Starting Young: Sexual Initiation and HIV Prevention in Early Adolescence

Ruth Dixon-Mueller


AIDS and Behavior. 2009;13(1):100-109. 

In This Article

What's Missing: Evidence on Other Risky Sexual Behaviors

Many young adolescents who say they have "never had sex" are engaging in unprotected oral or anal sexual activities. Questions remain unasked not only because they are controversial, but also because researchers and respondents may assume that "sexual activity" and even "heterosexual intercourse" refer only to penile-vaginal penetration. When the relevant questions are asked, a quite different picture emerges. Among primary school students aged 12 and over in the Mwanza region of Tanzania who said they were "sexually experienced" (four-fifths of all boys and two-thirds of all girls), half of both sexes said that their first sexual act was vaginal intercourse; 40% said it was oral-genital contact (presumably fellatio); and almost 10% said it was anal intercourse (Matasha et al. 1998:575).

Ethnographic accounts from Tanzania, India, Bangladesh, Mexico, and other settings portray a variety of sexual "games" in which boys engage as a form of male bonding that include anal penetration of younger or "effeminate" boys, group masturbation, and other activities (Barker 2000; Szasz 1998). Whether anal penetration is viewed as "sex" or "play" (or, alternatively, as male ritual, bullying or violence expressed in a sexual manner) is not always clear, however. Nor is the distinction between heterosexuality and homosexuality, the latter representing a disdained social category that most boys will reject even as they pleasure themselves with boys or are used as sexual outlets by other boys or men (Barker 2000; Brody and Potterat 2003; Rajani and Kudrati 1996). Boys living on the streets of Mwanza, Tanzania, and Bangalore, India, described repeated acts of anal rape by older boys or men enforcing their power (Rajani and Kudrati 1996; Ramakrishna et al. 2003). Apart from these resented acts, most street boys participated in initiation rites that involved the group rape of new boys; anal penetration of unwilling "sleepmates" to release sexual tension; and more consensual "comfort sex" with special friends until they acquired female partners (and sometimes afterwards as well).

Young male adolescents' experiences as active or receptive partners in anal intercourse and what it means to them have not been well studied in general populations. Yet such information is imperative for understanding potential male-male and male-female STI/HIV transmission routes during these vulnerable years. Given the very high risks of STIs/HIV for the receptive partner in unprotected anal intercourse if the insertive partner is infected, younger boys who are penetrated by older boys or men are particularly susceptible. In addition, forced anal penetration and other forms of violence and abuse can trigger a sequence by which young male victims subsequently act out the same behaviors with their male or female partners (Jewkes et al. 2006; Population Council 2004). Girls, too, may be subjected to anal penetration during episodes of sexual abuse or rape, or, willingly or not, by boyfriends, "sugar daddies," or as young brides. Although heterosexual anal intercourse is said to be not uncommon in countries such as Brazil, Puerto Rico, Peru, India and South Africa (Brody and Potterat 2003; Caceres et al. 1997; Halperin 1999; Lundgren 2000; Verma and Collumbien 2004), the practice remains largely uninvestigated among young people in developing countries. In the United States, 4.6% of all 15-year-old boys interviewed in the 2002 National Survey of Family Growth and 2.4% of girls said they had ever had anal intercourse with an opposite-sex partner; by age 19, 15.3% and 18.6% had done so (Mosher et al. 2005:21-22).

Surveys that refer to "oral sex" rarely ask boys whether they had fellatio only with girls or were insertive or receptive partners with other boys or men. Again, whereas evidence from developing countries is scarce (the Mwanza school survey reported above is one exception), U.S. studies have found up to one-third of 14-15-year-old male and female students admitting they have engaged in fellatio (Halpern-Felsher et al. 2005; Remez 2000; Schuster et al. 1996). In the 2002 National Survey of Family Growth, 30% of 15-year-old boys said they had ever "received" oral sex from females and 18% of 15-year-old girls had ever "given" oral sex to males (Mosher et al. 2005:21-22). To the extent that teenagers in these and other studies view fellatio as "not really sex" (e.g., see Kaufman and Stavrou 2004 on South Africa), risks to the receptive boy or girl -- although low per sexual act -- may be compounded by its higher frequency compared with vaginal intercourse in some populations and by the greater likelihood that fellatio is performed with multiple casual partners.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: