Adolescent Sexuality by Dr. Karen Rayne

Yesterday’s big news was the new Guttmacher Institute study that suggests teenagers are not using oral sex as a way to stay “technically still a virgin.” Rather, it says that teenagers who are engaging in oral sex are by-and-large also engaging in vaginal intercourse.

I must admit - I am rather surprised by this finding.  But I am, if nothing else, swayed and enraptured by good research.  Here’s what the Guttmacher Institute has to say about the numbers:

“Some teens may first experience oral sex immediately prior to vaginal intercourse, while others may initiate vaginal intercourse shortly before having oral sex. While only one in four teen virgins (26%) have engaged in oral sex, once teens have had vaginal intercourse, the proportion increases incrementally. By six months after first vaginal sex, more than four out of five adolescents (81%) have also engaged in oral sex, and by three years after first intercourse, nine in 10 (92%) have done so”

And here are the results that the Guttmacher Instutite draws from this data:

 “There is a widespread belief that teens engage in nonvaginal forms of sex, especially oral sex, as a way to be sexually active while still claiming that technically, they are virgins,” says study author Laura Lindberg. “However, our research shows that this supposed substitution of oral sex for vaginal sex is largely a myth. There is no good evidence that teens who have not had intercourse engage in oral sex with a series of partners.”

But I’m not so sure that I agree with Dr. Lindberg’s conclusions.  Please note that I have not read the actual research paper or analyzed the data myself!  But based on what I have read, here are my problems with her conclusions:

1. I was not able to find anywhere in the information on the study data-gathering about what the teenagers were claiming about their reasons behind their sexual decisions.  We can, with relative clarity given the breadth of this survey, know what the teenagers are doing, but we can’t know why.  So I think it’s jumping the gun to say that teenagers are not claiming to be virgins when they have had oral but not anal sex.  There is other research that does go into a bit more detail of teenagers’ understandings of the meanings of these various activities that suggests differently.
2. What about the 12 to 14 year olds?  I’m unclear on whether this study asked the 15-to-19 year old participants to think back on their sexual experience time-line (which is, of course, problematic in it’s own right) or asked about their current sexual activities over time (much better, in terms of creating quality research but presents it’s own problems in terms of funding).  But I’m concerned that younger teenagers were left out of the equation - it seems to me that many of these younger teens may be the ones who are claiming that one can have oral sex and still be a virgin.
3. What does it mean when you say “1 in 4 teen virgins”?  Did they ask “Are you a virgin?”  And then follow that up with questions about actual sexual activities?  The term virgin just needs to be tossed.  It confuses conversation - as it did the Guttmacher Institute’s press release.  So I hope for more linguistic clarity in Dr. Lindberg’s final paper.
4. The other point that is not fully addressed here is the sexual progression that teenagers go through.  Perhaps it’s common for a teenage couple to get comfortable with oral sex (in order to maintain virginity) and then quickly move on to vaginal intercourse.  In other words, perhaps oral sex is a “gateway sexual activity” to vaginal intercourse.  That’s not really addressed here at all.
5. Okay, one more point and then I’m (hopefully!) done.  I take great offense at Dr. Lindberg’s sentence: “There is no good evidence that teens who have not had intercourse engage in oral sex with a series of partners.”  There is, in fact, no conversation at all until this point about a series of partners.  I am worried that this sentence belies Dr. Lindberg’s unconscious assumption that a teenager who is engaging in oral sex is something of a “slut” and more likely to engage a “series of partners.”

I am fully aware that one research project cannot answer all of these questions.  Gaining a really well-rounded and informed understanding of adolescents’ sexuality will take far more time and money.   Nevertheless, I was disappointed to see that the Guttmacher Institute, as a highly respected research facility, did not temper their statement of results with a nuanced approach to what kind and scope of information this data analysis is really able to provide us.

However, one of the results of the study that I am really, really delighted to see was: Teenagers are having anal sex. (The Guttmacher Institute suggests about 1 in 10 teenagers between the ages of 15 and 19 has had anal sex.) The sex-ed implications are very, very clear. Anal sex carries higher risk than either vaginal or oral sex because of increased likelihood of STD transmission and the physical problems that can be brought on by moving too quickly, not using enough lubrication, and other problems that might induce tearing and serious internal injury - all of which compound the STD transmission risk). So we have to talk with teenagers about anal sex. They or someone they know is probably trying it out, or has tried it out, and the likelihood is that they have never had any information presented to them about how to engage in anal sex safely.

