Editorial note: Zoe Duby is a qualitative researcher in the field of sexuality and HIV prevention. In this piece, she reflects on how the ambiguity and lack of precision of sex-related definitions affect 1) the accuracy of data in research and clinical practice; 2) sexual decision making and risk behaviour; and 3) the accuracy of data on penile-anal intercourse. These issues are framed within the context of HIV research and programming, but their relevance extends to any sex-related field.
The manner in which sexual behaviour terms are defined, operationalised and interpreted has implications for research, policy, and clinical practice, and is central to ensuring the accuracy of reporting and the efficacy of interventions. Understanding how people conceptualise and define sex-related terms is vital for meaningful research and health interventions, especially for epidemics that are predominantly transmitted through sex, such as HIV in Africa. Nonetheless, much of the terminology relating to sex acts remains inconsistent and imprecise. A deeper exploration of these ambiguous terms – regularly used in research and clinical practice – and how they are understood sheds light on how phallo-vagino-centric heteronormative assumptions have shaped the study of sexual behaviour and the provision of sexual health interventions in the sub-Saharan African region.
The language we use to describe sex shapes our understanding of sex and mediates our sexual experiences. Sociocultural codes and conventions enable us to identify specific experiences and acts as sexual or not (1). Despite being widely used in research, clinical practice and everyday speech though, there exists no uniform, universally-accepted, context-independent definition of the word ‘sex’ and related terms. However, the HIV epidemic in sub-Saharan Africa is commonly understood to be primarily ‘sexually-transmitted’ and is considered the largest HIV epidemic driven by ‘heterosexual sex’ in the world (2). Most generalised HIV prevention efforts in the region have focused on ‘heterosexual sex’ as the key transmission vector, with transmission to women assumed to occur through ‘heterosexual sex’.
The HIV epidemic is therefore an important opportunity to examine scientific understanding of and language pertaining to ‘sex’. Research on how these concepts have been defined and conceptualised in African settings is scarce, and has largely focused on abstinence (3,4), or language and metaphors around sex (5,6). In efforts to find ‘African solutions’ to ‘the African AIDS problem’, programmes focusing on delaying sexual debut and promoting abstinence have formed a large part of HIV prevention efforts in Africa. Little attention, however, has been paid to how these concepts of sexual debut and abstinence have been defined, understood, and operationalised.
Ambiguous definitions affect the accuracy and quality of our data, as well as how HIV prevention messaging is interpreted by the public (7). There is a growing recognition of these problems of definitions in the United States and Europe, and increasing efforts to use terminology that is clearer and less ambiguous. However, despite Africa’s sexually transmitted HIV epidemic, this recognition and shift seems not to have taken place yet in most sex research on the continent. In this piece, the concepts of sex, virginity and abstinence are examined, highlighting how these and terms have been defined and operationalised in socio-behavioural research on sex and in HIV interventions in sub-Saharan Africa, as well as how they have been understood by research participants. These reflections are drawn from over a decade (beginning in 2006) of qualitative research exploring heterosexual penile-anal intercourse in the context of five sub-Saharan African countries.
Pervasive and widely used terms (such as ‘sex’, ‘intercourse’ and ‘coitus’) refer to sexual behaviour but generally remain ambiguous and lack clear, explicit definition. A number of terms relating to an individual’s ‘commencement of sexual activity’—such as ‘sexual debut’—are also unclear. These terms are commonly used in research and clinical practice in sub-Saharan Africa, but they rely on a phallo/vagino-centric heteronormative assumption. The terms phallo/vagino-centric or penile-vaginal penetrative heteronormativity refer to the ‘coital imperative’, an assumption that the ultimate objective of sex is penetrating the vagina with the penis, an assumption privileged above all else (8-10). It is typically assumed that discussions around ‘sex’ or related acts will be in reference to penetrative, penile-vaginal intercourse between a man and a woman (11,12). Similarly, heteronormativity means that heterosexuality is understood within the dominant social norms as the natural and normal sexual orientation (13,14).
