A January grant announcement for the Bush administration’s pet abstinence education program contains a bold, new articulation of federal abstinence-promotion policy. The guidance defines abstinence as "voluntarily choosing not to engage in sexual activity until marriage." It then goes on to broadly define sexual activity as "any type of genital contact or sexual stimulation between two persons including, but not limited to, sexual intercourse" (emphasis added). Although neither as explicit nor as restrictive as some hard-line abstinence proponents would have liked, these definitions make clear that the activities the federal government expects unmarried people to abstain from go well beyond "traditional" intercourse. Yet in going so far as to preclude behaviors of any kind among unmarried people that result in "sexual stimulation"—including kissing, in some circumstances—the policy renders itself completely out of touch not only with long-standing patterns of teenage sexual behavior, but also with at least some behaviors that many adults would consider developmentally appropriate for teenagers.

An Evolving Public Policy

The federal government has promoted premarital abstinence since 1981, when it enacted the Adolescent Family Life Act (AFLA) to promote "chastity and self-discipline" for adolescents as the answer to nonmarital teenage births. The program seeded the creation of the nation's first abstinence-only education curricula, but for over 15 years, Congress devoted relatively little money to the effort. That changed in 1996 with the enactment of the federal welfare reform law, which was intended, in part, to "prevent and reduce the incidence of out-of-wedlock pregnancies"—not just among teenagers, but among all unmarried people. Accordingly, the law devotes $50 million a year in grants to the states for abstinence education programs that "exclusively" teach "the social, psychological, and health gains to be realized by abstaining from sexual activity" and that "a mutually faithful monogamous relationship in [the] context of marriage is the expected standard of human sexual activity." Neither AFLA nor the state grant program defined "abstinence" or "sexual activity," but given their respective emphases on preventing teenage and nonmarital births, it was relatively clear that the purpose of both programs was to discourage vaginal intercourse.

Concerned that some state governments were being insufficiently rigorous in administering "authentic" abstinence-only programs, the conservatives in Congress spurred the creation of a third abstinence education program to provide grants directly to community-based organizations, including "faith-based" groups. As a sign of its enormous popularity among the conservative base, funding for their program has almost tripled since the first year of the Bush administration. Across all three programs, the federal government now spends $176 million annually on abstinence education, with the Community-Based Abstinence Education (CBAE) program—the most restrictive of the three—enjoying the lion's share of the funding ($113 million) and all funding increases.

As funding for abstinence-only education rose under Bush, critics from both the left and the right increasingly voiced their concern that the lack of an established definition or common understanding of both what it means to be abstinent and what specifically constitutes sex or sexual activity was causing confusion among educators, young people and policymakers alike. Some abstinence-only proponents contended that the failure to go beyond vaginal intercourse and spell out a broader range of proscribed sexual behaviors placed individuals at risk not only of psychological and moral harm, but also of physical harm from sexually transmitted infections (STIs). Some opponents of abstinence-only education, for their part, began questioning and even taunting the administration, demanding to know just how broad was the range of noncoital behaviors that it was willing to condemn.

At about the same time, media reports—fueled by anecdote rather than evidence—began to create something of a social panic by claiming that oral sex was virtually rampant amongaffluent, suburban middle school students.Tales of casual "hookups" and the proliferation of thephenomenon "friends with benefits" similarly abounded, suggesting young people's sexual behavior was becoming detached not just from marriage, but from serious romantic relationships of any kind. A number of small-scale surveys of adolescents and college students began to give credence to this notion, by suggesting that young people today, unlike those of previous generations, may not regard oral or even anal sex to be "sex" (or "sexual relations," as famously asserted by President Clinton). Together, these factors began to raise questions about a range of adolescent sexual behaviors that had not been discussed openly before, including whether the increasing prevalence of abstinence promotion efforts and the pressure it placed on young people to preserve their virginity might be causing them to engage in "substitution" behaviors.

Given these developments, it was not surprising when the federal government finally moved to define abstinence and sexual activity in its January 2006 grant announcement for the CBAE program (related article, Winter 2006, page 19). In retrospect, it is somewhat amazing that the government went for so long without defining these terms. What was surprising, at least to those on the left, was the breadth of the activities captured within these definitions. According to this guidance, the goal of the nation's largest federal abstinence program is to persuade unmarried people that they should refrain from any activity that might be sexually stimulating, and that they should adhere to this standard at any age.

Still, some hard-line abstinence proponents remain unsatisfied with this definition, contending that it is too vague and does not go far enough. They argue that unmarried people should refrain from any activity that might be sexually arousing, and that such activity need not involve two people. By their definition, sexual activity to be abstained from obviously includes masturbation,but it also includes viewing pornography or even "suggestive" movies or television shows. Disagreement over this point is a major reason the National Consensus Process on Human Sexuality, convened by former U.S. Surgeon General David Satcher to bring together the leaders of a politically and ideologically diverse group of nongovernmental organizations working in this area, was unable to agree on their own definition of sexual abstinence.

New Research in Context

Although not as extreme as some would have liked, the standard envisioned by the CBAE guidance still conflicts with prevailing patterns of human sexual behavior, not only for unmarried adults but for adolescents as well. Adolescence is a time marked by physiological and psychological maturation. The formation and testing of romantic attachments and the physical expression of sexual feelings are a natural and developmentally appropriate part of this process. In fact, the single characteristic most closely associated with whether an adolescent is "sexually experienced"—defined as ever having had vaginal intercourse—is age. Only 13% of American females are sexually experienced by age 15; however, that proportion grows to 43% by age 17 and 70% by age 19. Although the age at which the typical American teenager first has intercourse has risen by a matter of months in recent years, the typical adolescent still has intercourse for the first time at age 17—almost a full decade before she marries. And even if the age of first sex had remained constant since 1970, the age of marriage has risen so dramatically that there would still be a six-year gap between the time when women first have sex and when they marry (see chart).