I’ve been disappointed by much of what I’ve read about this study - it primarily just repeats what the Guttmacher press release said with little or no analysis.  But if you’re looking for additional commentary, here is a good place to start.

Last week I wrote the first and the second parts of this series. I apologize for the longer-than-planned interlude before this, the third part!

Here is my position: Having sex with another person is a privilege, and with privilege comes responsibility. Hence, having sex with another person necessitates a level of responsibility both to that person and to yourself.

One commenter mentioned surprise that I used the word privilege to refer to sexuality - which she understands to be something inherent to our humanness, not a privilege. I agree. However, what I am talking about is the group of activities loosely categorized as “sex” as they happen between two or more people. And I do strongly believe that engaging with another person is a privilege, and that it requires responsibility.

In my first post, I outlined three levels of responsibility that sex requires: physical, relational, and social. In my second post, I described the physical responsibilities that come with sex. Today I’ll describe the relational, and tomorrow the social.

So what relational responsibilities come with having sex with someone? It means tending to the emotional relationship as well as the physical relationship. Here are some critical points:

1. Everyone involved has to actively want the sexual experience.
2. Everyone involved has to be on the same page about the meaning behind the sexual experience.
3. If someone is not in a state where they are able to make clear decisions because of drugs, alcohol, or emotional turmoil, don’t ask them to make sexual decisions.
4. If you have an STD/STI of any sort, you must disclose that before you get close enough that there is any chance of transmission.
5. If in doubt about someone’s desire, motives, or emotional or physical wellness, don’t have sex with them at that time.

I’ll be honest: I think this is fairly straight-forward stuff. But if these things were always self-evident to everyone, much would be different in this world. What that means is that teenagers need to learn these things as part of their sex education. There are lots of ways for teenagers to learn how to be relationally responsible sex partners, but probably the most common is through trial-and-error over time. But this method ends up with lots of people getting hurt until everyone has learned how to be sexually kind. I hope that you take the initiative, when you are talking about sex with teenagers, to provide guidance on how these teenagers can bring responsibility to their sexual relationships.

Yesterday I wrote the introduction to this series. Today I am writing about how talking with teenagers about sex as a privilege can lead to a discussion of responsibility to the physical aspects of a sexual relationship.

Once a teenager acknowledges that sexual activities are inherently different from non-sexual activities, the most obvious way to talk about these differences is the actual physicalness inherent in sexuality: sexual activities are inherently physically different from non-sexual activities and carry certain physical risks.

The question to ask:

“What responsibility does one have towards the physical well-being of one’s sexual partner(s)?”

Not many teenagers get asked this question, but I suspect that safe sex would be much more common if they were. This question could prove to be particularly revolutionary if teenagers responded by truly pondering the implications. While I generally suggest that adults keep their questioning to a bare minimum of one question, if the situation allows, I might try to slip in this second question into the conversation:

“What responsibility does one have towards the physical well-being of one’s own body, sexually speaking?”

I am sure that I never considered my responsibility towards my own physical, sexual health as a teenager, and I don’t think I ever overtly considered my responsibility towards my partner’s physical well-being.  What about you?  How did you conceptualize these issues as a teenager, or how have you guided your teenager in conceptualizing them?

Many thanks to Mrs. Y for taking over while I was gone. The conference where I was presenting last week was interesting and engaging. I, of course, went to all of the presentations on sex education. More on that later.

Today I want to tell you about my presentation. I gave an overview of my four-session parent class on adolescent sexuality. I was delighted to find my room completely full - we had to turn people away. But I was surprised to see the number of students who attended my session. I had assumed - clearly incorrectly - that the people who would be most interested in my presentation would be older, established professionals who teach sex ed themselves. There were, of course, a fair number of those sprinkled in. But most of the room was full of 18 - 22 year olds.

Here’s a general overview of what I talked about: Why parents need classes on how to provide effective sex education for their children and teenagers, and a relatively in-depth description of what I present, along with parent reactions from past classes. Throughout my presentation I provided examples of essential pieces of information that I tell parents to pass on to their teenagers, because most teenagers are lacking them. (For example: explicit instructions on how to use a condom, that the pull out method doesn’t work for pregnancy or STD prevention because precum can start to leak out of a penis as soon as it is erect and it includes semen, etc.)