The heteronormative framework sets boundaries around what physical behaviours constitute sex or not, disenfranchises non-heterosexuals, and excludes the diverse pairing possibilities in genital physiology (15). Additionally, by assuming that ‘heterosexual sex’ refers to penile-vaginal penetrative sex, other physical expressions of heterosexuality are also excluded (8). Anthropological studies from sub-Saharan Africa suggest that gendered role expectations and the centrality of penile-centric acts define what counts as ‘sex’ (16). Sexual activities such as intercrural (thigh) sex, manual masturbation, digital (finger) stimulation or penetration, kissing, and so on, are usually excluded from the definition of sex, with specific ambiguity as to how penile-anal penetration and oro-genital /anal sexual contact are situated.
People’s own definitions of sex are fluid and dependent on intention, context and factors at individual, interpersonal, and socio-cultural levels. Individual factors include gender, age, religiosity, ethnicity, HIV serostatus, sexual orientation, past sexual experience, and sexual socialisation (parents’/community’s permissiveness) (17). Motivations for defining sex also play a part; the same physical act may be defined in different ways by an individual depending on the anticipated consequences of the definition (18). Interpersonal factors include gender of sexual partners involved, the relationship context in which sex occurs, whether the act was consensual or not, and occurrence of orgasm, amongst others. At the socio-cultural level, influential factors include gendered sexual norms, religious beliefs around the importance of virginity, and the link between sex and reproduction. Sexual behaviour is thus “socially constructed” – different behaviours are defined as sexual and imbued with certain meanings across different cultural and social contexts. Definitions of sex are also influenced by factors relating to the audience—clinician/researcher/sexual partner—whose own interpretations will be influenced by their assumptions and many of the above mentioned factors. Despite the influence of these factors, individuals have some degree of agency in negotiating their own experience and definitions of sex. The complex interplay of the factors described here contributes to the ambiguous, sometimes contradictory definitions and conceptualisations of sex-related terms (19,20).
Most classifications of virginity loss, sexual debut and being sexually active in research from sub-Saharan Africa have been based on heterosexual penile-vaginal intercourse (21-23). However, this assumption is rarely explicitly cited, and despite a voluminous literature on virginity testing in South Africa (where the bulk of this data comes from), there is little mention of how ‘virginity’ and ‘sex’ are defined. Nonetheless, the penetration of a woman’s vagina by a penis is commonly perceived to be the act that enables her to transition to sexual maturity and womanhood (13,24). Female anatomical virginity is central to normative ideas of virginity in Africa, with ‘hymenal virginity’ (the integrity of the hymen, the porous membrane covering the lower end of the vagina) being the most common marker, despite the fact that this is an unreliable indicator of whether a vagina has been penetrated by a penis (14,24-29). This lack of clarity can have serious implications. For young Zulu women, for example, failing a virginity test may result in social exclusion, shame, and jeopardised marriage prospects. With the concept of female virginity in Africa and elsewhere so closely aligned with the vagina, this raises the question of how male virginity should be defined (26,28,29). There is still ambiguity about how sexual activities other than penile-vaginal sex are situated in conceptualisations of virginity and virginity loss.
There are value associations attached to being a virgin or non-virgin, which affect how the terms themselves are defined. People often choose to disregard or modify the dominant definition of virginity loss to suit their own purposes (14). The social desirability of virginity also has a gendered dimension. Virginity can be stigmatising for male adolescents, whereas the loss of virginity can be stigmatising for female adolescents. Male adolescents, more eager to transition to a non-virgin status, are more likely to consider a greater variety of sexual behaviours as constituting virginity loss than females (30). In contrast, individuals who consider virginity at marriage important are less likely to include behaviours like oral sex and anal sex in their definitions of sex or virginity loss, in order to maintain their virgin status and a positive social identity (30).
Like sex, definitions of virginity and virginity loss are also fluid and subject to context, circumstance, motivation and other situational factors. Factors influencing how individuals define ‘losing’ their virginity include their own previous sexual experience, moral views, and sex act-specific factors including male partner ejaculation, vaginal penetration by anything other than a penis, hymen rupture, or the occurrence of orgasm/climax (30-32). Oral and anal sex are rarely perceived to be causes of virginity loss, an event which is constructed to only take place through the occurrence of penile-vaginal sex (14). It follows that sexual orientation plays a part in how an individual understands virginity, with non-heterosexual people more likely to include acts such as oral and anal sex in their definition of virginity loss (14,33). The heteronormative definition of virginity loss (penile-vaginal penetration) thus denies non-heterosexual people sexual maturity, rendering ‘non-heterosexual’ sexual experiences as illegitimate (14).
