Assignment: Family Life-Cycle Stages
Assignment: Family Life-Cycle Stages
Although every individual experiences family life-cycle transitions in unique ways, common challenges and experiences often arise at these transition periods. For example, many couples experience changes in their sexual relationship after they become parents. Likewise, adults’ understanding of what it means to have “positive” sexual functioning may differ at different stages in the family life cycle. It is important for helping professionals to pay attention to the unique needs of the individual clients they serve, while also keeping in mind these common challenges and experiences that may arise.
The family life-cycle stages you will consider for this assignment are:
- Single adulthood
- Committed, long-term relationships
- Becoming parents
- Divorce/relationship termination and remarriage/re-partnering
- Older adulthood
The Assignment (2- to 3-page paper):
Use the five family life-cycle stages listed in the Sexuality in Adulthood Across the Family Life Cycle chart to organize your thoughts for this assignment. For this paper:
- Describe two common sexuality-related transitions or concerns at each stage.
- Provide two examples of how research and theory characterize positive sexual functioning during each stage.
- Briefly describe how you might intervene or use this information to assist clients.
Please utilize the resource attached.
Hensel, D. J., & Fortenberry, J. D. (2014). Life-span sexuality through a sexual health perspective. In D. L. Tolman & L. M. Diamond (Eds.), APA handbook of sexuality and psychology (Vol. 1) (385–413). Washington, DC: American Psychological Association.
385
http://dx.doi.org/10.1037/14193-013
APA Handbook of Sexuality and Psychology: Vol. 1. Person-Based Approaches, D. L. Tolman and L. M. Diamond (Editors-in-Chief)
Copyright © 2014 by the American Psychological Association. All rights reserved.
C h a p t e r 1 3
Life-Span SexuaLity through a
SexuaL heaLth perSpective
Devon J. Hensel and J. Dennis Fortenberry
In this chapter, we use sexual health as an organizing
paradigm for a life course perspective on sexuality.
Sexual health broadly refers to the functions of sex
and sexuality in all stages of life, emphasizing enacted
sexuality as a fundamental part of identity and a core
element of health and well-being (Centers for Disease
Control and Prevention, 2010; Pan American Health
Organization & World Health Organization, 2000;
World Health Organization [WHO], 2002). In distin-
guishing sexual health from sexuality, we refer to the
ways in which the cultural, social, psychological, and
biological constituents of sexuality are written into—
and expressed by—individual bodies over a lifetime
(see Chapter 25, this volume). Although not fully
developed in this chapter, a sexual health perspective
also allows us to explicitly link sexuality to more
fundamental issues of sexual rights and sexual justice
(see Volume 2, Chapters 8, 9, and 10, this handbook).
One challenge in undertaking a developmental
approach to sexual health is appropriating a single
working definition. Although several definitions
have been used (W. M. Edwards & Coleman, 2004),
the WHO (2002) has provided one of the most well-
known and influential of these definitions, compre-
hensively outlining sexual health as
a state of physical, emotional, men-
tal and social well-being in relation to
sexuality; it is not merely the absence of
disease, dysfunction or infirmity. Sexual
health requires a positive and respectful
approach to sexuality and sexual rela-
tionships, as well as the possibility of
having pleasurable and safe sexual
experiences, free of coercion, discrimina-
tion and violence. (p. 11)
We use this definition in the current work, arguing
that it both anchors and clarifies a life course under-
standing of sexual health in four important ways.
First, the sexual health perspective is multidi-
mensional, organized, experienced, and expressed
within an individual’s beliefs and values, relation-
ships, and behaviors as well as within larger contex-
tual sociopolitical systems. This organization
includes but, more importantly, transcends a limited
focus on adverse outcomes (World Association of
Sexuality, 2008; WHO, 2010). For example, deci-
sions about contraceptive and condom use can
reflect gender, class, and power dynamics or rela-
tionship-specific desires for intimacy and sexual
pleasure (Higgins & Brown, 2008) in addition to
concerns about preventing pregnancy or disease.
Second, the sexual health perspective emphasizes
the ageless importance of sexuality, with different studies
separately underscoring its salience during adolescence
(Tolman & McClelland, 2011; see Chapter 15, this
volume), early adulthood (Arnett, 2000; Boisard &
Zimmer-Gembeck, 2011; Hensel, Newcamp, Miles, &
Fortenberry, 2011; see Chapter 16, this volume), and
later adulthood (Mulhall, King, Glina, & Hvidsten,
2008; Schick et al., 2010; see Chapter 17, this volume).
Sex remains relevant in many relationships over many
years and decades and as older relationships are
replaced by newer relationships.
Third, sexual health embraces the continuity of
sexuality, with movement in and out of different
life stages bringing new experiences and new
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Hensel and Fortenberry
386
developmental challenges in each stage (Pan Ameri-
can Health Organization & World Health Organiza-
tion, 2000). For example, entering a new sexual
relationship in early adulthood may carry with it dif-
ferent perceptions of sexual risk than new sexual
relationships initiated in later adulthood.
Fourth, and perhaps most important, the sexual
health perspective underscores the connectedness of
sexuality, recognizing the interrelationships between
early and later sexually related experiences. For
example, although menarche and menopause are typ-
ically conceptualized as distinct, but separate, biologi-
cal endpoints on a woman’s reproductive continuum,
emerging evidence has suggested that contextual
effects, such as socioeconomic status and family
structure, may influence the onset of both events in
different ways (Mishra, Cooper, & Kuh, 2010). Like-
wise, the quality of an adolescent’s relationship with
his or her parents may have important long-term
implications for the quality of the adolescent’s rela-
tionship with future romantic or sexual partners.
These four characteristics of the sexual health
perspective—multidimensionality, agelessness, con-
tinuity, and connectedness—articulate sexuality as a
lifelong process, whereby participation in different
types of experiences and behaviors provides impor-
tant contexts of individual learning around sexuality
at each life stage (Centers for Disease Control and
Prevention, 2010; Fenton, 2010), with experiences
in one stage linking to experiences in later stages
(Jones & Barton, 2004; Nusbaum & Hamilton,
2002; Sandfort & Erhardt, 2004; WHO, 2007).
Despite this broadened theoretical framework, only
within the past decade has research on sexual health
expanded out of an adult-age time frame and come
to be viewed as a normative, and healthy, compo-
nent of both adolescence and old age (e.g., DeLama-
ter, 2012; Tolman & McClelland, 2011). An
unfortunate consequence of this late-blooming
inquiry is the lack of a cohesive, life-course view of
sexual health, one that links development across the
life stages.
Thus, in this chapter, we highlight the develop-
ment of two core aspects of sexual health across
the life course: partnering and sexual behavior.
Although far from providing an exhaustive discus-
sion of the entirety of life-span sexuality, in the
absence of a compelling longitudinal model, we
have purposefully focused this review by selecting
meaningful threads that unite the life stages. These
threads are important not only in their association
to each other but also as constructs that highlight
how sexuality changes within the unique develop-
mental considerations in each stage. Partnering
refers to the expectation, organization, and experi-
ence of sexuality in the context of interaction with
significant others (Sassler, 2010; see Chapter 10, this
volume). In this review, we describe how patterns of
partnering change over the life course and how these
changes influence the emotional, psychological, and
behavioral orchestration of sexuality. Sexual behav-
iors describe the behavioral ways in which sexuality
is expressed; in this review, these behaviors include,
but are not limited to, partnered and nonpartnered
behaviors as well as the absence of sexual behavior.
Comment is warranted regarding what we mean
by life stage. We have chosen to describe partnering
and sexual behavior within three life stages: adoles-
cence, adulthood, and later life. We have chosen not
to assign specific ages to these stages because con-
siderable variability exists in the literature as to what
constitutes the start and end of these periods.
Rather, because sexuality is as much a social con-
struct as an individual one, we use these socially
meaningful intervals to point out how specific social
changes within and between these stages contribute
to an evolution in sexuality. Where appropriate, we
point out how differences in specific ages associated
with these stages (e.g., late adolescent vs. emerging
adult or younger than 50 vs. older than 65) may add
to understanding.
PARTNERING
In this section, we discuss partnering as a venue for
sexual health across the life span. We purposely dis-
tinguish partnering from partnership as a means of
capturing the ongoing variability in the timing,
duration, and purpose of intimate relationships in
relation to sexuality occurring in each life stage. One
(or multiple) close relationships fulfill different
needs, such as sex, intimacy, companionship, par-
enting, or self-actualization, at different points in
time (Agnew, Arriaga, & Wilson, 2008), providing
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Life-Span Sexuality Through a Sexual Health Perspective
387
an ongoing understanding of one’s self as a sexual
person.
The past few decades have seen remarkable
changes in the nature of intimate relationship forma-
tion as well as in the volume of empirical literature
that describes these partnerships. Shifts in the timing
and sequencing of relationship stages have expanded
the way in which researchers consider relationships,
moving from a framework that dichotomizes roman-
tic attachments as either preceding or following het-
erosexual marriage to a framework acknowledging
the many options for sexual partnering across the life
course (Sassler, 2010). In industrialized societies,
most individuals, across gender, race/ethnicity, sex-
ual orientation, and other characteristics, can choose
from casual, shorter term, or longer term relation-
ships that may be monogamous or temporally con-
current or there may be a period in which an
individual has no partner at all. For some, partnering
may mean sharing a living situation as a precursor or
as an alternative to marriage, and for others, partner-
ing may mean maintaining separate residences.
An important aspect of a life-span perspective
on partnering is that each partnership’s form and
content provide a context for the (re)learning and
(re)organization of sexuality—and the experience of
sexual health—during one’s lifetime. The interper-
sonal interactions, individual or partner beliefs, and
social norms that characterize each partnership pro-
vide a lens through which to view sexual health
within the characteristics of each life stage. Changes
in partnerships, both voluntary and involuntary, cre-
ate opportunities for the new expression of old
beliefs and behaviors. For example, in adolescence,
the end of a relationship may mean the cessation of a
brief coupling, whereas in adulthood or later life, the
end of a relationship may mean the loss of a long-
term partner through divorce or death. We suggest
that although the terms we use to describe partner-
ing phenomena may have different meanings across
stages, their impact is equally felt and they are
equally influential in sexual health in each life stage.
Moreover, partnering experiences in earlier
stages inform the manner in which individuals per-
ceive and experience partnerships in later life stages.
For example, positive qualities of friendships and
early romantic relationships in adolescence provide
skills important to interpersonal emotion manage-
ment in early adulthood (Simpson, Collins, Tran, &
Haydon, 2007). Likewise, individuals entering into
adulthood with a history of secure, nurturing part-
nerships may potentially be more willing and able to
negotiate or accommodate a partner’s preferences
and desires, especially when making decisions about
the relationship. To this end, in this section we
review partnering patterns and transitions, describ-
ing the ways in which they both facilitate and con-
strain aspects of sexuality in adolescence, in
adulthood, and in later life.
Adolescence
Adolescent relationships (and to some extent,
emerging adult relationships) well exemplify devel-
opment in the processes of partnering and sexual
health because both are deeply entrenched in
changes within an adolescent’s social system. The
first of these changes centers on diversification in a
young person’s patterns of interaction. In industrial-
ized societies, interactions typically shift away from
exclusively same-sex peer groups in preadolescence
to concurrent same-sex and different-sex friendships
in early and middle adolescence (Collins, 2003).
These shifts help facilitate the progression to
later dyadic romantic relationships (Connolly,
Craig, Goldberg, & Pepler, 2004). These close
friendships provide lessons about the value of close-
ness, intimacy, and mutuality that are important in
later romantic relationships (Furman & Shaffer,
2003). For example, positive same-sex friendship
quality is linked to affection in (S. Shulman &
Seiffge-Krenke, 2001) and quality of (Linder &
Collins, 2005) romantic relationships. In middle
adolescence, young people typically note increasing
preoccupation with romantic feelings and emerging
relationships, placing great emphasis on the role of
these relationships in their lives (O’Sullivan, 2005).
Finally, by late adolescence, many young people
have experienced a serious romantic or sexual rela-
tionship (Carver, Joyner, & Udry, 2003; Collins,
2003). More recent work has also described how the
number of uncommitted sexual relationships (or
hook-ups) increase in late adolescence and emerg-
ing adulthood, particularly in the college population
(e.g., Bogle, 2008).
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Hensel and Fortenberry
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Although much more is understood about the
development of opposite-sex attraction in adoles-
cence, knowledge about lesbian, gay, bisexual, and
transgender (LGBT) youths in relationships is small
but growing (see Chapter 19, this volume). Estimates
of young men and young women reporting same-sex
attraction, same-sex activity, or both vary widely
(McCabe, Brewster, & Tillman, 2011; Pathela &
Schillinger, 2010). Although the average age of a first
serious same-sex relationship is 18 years (Floyd,
2002), many formative romantic experiences in ado-
lescence involve both same- and opposite-sex part-
ners (Collins, Welsh, & Furman, 2009). Developing
literature has suggested that these choices can be sep-
arate from long-term identification with sexual orien-
tation. For example, Lisa Diamond’s (2008) work has
suggested that sexuality is fluid between adolescence
and adulthood, with fluctuations in same-sex and
opposite-sex attraction, self-selected labels, and
same-sex and opposite-sex sexual behaviors.
Partnering in adolescence also provides a context
for first exposure to the types of experiences young
people will need to manage sexual relationships
later in life (Seiffge-Krenke, 2006). For example,
earlier relationships contribute to the development
of emotional skills in relationships, such as learning
effective communication about one’s needs (Stone
& Ingham, 2002), negotiating conflict management
(Giordano, Manning, & Longmore, 2010), manag-
ing verbal expressions of love and affection
(O’Sullivan, 2005), balancing first explorations of
sexual desire (Tolman, 2002), increasing intimacy
and trust with questions around fidelity and rela-
tionship power (Bryan, Aiken, & West, 1997;
Maticka-Tyndale, 1992; Wingood & DiClemente,
1998), and learning how to successfully end rela-
tionships (Giordano, Manning, Longmore, & Flani-
gan, 2012). At the same time, relationships provide
for behavior experiences: behaviors such as hugging,
kissing, hand-holding, and oral sex (Bay-Cheng,
Robinson, & Zucker, 2009; Epstein, Calzo, Smiler,
& Ward, 2009) emerge in early adolescent partner-
ships and become linked to more involved sexual
behaviors (e.g., penile–vaginal intercourse) as a
given relationship progresses or as a young person
moves into subsequent relationships (O’Sullivan,
Cheng, Harris, & Brooks-Gunn, 2007).
Some gender and racial/ethnic differences exist in
the emergence of different emotional and behavioral
skills. For example, young women often exhibit
more confidence in navigating relationships than
young men because the social dynamics contained in
these relationships mimic those in prior friendships
(Giordano et al., 2012). Young women appear to
have more nuanced understanding of partnerships,
ascribing different meanings to each relationship
depending on the intent (e.g., sex only vs. long-term
commitment) or the status of their partner (e.g., boy-
friend vs. coparent; Nelson & Morrison-Beedy, 2008;
Nelson, Morrison-Beedy, Kearney, & Dozier, 2011).
Young men generally experience oral and vaginal sex
earlier than female peers (Lammers, Ireland, Resn-
ick, & Blum, 2000), and White adolescents typically
have less sexual experience (e.g., ever having inter-
course, numbers of partners) than ethnic minority
peers (Santelli, Carter, Orr, & Dittus, 2009).
The partnering process remains important in
emerging adulthood. This time frame, after second-
ary or high school, is commonly regarded as one in
which individuals experience increased familial and
legal autonomy yet have not yet reached other life
transitions common in the mid- to late 20s (e.g.,
cohabitation, marriage, full-time employment).
Giordano et al. (2012) additionally pointed out that
emerging adulthood is also meaningful as a transi-
tion between adolescent relationships and the longer
term partnerships observed among many adults.
Their work illustrated that in the average span of 5
years, the movement out of teen dating relationships
into early adult dating and early adult cohabiting
relationships is marked by a decrease in communi-
cation awkwardness, greater confidence, increased
sexual activity, and greater feelings associated with
romantic love and other emotional rewards associ-
ated with the relationship (Giordano et al., 2012).
Thus, compared with adolescent relationships,
emerging adult relationships in this time frame
reflect an increasing degree of investment and wid-
ening of skills accrued within early relationships.
Reflecting on our earlier definition of sexual health,
this means that accrual of emotional and behavioral
experience contributes to higher levels of sexual
health during the developmental transition from
adolescence into adulthood.
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Life-Span Sexuality Through a Sexual Health Perspective
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A growing body of research has described the
“friends with benefits” (FWB) relationship form,
whereby adolescents and emerging adults regularly
participate in sexual behaviors with friends. FWB
combines attributes of both friendships and roman-
tic relationships, joining the benefits of the psycho-
logical intimacy and trust afforded by a friendship
with the sexual intimacy of a romantic relationship
while avoiding the expectations of commitment or
exclusivity often present in romantic relationships
(Bisson & Levine, 2009; Hughes, Morrison, &
Asada, 2005). FWB sexual activity also differs from
hook-ups, or no-strings-attached sexual behavior
(Bogle, 2008), which typically occurs once, usually
between people who are strangers or acquaintances,
but also without the expectations contained in a tra-
ditional romantic relationship (Paul & Hayes,
2002). Although FWB relationships are more often
characterized as an emerging adult phenomenon
(particularly among college students), they are also
prevalent in adolescence and recognized by teenag-
ers as distinctly different from romantic relation-
ships and casual sex partners but not different from
friendship except for sexual activity (Furman &
Shaffer, 2011). The types of sexual behaviors shared
in FWB encounters show wide variability, from kiss-
ing to manual–genital or oral–genital contact to
penile–vaginal sex (Epstein et al., 2009; Furman &
Shaffer, 2011; Olmstead, Pasley, & Fincham, 2012).
These relationships may confer developmental bene-
fits to sexuality compared with more committed
relationships, such as providing a relatively safe and
convenient environment to satisfy physical needs for
sexual contact (Bisson & Levine, 2009). Some stud-
ies have suggested differences by class, particularly
for emerging adult women, in perception of FWB
relationships, suggesting that less privileged women,
who are socialized into a faster track to adulthood,
are less likely to endorse delaying commitment and
participating in the hook-up culture (Hamilton &
Armstrong, 2009). It is as yet unclear how long-term
adult trajectories of sexuality differ among those
with and without FWB experience in adolescence
and emerging adulthood.