What startled me - although I shouldn’t have been surprised - was the number of college students who talked to me after my presentation, saying that they had received more sex education, and seen an adult (i.e., me) talk more candidly and honestly about sexuality in the last hour than they had ever before.

What a sad state of affairs - that our college students don’t know basic safety and physiology facts that have the potential to save their lives.

I hate it when things happen when I’m out of touch. On Tuesday, March 11th, the CDC came out with a press release that 26% of US teen girls has an STD.

This headline (just like my blog post title) is being widely spread and highly freaked out over. But there’s more in the press release, and these points are not getting enough attention. The CDC further specifies that:

• Actually, 1 in 4 teenage girls has one of the most common STDs (human papillomavirus (HPV), chlamydia, herpes simplex virus, and trichomoniasis). That means we’re not even talking about the many other less common, but still highly problematic STDs.
• The “average” reported rate is not evenly distributed among racial groups. African American teen girls are infected at almost 50%, while Anglo teen girls are infected at about 20%.
• Contraceptive services and STD services are both needed to help teenage girls get all the help they need, but few receive both kinds of services (38%). But even more depressingly, that 38% may be getting very poor quality services. Ridiculously, some of these programs can claim to be “contraceptive services” and still be lacking critical information like the connection between unprotected sex and pregnancy.

This is so depressing for so many reasons. But let’s hop over the negative, and talk about ways to address the multitude of problems this press release presents.

One potential solution that the CDC recommends is for public clinics to have an express visit option for STD testing. By allowing someone access to STD testing without requiring a doctor’s presence, far more tests can be done, and far more STD diagnosis can be made. At one NYC health clinic, 4,500 more individuals were tested for STDs, and diagnosis increased by 17%. Dramatic, yes? The CDC press release did not provide enough information about this potential solution. There’s no information about who would preform the tests, who would give the results, and at what point information about healthy and safe sexuality would be passed on.

However, what clearly needs to happen above all else is comprehensive sex education for everyone. The STD rates among Europe teenagers are far, far lower than US teenagers, and it’s not due to substantially lower sex engagement.

The radical difference between racial groups STD infection rates really struck me. Sexuality education is clearly a civil rights issue. We need to start talking about it in those terms.

How do you think we should respond to the CDC results?

(Written by guest blogger JustAnotherTeen.) 

“You seem very open, honest, and liberal, but you depict your parents as fairly rigid and conservative. How much do you think your parents impacted who you are and how did they do that? I like the person you present yourself as and I sense that you like yourself as well. Do your parents like you as you are or do you hide most of what you have shared with us?”

As I mentioned in the response above, I think some of my attitude and outlook on life are simply the opposite of my parents because I saw them every single day and I wanted to be different. For instance, my parents are often late everywhere they go, so therefore I have a tendency to be early for everything. I think my parents impacted me a lot in some ways, mostly because I consciously tried to be different than they are. My parents know somewhat that I am do not hold their values, but not the scale of which I disavow their narrow-minded ideas. For instance, they do not know that I am bi-sexual. They do not fully realize that I have had sex. I did not even tell them I was dating someone for half a year.

“What do you think are the basic criteria for people (teens) to have and be competent at in order to be able to make a healthy decision to be fully sexual? When do you think teens are harmed by sex too early or with the wrong people? Have you seen much of the problems that can be created by inappropriately early sexuality or do you think there is such a thing as inappropriately early sexuality?”

I think that the age of sexual maturity (being able to make the decision to have sex for the right reasons, not just peer pressure or such) depends greatly on the individual person, the way they were raised, and their partner. I think both partners need to understand that although sex feels good on a physical and emotional level, there can be serious consequences no matter what form or forms of protection are used. They need to understand different forms of contraception and be comfortable with each other and themselves. It should not be a spur of the moment thing in my opinion, but something that is discussed with maturity. That said, I doubt very seriously that any teenage couples are really that prepared, myself and my girlfriend included! I think teens can easily be harmed by sex with the wrong person, especially if there is a large age gap or something else that gives one partner authority. That is not to say that a 15 year old and a 17 year old should not be having sex, again it comes back to the individual relationship. As for problems with early sexuality, I think they are often the same for sex at any age: unwanted pregnancy and STIs, etc. Also, I believe younger people in general have a higher risk of being emotionally scarred but when I think about it, and I have no experience with this, it seems like older people (i.e. Over 20) can be scarred as well from bad relationships, sexual or otherwise.

