Warning: Teenagers may view noncoital sex as a safe option
Teens have gap in information about risky sexual behavior
You have just finished taking a medical history of an adolescent patient who has come in for contraceptive counseling. You have provided information on ways to prevent pregnancy and sexually transmitted diseases (STDs), and you’ve talked about the risks of being sexually active. But did your conversation specifically address oral sex?
Providers need to fill in this gap: According to a just-released survey of ninth-grade students, teens believe that oral sex is less risky to their health and emotions than vaginal sex, more prevalent among teens their age, and more acceptable among their peers.1 They also are more likely to try oral sex, according to the study findings. Although national medical guidelines recommend talking to teens about their involvement in sexual behaviors and ways to reduce their risk for STD infection, they do not specifically address sexual risk assessment or education regarding oral sex.2-5
"The fact that young adolescents around age 14 are having or considering oral sex and consider it safer and more acceptable than vaginal sex is important information for parents, health care providers, and others who work with youth," says Bonnie Halpern-Felsher, PhD, associate professor of adolescent medicine at the University of California, San Francisco, whose study group conducted the ninth-grade student survey. "When we counsel adolescents about the risks and benefits associated with sex, we need to understand how they perceive it among themselves."
Halpern-Felsher and her associates surveyed 580 ninth graders at two California public high schools. Students were given questionnaires on their sexual behavior and attitudes about sex.
Researchers found about one-fifth of the students reported having had oral sex, compared with 14% who said they had vaginal intercourse. About one-third of the students said they planned on having oral sex within the next six months, as compared with only a quarter of the students who planned to have intercourse.1
While oral sex does negate the risk for pregnancy and carries less risk for STD transmission, it is not risk-free. Research findings have linked oral sex as a potential transmission route for such STDs as herpes, hepatitis, gonorrhea, chlamydia, syphilis, and HIV.6-9
Teens also need to understand the social and emotional aspects that oral sex plays in intimacy issues, says Halpern-Felsher. Teens who participated in the survey said they believed oral sex was less likely to have negative social and emotional consequences, such as getting a bad reputation, getting into trouble, feeling bad about themselves, feeling guilty, or negatively impacting a relationship with a partner.1 While risks may be less with oral sex, teens still are opening themselves to emotional vulnerability, especially at a young age, says Halpern-Felsher. It is not just an easy replacement to vaginal sex, she points out.
Pledges don’t protect
For those who look to abstinence pledges for protection, results from another just-released study indicate that young adults who took virginity pledges as adolescents are just as likely to be infected with STDs as those who did not take virginity pledges.10
According to that study’s results, pledging may lead some young adults to engage in alternative sexual behaviors to preserve their virginity. Researchers found that among those pledgers who have not had vaginal intercourse, male pledgers were four times more likely to have anal sex, and male and female pledgers were six times more likely to have oral sex than nonpledgers.10
Such findings are troubling in light of increased funding for abstinence-only programs that include virginity pledges. According to the New York City-based Sexuality Information and Education Council of the United States (SIECUS), the U.S. government has spent more than a billion dollars on abstinence-only-until-marriage programs since 1982; of that funding, $620 million has been spent in just the last seven years.11
Address the issue
Teens may not consider oral or anal sex as sex, says Melanie Gold, DO, associate professor of pediatrics at the University of Pittsburgh School of Medicine. To them, such acts don’t seem to require the same level of relationship that the penis and the vagina requires, she observes.
So how do you address noncoital behavior in your discussions with teens? It all goes back to doing a good sexual history, which is a key part of doing a comprehensive medical interview, says Gold. Don’t just rely on the question "are you sexually active?" to cover all the bases, she states.
In conducting a sexual history, she goes over several behaviors and uses the following language:
"Sometimes people do these behaviors, and I don’t know which of these you do. I’m not asking you this to get into your business, but for instance, if you were having the kind of sex where you put a penis in your mouth, I might look in the back of your throat to see if there are any signs of infection. But I would never do that if that if you told me that was never the type of exposure you might have had."
By framing the question in this manner, Gold is able to ask about the behavior in a nonjudgmental way and is able to convey that she is asking the question to help the teen reduce her risk for infection or pregnancy.
Gold and her research team with the Sex Abstinence Feedback and Education (SAFE) study, a five-year study funded by the federal National Institute of Child Health and Human Development, have developed a "Range of What is Safest to What Is Riskiest Behaviors" chart to help teens understand how various activities might put them at increased risk for unintended pregnancies and/or STDs.
Using the chart is a good way to ease any uncomfortable moments in discussions, Gold suggests. A provider can simply point to a specific behavior and ask, "Have you ever participated in this?"
"You can’t use words like cunnilingus’; just say, Have you ever had the kind of sex where the penis is in the mouth? The penis is in the vagina? Have your ever put your mouth on somebody else’s penis or somebody else’s rectum?’ And you need to make sure they know what the rectum is," she says.
Since the chart shows a range of behavior, with the colors moving from green "safe" behavior, such as hugging, to red "risky" behavior such as intercourse (penis in the vagina), teens clearly can see the risks, says Gold.
References
1. Halpern-Felsher B, Cornell JL, Kropp RY, et al. Oral versus vaginal sex among adolescents: Perceptions, attitudes, and behavior. Pediatrics 2005; 115:845-851.
2. Elster AB, Kuznets NJ. American Medical Association. AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Baltimore: Williams & Wilkins; 1994, p. 191.
3. Green ME, Palfrey JS. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Second ed. Arlington, VA: National Center for Education in Maternal and Child Health; 2000.
4. Stein ME. Health Supervision Guidelines. Third ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997.
5. U.S. Public Health Service. Clinician’s Handbook of Preventive Services: Put Prevention Into Practice. Second ed. Alexandria, VA: International Medical Publishing; 1998.
6. Edwards S, Carne C. Oral sex and transmission of nonviral STIs. Sex Transm Infect 1998; 74:95-100.
7. Hawkins DA. Oral sex and HIV transmission. Sex Transm Infect 2001; 77:307-308.
8. Vittinghoff E, Douglas J, Judson F, et al. Per-contact risk of human immunodeficiency virus transmission between male sexual partners. Am J Epidemiol 1999; 150: 306-311.
9. Rothenberg RB, Scarlett M, del Rio C, et al. Oral transmission of HIV. AIDS 1998; 12:2,095-2,105.
10. Brückner H, Bearman PS. After the promise: the STD consequences of adolescent virginity pledges. J Adolescent Health 2005; 36:271-278.
11. Sexuality Information and Education Council of the U.S. Virginity Pledgers More Likely to Engage in Risky Sexual Behavior Including Oral and Anal Sex. Press release. March 18, 2005.
You have just finished taking a medical history of an adolescent patient who has come in for contraceptive counseling. You have provided information on ways to prevent pregnancy and sexually transmitted diseases (STDs), and youve talked about the risks of being sexually active. But did your conversation specifically address oral sex?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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