The diversity we have described is important in a
life-course view of sexual health because the content
of these experiences has important implications for
positive sexuality in later life stages. For example,
when controlling for parent and peer influences,
adolescents with fewer partners and those with
higher quality relationships were more likely to have
higher quality emerging adult relationships (Collins
& Madsen, 2006). Likewise, higher levels of depres-
sion in mid-adolescence are linked to greater rela-
tionship conflict and lower problem-solving skills in
emerging adulthood (Vujeva, 2011). Moreover, bet-
ter relationships in adolescence and emerging adult-
hood are linked to better long-term adult sexual
health and well-being, including greater decision-
making power (Cyranowski & Andersen, 1998),
less sexual coercion (Abma, Driscoll, & Moore,
1998; Miller, Monson, & Norton, 1995; Nagy &
DiClemente, 1995; Oliver & Hyde, 1993; Shrier,
Pierce, Emans, & DuRant, 1998), higher condom
use efficacy (Wingood & DiClemente, 2000), and
lower unintended pregnancy (Fine, 1988).
In summary, partnering in adolescence contrib-
utes positively to both short- and long-term sexual
health. Romantic relationships, which find their
roots in early friendships, provide important venues
for formative emotional and behavioral experiences.
These experiences represent specific competencies
around which subsequent partnerships are orga-
nized and evaluated.
Adulthood
Partnering in adulthood is fundamentally different
from partnering in adolescence, not only in terms
of relationship content, but also in terms of the
benefits it provides to each member of the dyad.
Compared with adolescent and emerging adult rela-
tionships, adult relationships are characterized by
members’ experience in prior relationships, longer
relationship duration, and higher levels of commit-
ment and interdependence (Miller & Benson, 1999).
These types of positive, committed relationships are
important for individuals’ physical and mental well-
being (Proulx, Helms, & Buehler, 2007; see also
Chapter 11, this volume) in ways sometimes absent
from adolescent relationships. Moreover, adoles-
cents and emerging adults typically pursue partner-
ships with different goals than older single adults or
previously married individuals (Sassler, 2010); for
example, adolescents may choose partners on the
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Hensel and Fortenberry
390
basis of desire for sexual or intimate exploration or
for the social status the relationship affords (Con-
nolly & McIsaac, 2009), whereas adults may focus
on a potential partner’s emotional and financial
compatibility for a long-term relationship (Barry,
Madsen, Nelson, Carroll, & Badger, 2009), Finally,
time horizons and desired ends also shape relation-
ship behaviors among individuals of similar ages
(Sassler, 2010). We describe these differences in
more detail by evaluating two common relationship
forms in this life stage: cohabitation and marriage.
Much of the past decade’s literature has focused
on the difference in the dynamics of cohabitation
and marriage partnering forms. Concurrent with
delay in the age at first marriage, cohabitation is an
increasingly common partnering form, with differ-
ences in prevalence by completed education. One
study of individuals in the United States has sug-
gested that about two thirds of those with a high
school education, compared with about 45% of
those with some college, have lived with at least one
romantic partner (Kennedy & Bumpass, 2008), with
an average duration (14 months) shorter than that
of several other Western countries (Heuveline &
Timberlake, 2004). Many people use the cohabita-
tion period as a barometer of marital compatibility,
because slightly more than half of all cohabitations
end in marriage (Goodwin, Mosher, & Chandra,
2010; Sassler, 2010). However, cohabitation is not
an automatic precursor to marriage, suggesting that
coresidence also emerges out of changes in employ-
ment or housing, out of convenience (Sassler,
2004), or in response to an unplanned pregnancy
(Reed, 2006).
Some studies have shown that married couples
typically fare better than cohabiting couples on a
number of mental and social indicators (for a
review, see Sassler, 2010). However, how sexuality
emerges from within these typologies is far less
clear. One might argue that because the very intent
or focus in these relationships is different, one
should also expect important differences in the
ways individuals negotiate decisions about fertility,
sexual behavior, and the like. For example, relation-
ships formed around the intent to marry may have
more forward-oriented communication, whereas
more rapidly formed unions may preclude much
discussion of the future (Smock, Manning, & Por-
ter, 2005). In the long term, the impact of this dif-
ference may equip couples with a longer term
orientation to have more frequent and more open
communication about sexual preferences than cou-
ples whose focus is the here and now.
This sexual self-disclosure is a key element in
long-term sexual satisfaction, because communica-
tion both enhances intimacy and closeness and
allows partners to better understand each other’s
desires (Cupach & Metts, 1995). Among heterosex-
ual couples in committed long-term relationships,
better individual and partner sexual self-disclosure
was associated with greater levels of sexual satisfac-
tion (Rehman, Rellini, & Fallis, 2011). Likewise,
another study of committed couples found that bet-
ter sexual communication and better relationship
quality were associated with better sexual satisfac-
tion (Timm & Keiley, 2011). Moreover, relationship
quality, inclusive of relationship happiness, is asso-
ciated with significantly lower rates of relationship
dissolution for both cohabiting and married couples
(Yabiku & Gager, 2009). This hardiness can prove
to be important: Although cohabiting couples typi-
cally report higher monthly sexual frequency than
married couples (Michael, Gagnon, Laumann, &
Kolata, 1994), other work has suggested they are
also more likely to end the relationship when sexual
frequency is low, perhaps because they lack the
same resource set (e.g., stress management) as mar-
ried couples (Yabiku & Gager, 2009).
Race/ethnicity and sexual orientation are also
important contexts in which these resources are
negotiated. For example, financial hardship has
been associated with reduced relationship satisfac-
tion, particularly among African Americans
(Cutrona, Russell, Burzette, Wesner, & Bryant,
2011). Additionally, other work has noted that com-
mitted gay and lesbian couples have levels of rela-
tionship satisfaction and relationship resources
comparable to those of heterosexual married cou-
ples (Kurdek, 1995). A clinical study suggested that
same-sex couples have more quality interactions
than married couples (Gottman et al., 2003),
whereas other studies have found no difference
between committed gay, lesbian, and married
heterosexual couples (Julien, Chartrand, Simard,
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Life-Span Sexuality Through a Sexual Health Perspective
391
Bouthillier, & Begin, 2003; Roisman, Clausell,
Holland, Fortuna, & Elieff, 2008).