“Your girlfriend’s mom seems to have ‘come around’ and is coping adequately with your relationship. Do you think there is a down side to this arrangement? What would be the parameters you would want to set up today if you were the parent of a teenager yourself?”

If there is a downside, it would be that she sometimes seems overbearing about making sure we have birth control. I am fully capable of getting my own protection so it just gets annoying when she keeps asking if we need condoms, although I think she has realized in the past few months that I am capable of getting my own and has stopped asking. If I were a parent, I would want to be open about all matters of sexuality but also I would understand if they did not tell me when they started having sex or something like that. I would like to know their partners but also understand that this may not always happen. I think a parent of a teenager should be more of an advisor than a dictator, there at all times to talk but not to rule. However, as I get older my views may change but I hope to be a good father (of adopted children) one day.

Again, I really appreciate everyone who sent in questions, I really had to think about my answers! I enjoyed blogging here for the past two weeks and would like to do it sometime in the future if I or someone else can come up with ideas for new posts! Thanks to Karen for allowing me this opportunity, and if anyone still has questions, that e-mail address is still usable!

Thanks so much to Heather Corinna from Scarleteen for this information.

Planned Parenthood is now dispensing the pill without a pelvic exam. You can read more about it.

This is a relatively unusual program. Planned Parenthood’s requirements are that you do not have:

• certain conditions that make it inadvisable to use a hormonal method [of birth control]
• symptoms that must be evaluated with a pelvic exam

Now, there is some argument against getting yearly pap smears, for reasons of cost and the potential of false positive results of pre-cancerous cells. However, Heather suggested to me that Planned Parenthood is providing the pill without a pelvic exam simply in order to reach young women who are scared of their first pelvic exam, and are using that as an excuse to not use birth control. There is no indication on the PP website of why they have decided to stop requiring a pelvic exam.

For tomorrow: much discussion about the new CDC findings that teen pregnancy rates have started rising for the first time since 1991. (Yes, you are free to go into the appropriate tizzy of outrage at this information. While you wait for my comments, there’s lots to read about it: here and here and here are good places to start.)

Recently a young woman wrote me asking this question:

I am 19 and just recently lost my virginity, so my mom and I talked about how I should get on the pill. I’ve never had a pelvic exam (against my mom’s wishes) because I’m really shy and nervous about it, but she said that I can’t get the pill without having a pelvic exam, that makes sense but is it true? And how soon after I start the pill is it safe to have sex without a condom? Is a pelvic exam really as scary as I’ve heard?

And here is my answer to her:

These are all really good questions. Being shy and nervous about a pelvic exam makes a lot of sense. Here is a website that describes what will happen during your first gynecological visit (they describe a pelvic exam, although they do not name it as that specifically): http://www.scarleteen.com/article/pink/your_first_gynecologist_visit

Here is the factual information:
Your mom is right - you will need to get a pelvic exam in order to get on the pill. You can have sex without a condom after you have been on the pill for one complete cycle - from one period to the next.

Here is the emotional information:
It makes sense to be scared of a pelvic exam. It kind of marks a whole new beginning in your gynecological life - the need to be tested for STIs - and that’s not a pleasant thought. However, I can tell you that after you’ve had one or two, they won’t be scary any more. Don’t get me wrong - they can be uncomfortable, and if you don’t find the right person to do them, they can be embarrassing. But they do become a normal part of how you take care of your body.

So take some time and find the right person. Do you have a general doctor who you like and feel comfortable with? They will often do pelvic exams. If you don’t, then take some time and visit with several nurse practitioners or physician’s assistants. They are more likely to be female and not to be as rushed.

If money is a concern, you can go to Planned Parenthood. They are often (although not always) adept at talking young women through their first pelvic exam. They can prescribe the pill for you.

