Differences in Perceptions of What Constitutes Having “Had Sex”: DISCUSSION
As seen in Table 3, the differences in responses between our HIV-positive sample and those in Sanders and Reinisch’s study (unknown HIV status) are striking. While the hierarchical order of “yes” responses remains primarily the same in both studies (with deep kissing and breast contact items receiving the fewest “yes” responses followed by genital touching, oral-genital contact, anal intercourse and vaginal intercourse), the actual percentage of “yes” responses vary greatly.
One of our hypotheses going into the study was that an ethnic minority population might demonstrate a different sense of what behaviors constituted sex than a largely white population. Indeed, minority respondents from our sample provided a much more inclusive definition of what it means to have had sex. In Sanders and Reinisch’s study, >99% of the respondents agreed that penile-vaginal intercourse was sex, and for deep kissing and all breast contact items <4% agreed this was sex. Our sample never had >81% agreement overall (for penile-vaginal intercourse) and no behavior—not even deep kissing—had <35% agreeing that the behavior was sex.
There are likely multiple reasons for the differences in our findings, including having an older, predominately minority and largely male sample. In addition, it is possible that the terminology used in the survey questions was not understood by the patients.
Table 3. Comparison of Sanders and Reinisch and Rowlings et al
|Number and Percentage of “Yes” Responses when Asked, “Would You Say You Had Sex If…?”|
|Questions||Sanders||and Reinisch (n=599)||
Rowlings et al. (n=279)
|oral contact with your breasts or nipples?||3%||
|you touched a person’s genitals?||13.9%||
|oral contact with another person’s breasts or nipples?||3.4% –||
|your penis in a person’s anus?||N/A||
|a person’s penis in your anus?||N/A||
|you had penile-vaginal intercourse?||99.5%||
|you touched another person’s breasts?||3.4%||
|oral contact with your genitals?||40.2%||
|oral contact with another person’s genitals?||39.9%||
|a person touched your breasts?||3.0%||
|a person touched your genitals?||15.1%||
Having HIV infection may also be a factor. Perhaps due to already having been infected with HIV through primarily sexual activity, our sample may be expressing a more generalized idea of what constitutes sex because they are interpreting it in terms of risk. For instance, at some level patients understand that when combined with the right set of circumstances, many of these behaviors could possibly lead to acquiring sexually transmitted diseases (such as herpes, gonorrhea, syphilis). However, patients also know, sometimes from personal experience, that not every occurrence of anal or vaginal sex will always result in HIV infection. This could possibly explain why all behaviors have >35% “yes” responses and none have >81% overall. In this light, responses are perhaps not so much a reflection of what behaviors patients consider to be sex as they are a reflection of the degree to which patients perceive these behaviors to carry a risk of HIV transmission.
Concern over the terminology used in the questions is particularly valid. The specific questions are consistent with those used by Sanders and Reinisch. In addition, the phrasing of the questions also tends to mirror the type of conversations that occur in medical practices. Most often, anatomical terms are used in lieu of more lay or street slang for sexual behavior. The fact that some questions may have been erroneously answered “yes” could be explained through patients not understanding or misinterpreting terms (e.g., penile for penal).
During the period from 1999-2002, approximately 64% of heterosexually acquired HIV infections reported in the United States were found to occur in females. In light of these changes in the HIV epidemic, researchers have begun to pay increasing attention to high-risk sexual behaviors among females, such as anal sex. HIV-infected women in our sample were significantly less likely than men to consider receptive anal intercourse and either giving or receiving oral sex to be sex. A clinician screening a female patient such as this would be likely to misinterpret the meaning of her response to questions addressing the practice of “safe sex” through condom use. Other research has identified the existence of significant misperceptions among minority women regarding the meaning of “safe sex”. Would the patient above consider herself to still be practicing “safe sex” if she was not using condoms during oral-genital contact or anal intercourse but was for vaginal intercourse? If a clinician lacks a solid understanding of how this hypothetical patient defines “sex,” these questions go unanswered or even unasked, and an HIV-positive woman may continue to place herself and others at risk for (re)infection.
The 28.1% of female participants that affirmed having had a female sexual partner is an unusual finding and warrants confirmation in future surveys.
As the HIV epidemic moves well into its third decade, it has increasingly become a disease affecting African Americans and Latinos in the United States. In our sample, African Americans and Latinos were less likely than whites to consider oral-genital contact to be sex. This same pattern also held true for anal intercourse.
Much more research is needed in this area to determine: 1) if these findings are representative of HIV-infected minority patients in other sites and, if so, 2) what association these perceptions of sex may have with the changing demographics of the epidemic. In addition, it is important to determine if these findings are representative of uninfected minority patients given the goal of primary HIV prevention.
Another relevant finding revolved around items В and L (touching the genitals). Overall, slightly more than half of the sample agreed that if this was the most intimate behavior engaged in then this was not sex. African Americans, in particular, were significantly less likely to consider that manually stimulating another’s genitals was sex. When an HIV-positive patient states he/she is not having sex, could he/she actually be engaging in genital contact behaviors such as mutual masturbation? While mutual masturbation is certainly not the most effective way to transmit HIV, it is nonetheless possible if bodily fluid is transferred between participants. Clinicians may need to ask more precise questions to fully understand the sexual behaviors engaged in by their clients, assess their potential risk and counsel them on risk-reduction methods (e.g., is ejaculation occurring during mutual masturbation? Are sexual fluids being transferred between genitalia?). However, without a prior understanding of how patients conceptualize sex, this line of questioning would likely not occur.