Understanding College Students Perceptions of “What is Sex”?

Background: While there is strong consensus that vaginal and anal intercourse both constitute “having sex”, there is far less agreement about other sexual behaviors which also increased risk. The purpose of this report is to examine responses regarding which sexual interactions are classified as “having sex” by university students. Methods: We completed a cross-sectional survey of 1991 college students at 2 universities using a self-administered questionnaire during 2010 and 2011. The main dependent variable examined dichotomous responses to a series of 11 items regarding whether respondents considered various sexual behaviors as “sex.” Results: Penile-vaginal intercourse and penile-anal intercourse was endorsed as “sex” by 94% and 76% of respondents, respectively. Receiving oral-genital contact from a and providing oral-genital contact to another person were both classified as “sex” by about 45% of college students. Less than 25% of respondents reported that other behaviors including touching/fondling genitals, deep kissing, oral contact with breasts, or touching breasts represented “sex”. Conclusions: Given the ambiguous definitions of what constitutes “sex” among young adults, these findings underscore the need to use explicit behavior-specific terminology in sexual health promotion, research, educational and clinical settings to clearly communicate risk.


Introduction
Although there is ongoing research investigating sexual behaviors in adolescents and young adults, there is substantial ambiguity surrounding how people in this age group define specific sexual behaviors. While the term "sexual intercourse" most commonly denotes penile-vaginal penetration, a variety of views exist concerning what constitutes "having sex." The term "sex" can also be used to describe various forms of sexual intercourse such as the act of vaginal, anal, or manual (using hands), or oral-genital stimulation, with a partner [1]. Still, many researchers maintain that "sex" is difficult to define and can differ across gender, age, and scenario [2][3][4][5][6][7][8]. Sex can be regarded as a risky behavior as it may lead to unplanned pregnancies and Sexually Transmitted Infections (STIs), including Human Papilloma Virus (HPV) and Human Moreover, the proportion of young people who have had sexual intercourse increases rapidly as they age through adolescence; 95% of 25-year-olds reported having had sexual intercourse [9].
A greater understanding of these definitions is needed to better estimate disease risk associated with these behaviors and as well as to inform public health interventions to mitigate these risks.
Several studies have examined how university students in the United States perceive various forms of sexual contact. A 1999 publication of data collected in 1991 reported that only 40% of 599 college students identified either receiving or providing oral sex as "having sex" compared with 81% who endorsed penile-anal intercourse and 99% who endorsed penile-vaginal intercourse as "having sex" [7]. Data collected from university students in 1999,2001,2007 and 2010 reported similar findings [10][11][12]. A more recent study published in 2015 based upon data from 594 undergraduate students found that nearly one-half of students expressed uncertainty about whether oral sex constituted "having sex"; where approximately 25% selected "probably not sex" and 23% selected "probably sex." In addition, certainty that a behavior counted as "having sex" differed when rating their own behaviors compared to rating a partner's behaviors [8]. While there is strong consensus, although not unanimity, that vaginal intercourse constitutes "having sex", there is far less agreement about other sexual behaviors. These inconsistent definitions of sex may lead adolescents and young adults to underestimate the health risks and implications associated with various types of sexual activity, particularly anal and oral sex. The purpose of this report is to examine responses regarding which sexual interactions are classified as "having sex" by university students.

Methods and Materials Design
This cross-sectional study involved completion of a selfadministered questionnaire by college students at two different universities. This research protocol was approved by the Social and Behavioral Sciences Institutional Review Board (SBSIRB) at the University at Buffalo (Study # 3065: Adoption of the HPV vaccine: A pilot study of knowledge and attitudes in western New York) and all participants provided assent.

Study Population
Male and female students were recruited from two universities during two academic years (2010 and 2011) using an approach as previously described [13]. Students were recruited using a convenience sample using similar approaches. At university A, eligible students were enrolled from various health courses and received extra credit, while at university B students were enrolled in general psychology classes and were offered research credit toward the fulfillment of their course requirements in exchange for their participation. These courses were targeted based upon their inclusion of students from across varied academic majors and class levels. Respondents completed an Internet-based survey outside of class time. The analytic file was restricted to persons who selfidentified as ages 18-26 years since these ages were considered to reflect a typical college age population.

Survey Instrument
Data presented in this paper focuses on a module of a larger main survey, which contained sections on respondent demographics,

Outcome Measure
The main dependent variable examined dichotomous responses to a series of 11 items regarding whether respondents considered various sexual behaviors as "sex" [7,14]. Respondents were asked "Would you say you 'had sex' with someone if the most intimate behavior you engaged in was... (mark yes or no for each behavior)." Each of the items was phrased in a manner which was neutral about gender or sexual orientation (Table 1-5).

Statistical Analyses
Descriptive statistics and chi-square tests were used to explore associations between the dependent and independent variables. All significance testing was assessed using a p-value of <0.05. Analyses were completed using SPSS version 21.0.