Now, I want to explain myself before the inevitable rush of comments asking why I did not explain the negative side effects of birth control pills to this young woman. First, I did not mention it in my e-mail response because the pill works really well for some women, and second because that’s not the question she asked me. Nevertheless, if this young woman reads my blog (or if her mother does), she’s just gotten access to information about how the pill can be harmful.

Do you have questions you’d like the answer to? Questions about sex, teenagers, parenting teenagers, or teenagers having sex? E-mail them to me, and I’ll post the answers here.

I’m actually, grudgingly, impressed. There are a fair number of US-based websites that provide good information about sex and sexuality to teenagers. What there is not is the plethora of organizations that provide actual services to teenagers (and younger children) like there is in England. (You can see my post from yesterday for more on the UK organizations.) So here’s what I found for US teens:

Advocates for Youth — Advocates for Youth is dedicated to creating programs and advocating for policies that help young people make informed and responsible decisions about their reproductive and sexual health. Advocates provides information, training, and strategic assistance to youth-serving organizations, policy makers, youth activists, and the media in the United States and the developing world. They also host a number of other good websites: Ambiente Joven (for Latino GLBTQ youth), My Sistahs (for young women of color), and Youth Resource (for all GLBTQ youth).

Campaign for Our Children, Teen Guide — Information about sex and sexuality for teenagers. Generally pretty good. Has a game called STD Defenders. I can’t play it, though, because I don’t have OS 9 on my Mac. They also have a PC version. I’d love to get a little review of this game, so if you play it, let me know what you think.

Families are Talking for young people — This is a website hosted by SEICUS (Sexuality Information and Education Council of the United States), a really good organization. Here is how they describe the site: This is a starting place for teens to learn about sexuality issues. It’s about how to Talk About Sex…and to help yourself feel good and stay healthy. It’s about knowing your goals, learning how to achieve them and how to get there. It’s all about making and keeping choices true to yourself. Let’s talk about how to express yourself and take care of yourself, all of yourself. Sex? Yes, sex is something we need to talk about before we do something about it. These pages can help.

Go Ask Alice — Go Ask Alice! is the health question and answer Internet resource produced by the Alice!, Health Promotion Program at Columbia university - a division of Health Services at Columbia. It’s the question-and-answer service I like the most. I even link to it on my blogroll.

I Wanna Know — A website hosted by the American Social Health Association. Provides answers to your questions about teen sexual health and sexually transmitted diseases.

Just Say Yes — Just Say Yes is about having a positive attitude towards sexuality — gay, straight, bisexual, or whatever. It’s about saying “yes” to sex you do want, and “no” to sex you don’t. It says there’s nothing wrong with you if you decide to have sex, and nothing wrong with you if you decide not to. You have the right to make your own choices, and to have people respect them.

Planned Parenthood – The best-known organization around for providing sexuality-related health care services to the under-served, under-represented, and under-aged. Planned Parenthood health centers offer high-quality sexual and reproductive health care, including family planning, gynecological care, STI/STD testing and treatment, pregnancy testing, and abortion services. They also have a website specifically for teenagers called Teenwire.

Scarleteen — Sex ed for the real world — While we at Scarleteen do not hold to the notion that telling young adults to just go have sex is a better solution, we strongly feel that belying judgment and furnishing them with the facts they need to know REGARDLESS of whether or not they are sexually active readies them to learn to make their own choices, and that often unheard perspectives help develop their own systems of ethics and values when combined with the perspectives of peers, schools, parents, other mentors and their overall culture and communities. One cannot make a decision from a position of informed consent without actually being informed.

Sex, etc. — Sex, Etc. is an award-winning national magazine and Web site on sexual health that is written by teens, for teens. It is part of the Teen-to-Teen Sexuality Education project developed by Answer (formerly the Network for Family Life Education), a leading national organization dedicated to providing and promoting comprehensive sexuality education. Answer is part of the Center for Applied Psychology at Rutgers, the State University of New Jersey.

Teen Drug Abuse — TeenDrugAbuse.us was created to help spread information about the teen drug abuse problems in the U.S. TeenDrugAbuse.us features content and articles that are intended to bring awareness to these issues.

So, there we go. Like I said at the beginning - we’re long on information, short on actual help or action. I look forward to the day when there is a general social acceptance of adolescent sexuality in the US, and when we’re able to address the young people who engage in sexuality appropriately and healthfully. Do you know of any other good organizations that should be included in this list?