There are also implications for sexual health and risk reduction. Social pressure to remain a virgin is likely to increase the risk of infection by acting as a barrier to young people’s use of prevention and encouraging alternative, non-vaginal sexual practices. With the idea that neither oral sex nor penile-anal intercourse constitute sex or a loss of virginity, non penile-vaginal sexual acts are used as a means of maintaining ‘technical’ virginity, practicing abstinence and delaying sexual debut, despite the fact that practices such as anal sex may actually significantly increase risk of HIV infection (34-40). Examples of this can be found amongst young Zulu women in South Africa, who engage in penile-anal sex in order to maintain the integrity of their hymens and thus pass ‘virginity tests’ (41-44).
Similar to assumptions that having sex equates with a penis entering a vagina, the term ‘abstinence’ is most commonly based on the non-occurrence of heterosexual penile-vaginal sex (36,37). Historically, intervention designers and policymakers targeting ‘sexual debut’ and ‘abstinence’ have neglected to specify what the terms actually mean (45,46). Definitions of abstinence used by institutions such as UNAIDS, USAID and PEPFAR include terms such as ‘not engaging in sexual intercourse’, ‘delaying sexual initiation’ and ‘postponing sex’, but fail to explicitly define these terms (4,14,18,37). Abstinence proponents, often connected to faith-based institutions, generally define abstinence in moral terms, using ambiguous language such as ‘chaste’ or ‘virgin’ and framing abstinence as a ‘commitment to chastity’ (45).
Like sex and virginity however, individuals define what they mean by abstinence depending on context and situation. Evidence suggests that abstinence definitions are even more fluid than virginity; for example, the definition of whether or not someone is abstinent often being based on the period of time that has elapsed since they last engaged in ‘sex’ (47). Further, the way in which abstinence is defined differs throughout stages of adolescence and adulthood (48). Research examining how young people in sub-Saharan Africa define the concept of abstinence has found that definitions are variable and interpretations of ‘abstinence’ include ‘stopping sex’, not wanting to have sex, not having sex specifically in order to avoid contracting HIV, and refraining from premarital sex (4,49).
The inconsistency of definitions for sex-related terms has implications for the reliability of research data. Data collection tools for research and clinical practice have been based on expectations about how respondents define sex, with a presumption that definitions are consistent, shared by respondents, and match those of the researcher/clinician. Current approaches for collecting patient sexual risk data are highly variable, imprecise and can lead to misclassification of an individual’s sexual risk (21,50). For example, simply asking respondents if they have ‘had sex’ is vague and open to interpretation; as shown above, someone who does not consider activities such as oro–genital contact or penile-anal intercourse to be ‘sex’ will answer negatively rendering their risk assessment inaccurate. Similarly, if these terms are unclearly used in research or sexual history taking, individuals who may have already been engaged in partnered sexual behaviour but still self-identify as a virgin due to diverse ‘virginity loss’ definitions may be overlooked. Studies examining sexual debut and abstinence in which questions such as ‘have you ever had sex?’ encounter similar issues of ambiguity and may be further impeded by the stigmatisation and cultural prohibition of non penile-vaginal sexual practices, which often result in underreporting (51,52). When imprecise terms are used, there is a high risk for misclassification bias in research and sexual history taking, with potentially dramatic implications for the accuracy and reliability of data on sexual histories and risk behaviour (53,54).
The reliability of data and the use of ambiguous and undefined terms such as sexual intercourse, sex and virginity has implications for HIV interventions. Historically, many HIV prevention programmes in Africa aimed at young people have focused on advocating delayed sexual debut, abstinence, and virginity maintenance, often without clearly defining these concepts and behaviours (55). These ambiguous concepts have also been used as indicators for the effective monitoring of national HIV programs, and in sub-Saharan African National Demographic and Health Surveys (DHS), intended to collect and disseminate accurate and nationally representative data on public health. There is an implicit assumption that rather than being fluid and contextually specific, definitions of sex-related terms are robust and universal. Adolescents who have not had sex or ‘debuted sexually’ may have already engaged in penile-anal sex and oral sex, but this information is typically not captured in research or clinical history taking (23). While penile-anal sex may be practiced as a means of maintaining virginity, delaying sexual debut, and remaining abstinent, reasons for adopting these behaviours also include a perceived lower risk of adverse health or social consequences due to misinformation (51,55,56). In reality, these terms are deeply subjective and socio-culturally defined, and their interpretation and meaning varies widely.