In summary, partnering in adulthood, although
different in content and purpose than in adolescence
or in later life, still has important implications for
sexual health. Relationships in this life stage, which
build on the experience of adolescence, lasting lon-
ger and involving more commitment than relation-
ships in younger years, confer mental and physical
health benefits to their members.
Later Life
In this section, we review the nascent literature
describing partnering in later life (see Chapter 17,
this volume). An important challenge around a body
of knowledge in its infancy is the dearth of detail
necessary to describe the dynamics of how sexuality
is enacted within specific partnerships and how
these choices may link back to earlier relationships.
Although it is becoming clear that sexuality is a
salient aspect of identity and well-being among
those in their aging years, it is less clear how specific
aspects of sexuality (such as sexual orientation or
sexual desire) affect the ways in which people select
and organize close relationships in this time frame.
An important focus for emerging research in this
area will be to consider the impact of historical con-
text on sexuality and partnering. For example,
although those currently in adolescence and adults
have come of age in a time of lessening negativity
toward LGBT individuals and toward partnering
forms that do not include marriage or children, indi-
viduals now reaching old age represent a generation
who lived through times when same-sex desires or
relationships and nonmarital or childless partner-
ships were stigmatized and, for the former, criminal-
ized. Only since the 1960s, when the current elder
cohort was already in mid-adulthood, have civil
rights movement ideals encouraged the cultural
acceptance of relationships that were not heterosexual
or did not include traditional marriage or children
(Fredriksen-Goldsen & Muraco, 2010; Park, 2002).
These patterns have considerably challenged
what is known about the variety of partnering expe-
riences in this cohort (DeLamater, 2012). Not sur-
prisingly, several national and international studies
have suggested that marriage remains the most
common partnering type into later life (Kontula &
Haavio-Mannila, 2009; Lindau et al., 2007; Waite,
Laumann, Das, & Schumm, 2009), both overall and
across different racial/ethnic groups (Calasanti &
Kiecolt, 2007). Although some of the individuals in
these marriages may be heterosexual, it is worth
emphasizing that heterosexual marriage and same-
sex preference are not necessarily independent. In
several samples, approximately one third of the gay
men older than age 55 (and as many as one half of
lesbians in that age group) reported a previous mar-
riage to an opposite-sex spouse (e.g., Herdt &
McClintock, 2000), perhaps associated with com-
mon generational expectations earlier in life. Little is
known, however, about how these marriages may
have influenced their current relationship choices.
However, at the same time, because of longer life
spans, the number of divorces and proportions of
those never married, those entering or reentering
(Calasanti & Kiecolt, 2007; King & Scott, 2005;
Sassler, 2010), or those wanting to enter or reenter
(Carr, 2004; Mahay & Lewin, 2007) intimate rela-
tionships in later life is increasing. Few aging indi-
viduals choose to cohabit: Studies from the United
States and from Europe have suggested that estab-
lishing a joint residence accounts for less than 10%
of men’s or women’s partnering patterns past age 65
(Kontula & Haavio-Mannila, 2009; Waite et al.,
2009). In comparison to younger peers, older indi-
viduals who do choose to cohabit usually do so as
an alternative, rather than as a precursor to, mar-
riage or remarriage (Sassler, 2010), but typically
report more equitable, happier, and more stable and
harmonious relationships than do younger cohabit-
ing couples (King & Scott, 2005). Such equity may
have an important influence on how sexuality is
(or is not) a part of these relationships; however,
research has typically emphasized the declines in
sexual function and desire during the later stages
of life rather than seeking to understanding how
changes in relationship forms may also enhance sex-
uality between dyad members (Kingsberg, 2000).
Recent work has also identified that many people
in the later life stage are “living apart together”
(LAT); that is, participating in an intimate relation-
ship while maintaining separate residences. LAT
relationships are viewed as a means of balancing a
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Hensel and Fortenberry
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shared, intimate life with autonomy and indepen-
dence in taking care of children or older parents
(Haskey & Lewis, 2006), as a means of maintaining
separate finances, or as a way of staying near family
and friends instead of moving in with a partner
(de Jong Gierveld & Hagestad, 2006). About 10%
of men and women older than age 65 are reported
to be in an LAT relationship (Kontula & Haavio-
Mannila, 2009). LAT partnerships may also provide
benefits for sexuality, allowing a connection
between individuals without the stress of trying to
legally integrate two lifestyles. Indeed, research has
suggested that the healthiest relationships are those
in which a couple is close but have autonomous and
differentiated identities (Kingsberg, 2000).
Gender exerts an important influence on partner-
ing during later life. Women are generally less likely
to be part of a couple than men, particularly at the
oldest end of the age spectrum (Heaphy, Yip, &
Thompson, 2004; Kontula & Haavio-Mannila, 2009;
Lindau et al., 2007; Waite et al., 2009). In Western
countries, women typically live about 5 years longer
than men (Austad, 2006; Waite et al., 2009); by age
85, this means there are two women for every one
man (U.S. Census Bureau, 2010). Among heterosex-
uals, this shortage both reduces the number of
monogamous partners available to women and
shortens the amount of time a woman may be able
to spend in a partnership (Karraker, DeLamater, &
Schwartz, 2011; Sassler, 2010). Similar age differ-
ence patterns have been observed in older adults’
same-sex relationships (Bennett & Gates, 2004)
Partnerships in later life confer similar benefits
on sexuality as do those in earlier life stages. For
example, some work has suggested that new rela-
tionships for women in later life can bring sexual
satisfaction and emotional intimacy absent from ear-
lier relationships (Hurd Clarke, 2006). Individuals
may also choose nonmarital relationships as a means
of obtaining the benefits of long-term physical or
emotional intimacy without the sacrifices associated
with partner caregiving (de Jong Gierveld & Hages-
tad, 2006). Individuals in LAT relationships per-
ceive moderate to high levels of support from their
partners but report less instrumental support than
do those who are married or cohabiting (Hurd
Clarke, 2006). Additionally, adults older than age
60 have reported seeking new relationships in later
life specifically as a means of receiving emotional
and sexual equality in relationships (Malta & Farqu-
harson, 2012). A more specific description of sexual
behavior within older relationships is detailed in the
next section.