Results
The final analytic file contained 1991 students ages 18-26 years, with 815 respondents during calendar year 2010 and 1176 from 2011. As shown in Table 1, respondents were 59% female, 67% were ages 18-19 years, 77% white, 94% non-Hispanic and 89% reported being born in the US. Nearly all respondents reported having sex with opposite gender partners (e.g., heterosexual). Table 2 summarizes responses addressing whether respondents would say that they "had sex" based on a series of statements describing various intimate behaviors. Overall, 94% of respondents agreed that penile-vaginal intercourse represented "sex." Penileanal intercourse was endorsed as "sex" by 76%. Receiving oralgenital contact from a partner and providing oral-genital contact to another person were both classified as "sex" by about 45% of

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Copy@ Martin Mahoney college students. Between 20% and 25% of respondents reported that another person touching/fondling their genitals or touching/ fondling someone else's genitals represented "sex". Between 12% and 15% of respondents stated that they "had sex" with deep kissing, oral contact with another person's breasts, someone else having contact with their breasts, another person touching/fondling their genitals or touching/fondling someone else's genitals. Significantly more males than females classified touching/fondling another person's breasts, someone touching/fondling their genitals, or deep kissing as "having sex". Females more commonly reported oral-genital contact and penile-anal intercourse as "having sex." Subcategories may not sum to column totals due to missing data.
*Data for 2011 only. As shown in Table 3, there were no differences by age group in the proportion of persons identifying penile intercourse and anal intercourse as "sex"; however, a slightly larger proportion of persons in the 20-26-year-old group compared to persons ages 18-19 years consistently endorsed oral and/or manual contact with breasts and genitals as "sex". Table 4 presents responses stratified by country of origin. Respondents who self-identified as foreign born were more likely than US-born respondents to identify oral or manual breast contact, manual genital contact and deep kissing with another person as "sex", while a larger proportion of USborn respondents identified penile-vaginal intercourse and anal intercourse as "sex".

Discussion
The importance of standardized terminology in sexual and reproductive health cannot be underestimated since understanding how individuals define "sex", abstinence, safe sex, and other concepts has significant implications for sexual health [15]. With regard to sexual violence, persons engaging in sexual behaviors need to provide clear and affirmative consent, which requires a shared understanding of terms like "sex" and/or using more explicit language to reference sexual behaviors. In addition, the behaviors not only pose challenges for physicians and health educators, but also for researchers and policy makers who rely upon self-reported data on the frequency and prevalence of sexual behaviors, which rests, in part, on a common understanding of the questions being asked and the terms being used. However, having ambiguous definitions of the term "sex" is not unique to young adults in America, as a series of studies conducted in Australia, Canada, and the United Kingdom have also demonstrated considerable variability in how university students define "having sex" [16][17][18][19].
Our findings did reveal some differences by gender regarding which interactions were viewed as "having sex". Although these differences were statistically significant, they were relatively modest quantitatively. Findings in this report and in similar studies among college populations in the United States, tend to diminish the significance and hazards of oral sex. Adolescents tend to view oral sex as less risky and characterize this behavior as "casual" and "non-intimate" [20]. Oral sex is effective in transmitting various viral and bacterial pathogens [21].
The college environment appears to exert a strong influence on sexual attitudes and behaviors [15,[21][22][23]   Consistent with previous studies, we found that less than onehalf of respondents defined receiving or providing oral-genital contact as "sex", which may reflect Sanders and Reinisch's notion of "technical virginity" in which sexual contact which does not culminate in penetrative intercourse is not considered to be "sex" [7]. This is best recognized during the 1998 debate regarding whether former President Bill Clinton engaged in "sex" with Ms.
Monica Lewinsky during several alleged encounters between 1995 and 1997. These attitudes may also be reflective of societal and media representations minimizing the consequences of oral sex combined with a traditional cultural emphasis on penetration as a defining feature of sex. In addition, school-based sex education programs and popular media may have contributed to the "normalization" of oral-genital contact [24]. However, this finding is especially concerning given the risk of transmitting STIs through oral-genital contact (Prevention, 2013) [25] as well as through other intimate behaviors associated with "hooking up" and "friends with benefits" relationships, all of which involve varying degrees of skin-to-skin contact facilitating spread of potential infections.
Strengths of our current study include the use of survey items which are identical to those used in similar studies, data collection over two time periods at two large state universities, a sizable study population, and a focus on a typical college age range of 18-26-year-olds. These findings are most generalizable to similar college student populations. One potential limitation of our study is the reliance upon a convenience sample of mostly whites and selfidentified heterosexual respondents. Defining sex as solely vaginal/ anal intercourse may exclude women in same-sex relationships from having sex at all and seems to inadvertently premise sex on male participation. Accordingly, it might be necessary to modify survey items on how "sex" is defined to be more reflective of the sexual diversity of college students and to acknowledge the importance of using more inclusive language in healthcare setting and health education/promotion activities. In addition, progress has been made since 2011 with respect to accessing available resources and improving LGBTQ+ sexual health among college students. Other limitations include the lack of contextualization of items in terms of interpersonal behaviors within or outside of established relationships, potential differences in responses by culmination of orgasm and the lack of psychosocial measures. We were unable to assess for racial/ethnic differences in response beyond an assessment of "foreign born". c) While responses were statistically different by gender and by age group, the magnitude of these difference was generally modest.

Conclusions
d) Respondents who self-identified as foreign born were more likely than US-born respondents to identify nonpenetrative breast and genital contact as "sex".