Hunt and Davies (1991) suggested that there are three approaches to dealing with the challenge of sex definitions in sex research. The first is to ignore the question of how sex is defined, assuming that the imprecision of language is trivial and will be swept up in the sampling process, and that differences in meaning between participants/researchers will be minor and insignificant. The second approach is the imposition of terms with strictly defined meanings that result from pilot testing of terms, thus providing a common currency for discussion. The third approach is an in-depth investigation of the various terms used by the target study population, and then the employment of these terms as the basis of subsequent investigation. Below I offer two additional recommendations.
Researchers and those working in clinical practice should use behaviourally specific, unambiguous language in order to ascertain accurate information about sexual behaviour and sexual risk from participants/patients, not assuming a mutually shared definition of terms (40,54,57,58). In order to ensure effective education and risk prevention, words that have any potential for ambiguity or multiple interpretations should be avoided (57). Researchers also need to be cognisant of the fluidity and inconsistency of sexual behaviour terminology, and increased attention needs to be paid to the variables and contextual factors that influence the ways in which sexual behaviour is defined and classified, particularly when it has implications for HIV and STI risk.
The focus of this piece has been on the English-language terminology around sex, virginity and abstinence as this is the dominant language of medical research and clinical practice, both in sub-Saharan Africa and more broadly in global health. The definitional and conceptual dilemmas around sex-related terms are amplified in cross-cultural research, where it should be ensured that translated terms are equivalent, accurate, precise, unambiguous and inoffensive (53). In multi-lingual contexts, attention to ambiguity is particularly important and complex, especially where terms may have multiple possible interpretations or translations (53). In order to improve risk assessments, and for the clear, unambiguous standardised communication of information, the challenge lies in developing operational terms that are as physiologically precise as language allows and are sexuality- and value-neutral.
It may not be possible to resolve the substantial terminological challenges shared by researchers, prevention specialists and clinicians simply by proposing the adoption of biologically- and behaviourally-specific definitions. The latter has been tried many times and found to have both strengths and weaknesses, and additional challenges arise when explicit definitions make patients/participants and researchers uncomfortable. It is important to appreciate that these recommendations are themselves culture-bound and limiting, and may be seen to negate cultural and linguistic diversity (53). However, the clear impact of terminological challenges on research and practice provide an impetus for working toward improving our shared understanding. Further exploration into how innovative research methods, such as visual tools, body mapping exercises and three-dimensional models, could be used to reduce misinterpretation and ambiguity of terms (53).
Like sex research more broadly, the bulk of research on virginity, sexual debut and abstinence in Africa, has also been based on heteronormative, vagino-centric assumptions. Conventional language related to sex fails to encompass the varied sexual practices that humans engage in, provide for the different boundaries that people draw around what constitutes sex and what does not, and fails to reflect the fluidity and contextuality of notions of virginity, abstinence, and definitions of sexual acts. Other sexual behaviours have been largely overlooked and excluded from research and clinical practice as a result of the assumptions embedded in commonly used terms and definitions, as well as due to denial, taboo and sexual communication norms.
Greater attention needs to be paid to the complexity, problematic ambiguity and inconsistency of conceptualisations and definitions of sex-related terms. Although sex, virginity and abstinence are social and contextual constructs whose meaning and interpretation varies across individuals, these terms continue to be used as if their meanings were unambiguous. As shown here, this can affect the quality and accuracy of data, with considerable implications for HIV and other sexual health interventions.
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Zoe Duby is a qualitative social science researcher in the field of sexual behaviour and HIV prevention, and has worked within various HIV prevention research collaborations across East and Southern Africa. Her research focus has primarily been on high risk and socially stigmatised sexual behaviours in the context of sub-Saharan Africa.
Division of Social and Behavioural Sciences
School of Public Health and Family Medicine
Level 3 Falmouth Building
University of Cape Town