In summary, a young but developing body of lit-
erature has confirmed the changing face of partner-
ing in the later life stage. Intimate relationships
remain an important piece of sexual health in the 6th
decade of life and beyond, with increasing numbers
of individuals entering or reentering partnerships
amid changes in expected longevity, marriage
length, and prevalence of individuals who never
marry. Commensurate with scholarship on relation-
ships in the adolescent and adult life stages, later life
relationships have been found to provide important
benefits to their members. As this area of inquiry
continues to grow, we hope research will illuminate
additional details of the development of partner-
ships in this time frame, particularly with respect to
mechanisms of partner selection and the long-term
experience of those who are LGBT.
SEXUAL BEHAVIOR
In this section, we discuss another key venue of sex-
ual health: sexual behavior. We begin by arguing
that the past decade’s research on sexual behavior,
in regard to any point in the life span, has seen two
important developments in consideration of the
question “What is sex?” The first of these develop-
ments is a movement toward a more inclusive
behavioral definition, one that transcends a tradi-
tional focus on penile–vaginal intercourse as sex to
consider how different types of intimate contact
with partners (e.g., kissing, hugging, holding hands,
genital touching, oral sex, or penile–anal sex), non-
partnered behaviors (e.g., solo masturbation), and
the absence of any behavior that may be considered
sexual behavior. The second of these developments
places emphasis on how a specific context helps to
give rise to, organize, and assign meaning to specific
behaviors. Within a life course perspective, these
developments are key pieces to understanding
how specific behaviors may be differently selected
(or omitted) across life stages as a function of
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Life-Span Sexuality Through a Sexual Health Perspective
393
opportunities or constraints within a specific life
stage. For example, limitations on sex in adoles-
cence may be constructed around the desire to post-
pone sexual activity for a specific time or event (e.g.,
a serious relationship or for after marriage), or it
may refer to the ways in which young people
orchestrate intimate contact within the boundaries
of parental supervision and curfews. In later life, the
salience of limitation may be expressed in terms of
declining physical health, especially after age 60.
Likewise, sex may serve different interpersonal func-
tions with different partners at different times in
one’s life, perhaps as a means of having a child or as
a means of increasing intimacy in a relationship. To
this end, we review the content, frequency, and
meaning of specific behaviors, particularly as posi-
tioned within the social and historical framework of
a specific life stage.
Absence of Sexual Behavior
We have purposefully chosen to use the term
absence rather than one of the more often used cul-
tural terms (e.g., abstinence or celibacy) as a means
of highlighting the definitional ambiguity that
occurs when one describes how people voluntarily
or involuntarily opt out of sex. As we describe in
more detail, even the term absence itself is somewhat
misleading, assuming an all-or-none dichotomy
rather than accurately describing how (and why)
precisely which behaviors are (and are not) removed
from a person’s sexual repertoire.
An important pitfall of this oversimplification
is the incorrect assumption of similarity between
the absence of sexual behavior among adoles-
cents, adults, and older adults and this absence
among younger children (de Graaf & Rademak-
ers, 2011; Rademakers, Rademakers, & Straver,
2003; see Chapter 14, this volume). For children,
absence is an inappropriate concept because they
have not yet developed cognitions about sex to
make such decisions a relevant choice (Reynolds
& Herbenick, 2003). However, absence in life
stages beyond childhood is defined by behavioral
choice, whether that choice is associated with an
adolescent’s views regarding the appropriate con-
text of first sex or with how an older couple man-
ages diminished desire or physical capacity.
During adolescence, particularly in the United
States, the absence of sexual behavior is often
couched in one of two applications of the word
abstinence. As described in a review on abstinence
(Santelli et al., 2006), in the behavioral sense, a per-
spective often used by developmental researchers
and health researchers, abstinence refers to either
the postponement of sex (often penile–vaginal) or
refraining from sexual activity after its initiation. In
contrast, as used by some government and religious
institutions, abstinence is frequently defined in
moral terms, using language such as chastity or vir-
ginity to describe the attitudes or commitments
young people voluntarily make to postpone sex
until marriage (Goodson, Buhi, & Dunsmore, 2006;
Santelli et al., 2006). As described in more detail
later, research has suggested that considerable vari-
ability exists in how adolescents themselves inter-
pret and express these two definitions.
Culturally, the absence of sex is constructed dif-
ferently in the adult and aging adult life stages.
Among adults, because sexual activity is an expected
component of long-term relationships (J. Edwards
& Booth, 1994), its absence is scripted as an invol-
untary choice, particularly as an unintended side
effect of different events, such as after childbirth
(Pauls, Occhino, & Dryfhout, 2008) or in the man-
agement of different medical problems, such as HIV
(Bogart et al., 2006) or cancer (Sadovsky et al.,
2010). Conversely, even amid a growing under-
standing of the importance of sexuality in the latest
parts of life (Bradford & Meston, 2007), stereotypes
still invoke a presumed asexuality of old age in
which the “natural” cessation of sexual activity is
welcomed by individuals (Bradford & Meston, 2007;
Hyde et al., 2010). As we suggest in this section,
however, individuals themselves differ considerably
in their evaluation of a cessation of sexual activity,
the reasons why it happens, and the impact of this
cessation on their understanding of sexuality.
One challenge in understanding the organization
of sexual behavior is appropriating a clear definition
for when sex does and does not occur, particularly
in terms of accurately estimating behavior preva-
lence. This difficulty is especially the case in the
adolescent stage. Indeed, most research has sug-
gested that adolescents frequently report no oral,
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Hensel and Fortenberry
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vaginal, or penile–anal sex (Hensel, Fortenberry, &
Orr, 2008). As described earlier, however, most
research describing any kind of absence of sexual
behavior in adolescence has primarily been con-
structed around behavioral or moral definitions of
abstinence. One qualitative study of adolescent men
and women, primarily African American, at high
risk for unintended pregnancy and sexually trans-
mitted infection, showed that the majority of young
people conceptualize abstinence in terms of the pri-
mary abstinence, meaning an absence of lifetime
intercourse experience (Ott, Millstein, Ofner, &
Halpern-Felsher, 2006). Other studies, however,
have suggested that secondary abstinence (sexual
experiences followed by periods without sexual
activity) is a common phenomenon among some
adolescents and emerging adults (Loewenson, Ire-
land, & Resnick, 2004). Many secondary abstainers
still participate in other partnered sexual behaviors
such as kissing, breast fondling, genital stimulation,
and oral sex. Some gender differences exist in these
patterns, with young women more likely than men
to view vaginal sex as counting as sexual experience
and White youths more likely than Black youths to
view penile–anal sex as abstinence (Bersamin,
Fisher, Walker, Hill, & Grube, 2007). Among a
sample of university students, men were more likely
to adopt a narrower definition of abstinence than
female peers, including an absence of manual–
genital stimulation (Byers, Henderson, & Hobson,
2009).