There are many very cool resources about sex and sexuality for teenagers in the UK. I’ve spent some time this week surfing through them, and thought some of you might be interested as well. (I have a fair number of readers from England, but the Internet sides of these organizations are clearly available to everyone, regardless of local.)

Brook Advisory Centers — Putting Young People First — is the only national voluntary sector provider of free and confidential sexual health advice and services specifically for young people under 25. Brook is a registered charity, and has 40 years’ experience of providing professional advice through specially trained doctors, nurses, counselors, and outreach and information workers to over 200,000 young people each year.

bpas for young people — bpas supports reproductive choice by advocating and providing high quality, affordable services to prevent or end unwanted pregnancies with contraception or by abortion. bpas is now Britain’s largest single abortion provider and cares for almost 50,000 women with unwanted pregnancies each year, as well as providing emergency contraception, sterilisation and vasectomy.

ChildLine — Truly an amazing organization, one that will never, ever be duplicated in the US, regardless of the dire need. Here is their description: ChildLine is the UK’s free, 24-hour helpline for children in distress or danger. Trained volunteer counselors comfort, advise, and protect children and young people who may feel they have nowhere else to turn.

Education for Choice — Education For Choice is the only UK-based educational charity dedicated to enabling young people to make informed choices about pregnancy and abortion. Education For Choice’s work is focused on the word choice. Whilst we concentrate on the issue of abortion, as it is the issue that receives least attention, we believe that work with young people should value all pregnancy choices equally. Our ethos is that the best outcomes of unintended pregnancy occur when the woman involved has been able to make her own informed choice.

Family Planning Association (fpa) — FPA is the UK’s leading sexual health charity. Our purpose is to enable people in the UK to make informed choices about sex and to enjoy sexual health. (fpa provides services and information to teenagers as well as adults.)

Get Connected — Get Connected provides a free, confidential helpline that gives young people in difficult situations the support and information you need to decide what you want to happen next. It could be anything from a listening ear to somewhere safe to stay for the night.

like it is — likeitis gives young people access to information about all aspects of sex education and teenage life. Topics on the likeitis site include: teenage pregnancy, help and advice, periods, lovebugs (sexually transmitted infections), sex, peer pressure, sexuality, contraception, emergency contraception, and puberty.

London Lesbian and Gay Switchboard — We are a voluntary organization with charitable status. We have currently just two paid workers, and all volunteers identify as lesbian, gay or bisexual. This enables us to more fully understand the needs and situations of our callers. We are committed to discussing safer sex and the prevention of the spread of HIV and AIDS and other sexually transmitted diseases. Whilst we never try to influence the decisions of our callers, we aim to make them aware of the wider implications and the issues facing them.

Needtoknow — Information portal for teenagers with an online magazine and signposting to other useful websites. Sections include health, relationships, money, travel and the law.

RU thinking — Sexwise is a helpline that offers free, confidential advice on sex, relationships and contraception. Anyone under 18 can call. It’s open from 7am to midnight, seven days a week.

There-4-Me — There4me is for you if you’re between 12-16 years old and are worried about something and need some help. We can help with loads of issues like abuse, bullying, exams, drugs and self harm. If there’s something bad that’s happening and you want to know what to do, you can talk to us and no one else has to know.

The Hideout — The Hideout provides help, information and support for children and young people – whether you’re currently living with violence, you’ve experienced violence in the past or if you know someone else going through it and you’re looking for help and information. We’ve included lots of information to explain what domestic violence is, how it affects you and where you can go for more help.

The Site — TheSite.org aims to be the first place all young adults turn to when they need support and guidance through life. We believe all young people have the capacity to make their own decisions and life choices, provided they have access to high quality, impartial information and advice. We don’t tell anyone how to lead their lives - we just believe everybody should have all the information they need to make their own decisions.

Young Minds — YoungMinds is the UK’s only national charity committed to improving the mental health and emotional well-being of all children and young people.

Well! If you’ve managed to read this far, I hope you are as impressed as I am. Thanks to the sites listed here (especially Brook), who listed each other, and that made organizing this list really quite easy! And so impressive! I hope to gather a list of similar resources for the US tomorrow. I’m afraid it won’t take near as much time, because our resources are so piddly!