Even Doctors Don’t Agree on What Counts as Having Sex

When people are surveyed about which behaviors count as “having sex,” it’s nearly impossible to find 100% agreement on anything. For example, studies of college students find that, while most (but not all) agree that vaginal and anal intercourse constitute sex, they’re very split over whether things like oral sex and manual stimulation count. Also, while the vast majority don’t count things like deep kissing and nipple stimulation as sex, there are at least some who do.

This poses a problem for physicians who are trying to take a sexual history, given that some of the most common (and most recommended questions) to ask are: “Are you having sex?” and “Are you sexually active?” Depending on the activities patients count as sex when answering these questions, doctors may or may not get the information they need to provide appropriate testing recommendations and counseling.

In the doctor’s office, however, it’s not just the patient’s definition of sex that matters, but also that of the physician. For example, if doctors themselves don’t count certain activities as sex—and those activities pose a potential risk for sexually transmitted infections, such as oral sex—then it stands to reason that they might not be offering comprehensive sexual health care.

In a study of over 100 first-year medical students, researchers sought to understand how physicians in training define sex. They were given a list of 31 potential sexual behaviors and were asked to report whether each one counts as sex or not.

There was pretty much universal consensus that penile-vaginal (100%) and penile-anal penetration (99%) counted as sex. Compared to studies of college students, these numbers are actually quite a bit higher, given that about 1 in 4 college students don’t count anal sex as sex. This is a positive finding, given what we know about the STI risks associated with anal sex.

However, there was much more variability when it came to other activities involving genital contact. For example, 31% did not count oral-genital contact as sex, while 65% did not count genital-genital contact (no penetration) as sex. That is less reassuring, given that we know that many STIs can potentially be spread through oral sex (e.g., gonorrhea, syphilis) and that some can be spread through skin-to-skin contact (e.g., herpes, HPV).

Age and gender were unrelated to what medical students counted as sex; however, sexual identity had an effect, such that those who identified as anything other than heterosexual were more likely to count non-penetrative activities as sex.

What all of this tells us is that even those we entrust to take care of our sexual health do not necessarily have consistent definitions of what sex is—and that points to a need for enhanced sex education in medical school to ensure that when doctors ask patients for their sexual history, they are getting the most useful and important information possible.

These findings also suggest that, rather than doctors asking very broad, general questions about whether someone is “having sex” or is “sexually active,” more valuable information might be obtained by asking about engagement in specific sexual behaviors. This approach can help to sidestep discrepancies in people’s personal definitions of sex and help to zero-in on the behaviors that are necessary to know for taking care of a patient’s sexual health.

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[1] Talley, H., Cho, J., Strassberg, D. S., & E. Rullo, J. (2016). Analyzing medical students’ definitions of sex. American Journal of Sexuality Education, 11(2), 129-137.

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