The focus on abstinence as a voluntary sexual
behavior is additionally supported by abstinence
pledge research. Research using the National Longi-
tudinal Study of Youth found that although pledgers
typically delayed first sex (defined as first penile–
vaginal sex) 6 months longer than nonpledgers
(Bearman & Brückner, 2001), almost a third of
those with prior intercourse experience “reclaimed”
sexual virginity by the subsequent wave (Rosen-
baum, 2006). A qualitative study of young adults in
the United States has supported this idea, noting
that although most participants generally refuted the
idea of secondary virginity, more women than men
and more Latinos than Whites, Asians, or African
Americans believed that it might be possible under
some circumstances (Carpenter, 2011). Some
research has speculated that young people are less
likely to classify a behavior as counting as absti-
nence if they have an orgasm (Byers et al., 2009).
Both adolescents and emerging adults articulate
benefits to primary and secondary abstinence,
including social or health risk avoidance (Long-
more, Eng, Giordano, & Manning, 2009; Morrison-
Beedy, Carey, Côté-Arsenault, Seibold-Simpson, &
Robinson, 2008; Ott, Pfeiffer, & Fortenberry, 2006)
and commitment to self or one’s morals (Morrison-
Beedy et al., 2008; Ott et al., 2006c). Abstinence is
also chosen by young people because of peer or
parental pressure (Longmore et al., 2009) as well as
to save their virginity for their future spouse (Abbott
& Dalla, 2008). Younger adolescents have described
abstinence as a normal aspect of a continuum that
uses developmental readiness as a standard for moti-
vated decisions for shifting from sexually abstinent
activity to sexual activity (Ott, Pfeiffer, & Forten-
berry, 2006). Middle and late adolescents combine
conceptual ideas of abstinence, such as commitment
and doing the right thing, with behavioral ideas of
abstinence, including avoiding sexual activity (For-
ste & Haas, 2002; Goodson, Suther, Pruitt, & Wil-
son, 2003).
Similar definitional variability exists in the adult
and aging adult life stages regarding what consti-
tutes an absence of sex. For example, using a defini-
tion of “no vaginal intercourse,” the National Survey
of Sexual Health and Behavior (NSSHB) found that
between 13% and 50% of adult women and between
15% and 40% of adult men in the United States
were without sex in the past year (Herbenick et al.,
2010c; Reece et al., 2010). In the same data, with the
same definition, these proportions were higher in
older age groups, with more women than men in the
60- to 69-year-old age group (58.1% vs. 46.3%) and
in the 70-and-older age group (77.1% vs. 51.1%)
reporting no vaginal intercourse in the past year
(Herbenick et al., 2010b, 2010c; Reece et al., 2010;
Schick et al., 2010). Alternatively, about 60% of a
sample of 75- to 95-year-old men in Australia
reported that they generally had no sexual activity
in the past year (Hyde et al., 2010). Similar propor-
tions of absence, with different definitions, have
been seen in studies from several countries (Kontula
& Haavio-Mannila, 2009; Lindau et al., 2007;
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Life-Span Sexuality Through a Sexual Health Perspective
395
Michael et al., 1994; Nettleman, Ingersoll, & Cep-
erich, 2006; Palacios-Ceña et al., 2012; Waite et al.,
2009).
An additional challenge arising from these varied
definitions is understanding the perceptions of or
motivations for the absence of sex in adult and aging
individuals’ lives. As suggested earlier, because sex-
ual activity is an expected aspect of adult long-term
relationships (J. Edwards & Booth, 1994), it is often
presumed that the cessation of sex, or even irregular
patterns of sex, are viewed as involuntary by differ-
ent individuals. Emerging research, however, has
supported the idea that in many adult relationships,
sex is absent or erratic, with different evaluations of
this absence depending on the member in question
(Donnelly & Burgess, 2008). Moreover, only
recently has the presumed asexuality of old given
way to the recognition that sexuality remains an
important component of relationships well into the
latest parts of life (Hyde et al., 2010). Long-standing
assumptions about sexual behavior and the aging
process have typically described a “natural” decrease
in sexual activity with increasing age, through
which individuals voluntarily “sexually retire”
(Gott, 2006) amid health issues, partnering changes,
or both (for a review, see DeLamater, 2012). More
recently, an exciting body of literature has emerged,
confirming that although permanent or sporadic
periods of sexual absence are a reality for some peo-
ple, others integrate sexuality within the unique
challenges of this life stage (DeLamater & Moor-
man, 2007; Gott & Hinchliff, 2003).
For example, declines in vaginal lubrication and
elasticity of vaginal tissue in later life may make sex-
ual activity uncomfortable for women, and erectile
difficulty may make penile–vaginal intercourse more
difficult for men (Trudel, Turgeon, & Piche, 2010).
In either case, the use of sexual medications or the
replacement of penile–vaginal intercourse with oral–
genital sex may be possible. Additionally, common
chronic illnesses in older age, as well as the medica-
tions used to treat them, can contribute to lower
sexual desire, less sexual activity, or both in some
men and women (DeLamater & Sill, 2005; Lindau
& Gavrilova, 2010; Lindau et al., 2007; L. J. Smith,
Mulhall, Deveci, Monaghan, & Reid, 2007). Like-
wise, caring for a spouse with a chronic condition
such as Alzheimer’s disease might influence one’s
sexual life to a greater extent depending on the level
of stress introduced by the condition (Burgess,
2004). In response, some individuals may repriori-
tize the value placed on sex in light of different
physical or mental challenges, whereas others adapt
their sexual routine within the confines of these
challenges (DeLamater & Moorman, 2007; Howard,
O’Neill, & Travers, 2006; Kontula & Haavio-
Mannila, 2009).
