A new study purports to show a disturbing discrepancy between the number of teens who say they’ve “had sex” with those who test positive for STDs. Of those who supposedly said they’d been abstinent, 10% tested positive for at least one of the three common STDs (chlamydia, gonorrhea, and trichomoniasis). As such, researchers and journalists have assumed that at least 10% of those who said they hadn’t had sex must have been lying to their doctors about their sexual histories.
When I first saw the headlines — “Some young adults with STDs say they’ve never had sex”, “‘Abstinent’ teens test positive for STDs” — I assumed that a significant portion of the discrepancy could likely be accounted for by a failure to adequately explain to the teens what “sex” means. The fact is that in dominant culture, “sex” very unfortunately still means “penis-in-vagina intercourse” to the vast majority of people. Ask a lot of teens if they’ve “had sex” and they very well might say no and believe they are telling the absolute truth — even though they may have engaged in all kinds of non-intercourse sexual activities such as oral sex, hand to genital contact, non-penetrative genital rubbing, etc. And, of course, these kinds of sex all present the potential for STD transmission, to varying degrees.
But my assumption was wrong. The researchers didn’t fail to adequately define “sex” for the study participants — they explicitly excluded all non-intercourse activities themselves in their questioning, by asking only whether each person had engaged in sexual intercourse in the past 12 months.
So let’s talk, instead, about the problems with the study. Frankly, I’m appalled that it’s treated by researchers as though it can teach us anything useful at all. The wording of the question erases all sexual activity that takes place outside of cis heterosexual sexual pairings, contributing yet again to the cultural notion that no other sexual pairings exist, let alone matter. It also erases a good deal of sex that takes place between cis men and women, too — and if what went on during my teenage years are any indication, an even greater deal of what goes on between teenagers who are in sexual relationships but not ready for or interested in intercourse.
So we’ve ended up with some extremely inconclusive data. Even the researchers themselves acknowledge that some of the STDs among those who did not report engaging in intercourse could have been transmitted more than 12 months ago or through non-intercourse sexual activities. Though they try to downplay this likelihood, the fact is that you don’t know what you don’t take the time to ask. Posing better questions in the first place would eliminate a significant amount of guesswork.
Study findings indicate that “sole reliance on young adults’ self-reported penile/vaginal sexual activity as a marker for STD acquisition risk may be imprecise and further, could be problematic,” the researchers write.
They argue that future research should attempt to find ways to reduce “discrepant” reports by young people about their sexual activity.
The researchers note that they did not collect information about anal sex among men and that some cases of chlamydia may persist 12 months after sexual intercourse. And study participants only indicated whether they’d had sex had in the past 12 months.
“Given the length of the reporting interval, the previous 12 months, young adults’ retrospective recall could be inaccurate,” the researchers write. However, they add that “volitional underreporting” could explain discrepancies between self-reports and facts.
The findings suggest that doctors should do more than just ask young people about their sexual activity.
“Importantly, our findings reveal that if pediatricians and adolescent medicine physicians do not test all young people, there are likely a substantial number of missed cases of STDs that will go undiagnosed, untreated, and spread to future sex partners,” the researchers write.
Now, it’s not that I’m opposed to more STD testing. As long as informed consent is involved, this strikes me as a good idea. Once privacy and financial concerns are accounted for, consensual STD tests that turn up negative cause little harm. Not conducting STD tests that would have come back positive, on the other hand, causes a great deal. There certainly is a “better safe than sorry” argument to be made.
What unnerves me is the casual glossing over of the inadequacy of the questions asked — and the complete absence of a recommendation that doctors should ask better ones. I say that better than assuming young people to all be a bunch of liars, doctors should work harder to establish meaningful communication with patients and, importantly, to interact with them in a non-judgmental way. A way that doesn’t assume them to be straight, a way that doesn’t assume there’s only one kind of sex, a way that doesn’t suggest imminent judgment if a female patient says she has had sex, a way that doesn’t suggest an assumption that a non-white patient or low-income patient must have had sex. A way, in other words, that treats patients compassionately and humanely.
It’s also important to get to the root of the problem that’s even more insidious than the extremely common and even cultivated feeling of fear and intimidation towards doctors — the social fear of sexuality, and the dominant attitude that sexual activity is something to hide.
To the extent that some young people undoubtedly are lying about their sexual histories to their doctors, surprise is both a naive and irresponsible reaction. Most of us growing up in a sexphobic culture absorb the message through one means or another that sex is something to be punished — if you’re a woman, if you’re queer, if you’re trans, if you’re not married, if you’re non-white, if you’re poor, if you’re disabled, if you’re kinky. Pregnancy and STDs are often misconstrued as “punishments” for having kinds of sex that are not socially approved. And very real punishments are often enacted for certain sexual behaviors — whether they be slut-shaming, homophobic verbal and physical assaults, other forms of social ostracizing, or being cut off from financial support.
Young people are perhaps the most at risk for punishment for sexual behavior. Adolescent sexuality is frequently seen as flat-out wrong, and it’s still considered entirely appropriate for parents to penalize teens for consensual behavior they’ve engaged in with their own bodies. The law has the right to punish them, too — not all states allow minors confidential access to contraception, and most states require that parents be notified prior to an abortion. Coupled with huge gaps in sex education, there’s a lot of fear surrounding the acknowledgment of sexual activity for young people, and many legitimate reasons for it.
In other words, this isn’t just a problem of doctors not being patient, or compassionate, or kind, or understanding, or unbiased enough — though those are very real problems for many people. It’s a social problem regarding how we, as the dominant culture, treat sexuality. It’s something that can’t be cured with a few “sensitivity” trainings, with a book, with a small group of people just giving it a little practice.
But it is something to consider. What if those of us who were raised either explicitly or implicitly to believe that sex is dirty, secretive, and unspeakable hadn’t been? What if we didn’t see sex everywhere, but honest dialogue about it almost nowhere? What if the sex we saw portrayed was genuinely varied both in practice and participants? What if some entirely consensual sexual practices weren’t routinely portrayed as “weird” and “deviant” while non-consensual ones were portrayed as “normal” and “how it works”? What if sex was treated as healthy, for those who want to have it, when they want to have it? What if desired, consensual sex was not treated as something to be hidden, something that was frowned upon or disapproved, something that might result in shame — and not desiring or having sex was treated the same way? What if having an STD or unplanned pregnancy did not have a stigma attached to it? What if there was no confusion about what people meant when they talked about sex, because questions could be asked openly and without embarrassment? What if knowledge of your sexual orientation or activity wasn’t tied to the threat of not having a place to live, a caretaker to help you live independently, or money to survive? What if knowledge of your sexual activities wasn’t likely to be used as a weapon against you because of your race, class, disability, gender identity, or sexual orientation?
I imagine that there would be fewer teens — and adults, for that matter — lying to their doctors about their sexual activities. Because the reasons why we do so would be gone. And they’re not issues that doctors alone can fix, but ones that are on all of us.
One final point: while I imagine this only accounts for a fairly small portion of the discrepancy, it’s important to note that even with better, more inclusive questions being asked of patients, some who say they have not had sex yet still test positive for STDs will undoubtedly be telling the truth. It’s called sexual assault. Young people are particularly at risk for sexual violence, and this fact is almost universally erased whenever the topic of pregnancy and STD risk comes up. Most STDs are passed through consensual sex. But not all. There are very good reasons to ask patients about histories of sexual violence, including reproductive coercion, during medical visits. Assessing a patient’s risk for sexually transmitted diseases is just one of them.