SEX AND MARRIAGE
Although women in 2002 first have sex two years earlier than they did in 1970, there has been a far larger change in when they get married.
Source: Journal of Adolescent Health, 2006.

Moreover, limiting the discussion to vaginal sex provides only a partial picture of teenage sexual behavior. Teenagers engage in a range of noncoital behaviors, from kissing to "petting" to oral sex. In fact, oral sex is at least as common as vaginal intercourse among this age group, according to recent analyses of the National Survey of Family Growth (NSFG). This large, nationally representative, government-funded survey of over 12,000 individuals aged 15–44 included questions about oral sex for the first time in 2002, the most recent year data were collected. According to the NSFG, more than half of all female and male teenagers aged 15–19 reported that they have had oral sex (54% and 55%, respectively), slightly higher than the proportion for vaginal sex (53% and 49%, respectively).

As with vaginal sex, adolescents are more likely to have experienced oral sex the older they are. Also, oral sex is far more common among teenagers who have had vaginal sex than among those who have not. Still, the fact remains that a significant proportion of teenagers who have not had vaginal intercourse have had oral sex (24% of males and 22% of females). Of those, white adolescents and those from higher income households (who have the lowest rates of vaginal sex) are the most likely subgroups to report having had oral sex.

Why do some young people engage in oral sex but not vaginal sex? The NSFG sheds some light on this (see chart). Clearly, avoiding pregnancy is a major concern, particularly among boys; however, avoiding STIs is not. (Although there is a risk of STI transmission during oral sex, it is significantly reduced compared with vaginal sex. And, of course, oral sex precludes the risk of pregnancy.) A relatively large proportion of both teenage boys and girls see oral sex as less in conflict with their moral or religious beliefs—perhaps allowing them to technically remain "virgins" while still expressing themselves sexually. One in five teenage girls and boys report having had oral sex with someone who is not "the right partner" for vaginal intercourse, and an additional one in 10 say they have met the right partner but it is "not yet the right time." Combining these two relationship factors together suggests that many teenagers see oral sex as less intimate than vaginal sex.

TECHNICAL VIRGINITY
Teenagers who have had oral but not vaginal sex report a variety of reasons for postponing vaginal sex.
Source: Guttmacher tabulations of the 2002 National Survey of Family Growth, 2006.

Toward a Healthier Model

Given current patterns of teenage sexual activity, it is probably safe to say that efforts to prevent teenagers—let alone all unmarried people—from engaging in anything potentially sexually stimulating are at best unrealistic. At worst, such efforts may have harmful public health consequences, by failing to prepare young people for the time they, almost inevitably, will become sexually active. To date, there is no sound scientific research suggesting that abstinence-only education delays the initiation of sexual activity. There is evidence, however, that such programming, which either precludes information about condoms and contraception entirely or permits only negative information, may be making it harder for young people to effectively engage in protective behaviors down the road. According to research by Hannah Bruckner and Peter Bearman published in the 2005 Journal of Adolescent Health, most adolescents who pledged to remain virgins until marriage broke their vows, and these "pledge breakers" were less likely to use condoms and to seek testing and treatment for STIs than those who never took such a pledge. Additionally, the relatively small proportion who had kept their pledge and remained virgins (reported no vaginal sex) were more likely than virgins who never pledged to report oral (and anal) sex. These findings raise the possibility that virginity pledges, which are a centerpiece of many abstinence education programs, may be affecting the sequencing of sexual behaviors and may be prompting some young people to engage in behaviors such as oral sex to technically preserve their virginity—behaviors that many teenagers themselves consider to be less intimate than vaginal sex.

Similarly, more progressive researchers and advocates may bear some responsibility for divorcing sex from intimacy. Based on evidence that a key risk factor for having intercourse is being in a serious dating relationship, many such experts exhort parents and others to discourage adolescents from having such relationships. Yet this too may be having unintended consequences, because it may be deterring the relationships but not the sex. If teenagers want to have or are having sex, but are hearing from society and the people closest to them that they should not be "seriously" dating, then these efforts may, in fact, help fuel rather than stem the casual sexual hookup culture that is the cause for so much alarm.

A potentially healthier, albeit more daring, alternative might be appropriately found in the experiences of other developed countries that are more accepting of teenage sexual activity and that seem to have better adolescent sexual and reproductive health outcomes as a result. In northern European countries such as Sweden, Switzerland and the Netherlands, sex among at least older teenagers is generally accepted, and there is little, if any, societal pressure to remain abstinent. But with that acceptance comes strong cultural norms that emphasize that sexual activity should occur within committed relationships—married or otherwise. Teenagers in these countries have longer-lasting relationships and therefore fewer sexual partners than do their peers in the United States, even though they begin having sex at about the same age. This translates to lower STI rates. By the same token, because sex is more likely to be an expression of caring within the context of an established relationship, and because childbearing is socially understood and accepted to be appropriately reserved for adulthood, individuals have a keener interest in protecting themselves and their partners from an unplanned pregnancy. Effective contraceptive use is facilitated, resulting in a far lower teenage pregnancy rate than that found in the United States.

All of this suggests that the U.S. emphasis on stopping young people from beginning intercourse—almost at any cost—may be directly and indirectly harming American youth. It is clearly hindering important conversations about sex and childbearing; the shared responsibility that couples have to protect themselves from unwanted pregnancy and disease; and perhaps most important, the value of relationships, intimacy and commitment, as they relate to sex among not only adolescents, but adults as well.