assess how changes in sexual activity or in contraceptive behavior contributed to recent declines in adolescent pregnancy rates as long as information on sexual activity unlinked to pregnancy remains unavailable. For example, while different groups have attributed a greater or lesser share of the declines in pregnancy rates to increased abstinence,⁶⁰ how much of that "abstinence" corresponds to sexual activity other than intercourse is still unknown.

Another advantage to using a broader measure of sexual activity is being able to more fully measure the impact of various programs and curricula that address adolescent sexuality. As Sarah Brown stresses, "if, for example, we found that there was a curriculum that delayed the age of first vaginal intercourse, but increased the preponderance of oral sex, we should know that."⁶¹

Currently, the principal outcome measures used in evaluations of both comprehensive sexuality and abstinence-based programs are the standard ones of vaginal intercourse, pregnancy and contraceptive use. That holds true for the Mathematica national evaluation of Title V abstinence education programs. The project director, Rebecca Maynard, explains that after much debate, the group that devised the questionnaire settled on the stable outcome measure of intercourse for the first wave of follow-up, to assure that the evaluation was not measuring different definitions of sex, as opposed to different behaviors.⁶²

Even if there is agreement on the need to expand the definition of sexual activity to create more accurate research and evaluation tools, getting those items onto survey instruments remains a concern. Some researchers assert that surveys need to be allowed to capture self-reports of these especially sensitive behaviors in the most private setting and mode of administration possible (i.e., using audio computer-assisted self-interviews rather than personal interviews). Others say that should national-level studies prove impossible because of the constraints of funding agencies, then small-area studies would be of value, especially in higher prevalence areas where there might be greater receptivity to gathering such data.

Other professionals are clearly worried about the prospect of gaining parental consent—what Brown terms "the 800 pound gorilla in the room"⁶³—especially since many of the adolescents purported to be engaging in sexual activities other than intercourse are younger than 15, the minimum age usually included in traditional surveys. Stan Weed, who has experience drafting questionnaires in the new climate of ostensibly greater participation in oral sex, suggests that advance focus-group research can be helpful in countering objections to questions from parents and school administrators. If findings illustrate that the behavior is prevalent, for example, then the evaluation team can use that information to explain why those questions need to be asked.⁶⁴

Although the well-known technique of asking 18-year-olds to report on their earlier experiences was also mentioned, some experts point out that parents' willingness to grant consent might have recently changed. Joyce Abma, a demographer at the National Center for Health Statistics, for example, is hopeful that "maybe we're in an era where people understand the dire nature of STD transmission and HIV. So if the message is that this could possibly contribute to both a better understanding of and eventual lessening of these serious health conditions, then there might be a greater possibility of cooperation."⁶⁵ This belief is echoed by others, who talk of the need to engage parents directly and to not necessarily assume that they would deny permission.

Clinical Care

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.⁶⁶ 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."⁶⁷

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Lisa Remez is associate editor of