For individuals in either the adult or the aging
adult life stage, partnering status and the dynamics
of partnering have a major influence on the type and
frequency of sexual abstinence. For example, the
NSSHB, a cross-sectional survey of sexual behaviors
and attitudes of individuals ages 14 to 94 years, has
noted a decreased likelihood of any vaginal sex in
the past year among unpartnered adult men and
women in all age ranges, with the greatest discrep-
ancies noted in the 30- to 39-year-old age range and,
among those who were single, in the 60-and-older
age range (Herbenick et al., 2010b, 2010c; Reece et al.,
2010; Schick et al., 2010). Although the effects of
partnership are similar across both life stages, the
midlife shift may reflect a delay in first marriage or a
transition between relationships, whereas the latter,
particularly for aging women, is likely to reflect pau-
city in partner availability after the death of a spouse
(Sassler, 2010). Within adult relationships, sexual
activity may also temporarily cease during late preg-
nancy, immediately after childbirth, or both (De
Judicibus & McCabe, 2002). Additionally, after
menopause some women slow in their sexual activ-
ity, finding less interest in sex (Dillaway, 2005).
Calling the absence of sex celibacy (broadly defined
as the absence of intimate sexual contact), a qualita-
tive study of married or long-term heterosexual cou-
ples in involuntarily celibate relationships (Donnelly
& Burgess, 2008) has suggested within-relationship
patterns of celibacy are variable, including a gradual
slow down, an abrupt slow down, or little sexual
activity ever. In this study, all participants identified
negative outcomes from celibacy; those opting to
remain in relationships despite the celibacy did so
because of stronger nonsexual benefits (e.g., support
and love), lack of alternative residence, or social
proscription of relationship dissolution. In another
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study, short-term voluntary absence of sex among
high-risk women was associated in one study with
older age, no sexually transmitted infection or his-
tory of drug use, and not being married or pregnant
(Nettleman et al., 2006).
In summary, we have suggested the importance
of considering the absence of sex in the spectrum of
sexual behaviors available to people across the life
span. We highlighted the considerable definitional
ambiguity around what is meant when people say
they do not have sex, emphasizing that these mean-
ings are constructed in ways illustrating both the
characteristics unique to each life stage and the rela-
tionships in which the absence occurs. For adoles-
cents, this absence is intimately intertwined with
behavioral and moral descriptions of abstinence,
particularly in terms of penile–vaginal sex. As young
people themselves describe, however, wide variabil-
ity exists in how individuals view precisely what this
means, often substituting other behaviors. In con-
trast, adult relationships are often judged on the
presence of sex, with its absence, irregularity, or
periodic cessation viewed as something involun-
tarily chosen by members in a relationship. Finally,
we note the shifting assumptions about the increas-
ing absence of sex in the aging population, suggest-
ing that individuals construct sexual lives around
changing relationship forms and the limitations of
physical and mental health.
Solo Masturbation
In this section, we discuss the organization of solo
masturbation across the life span. We differentiate
between masturbation that occurs with an individ-
ual by him- or herself and that which occurs with a
partner. We do this as a means of illustrating how
aspects of sexuality are enacted within specific
behavioral opportunities and constraints.
Of all sexual behaviors, solo masturbation tends
to be the most difficult to study because it carries a
long history of stigmatization and association with
immorality or pathology (Rye & Meaney, 2007).
For the most part, the latter has lessened consider-
ably, but many social and gender norms still pro-
scribe masturbation, particularly among women
(Gagnon & Simon, 1987; Pinkerton, Bogart, Cecil,
& Abramson, 2003). Nevertheless, evidence has
suggested that it is a widespread behavior across all
life stages and is increasingly being endorsed as a
means of promoting sexual development and sexual
health (Coleman, 2003). For example, in contrast to
partnered sexual behaviors, which may be orches-
trated around a variety of different needs (e.g., emo-
tional intimacy, reproduction, making money), solo
masturbation may be a relatively easy way to focus
solely on meeting one’s personal sexual needs (Rye
& Meaney, 2007). Moreover, solo masturbation has
also increased in visibility as a safe-sex alternative
when there is a risk of sexually transmitted infection
or pregnancy (Coleman, 2003).
Most retrospective data have suggested that onset
of masturbation occurs somewhere between ages
13 and 15 (Pinkerton, Cecil, Bogart, & Abramson,
2003), with reported frequencies from the NSSHB
varying for young men between a few times a week
to a few times per year, and the majority of young
women (45.5%) masturbating a few times per year
(Robbins et al., 2011). The majority of adults have
lifetime experience with masturbation (Gerressu,
Mercer, Graham, Wellings, & Johnson, 2008; Lau-
mann, Gagnon, Michael, & Michaels, 2000; Pinker-
ton, Cecil, et al., 2003; A. M. A. Smith, Rosenthal, &
Reichler, 1996). Data from the NSSHB for adults 18
to 59 years old have shown that about 60% of men
and 40% of women solo masturbated in the past 90
days. Frequency of masturbation typically increases
when people perceive social norms in support of it
(Pinkerton, Cecil, et al., 2003). Although masturba-
tion generally decreases with age, with the lowest
past-90-days prevalence in the 70 and older age
group (men, 35.8%; women, 16.1%), these data do
show that a considerable proportion of people mas-
turbate throughout their lives (Herbenick et al.,
2010b; Reece et al., 2010). Other research in the
aging population has generally supported these data
(Kontula & Haavio-Mannila, 2009; Palacios-Ceña
et al., 2012).
Solo masturbation may also have several impor-
tant influences on developing sexuality, serving as
an important means of learning about one’s body
and sexual responsiveness (Atwood & Gagnon,
1987; Kaestle & Allen, 2011). Work among late
adolescent women has shown that individuals with
negative masturbation experiences typically also had
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Life-Span Sexuality Through a Sexual Health Perspective
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negative first sexual experiences with penile–vaginal
sex, with only a minority of women (25%) finding
masturbation enjoyable and rewarding (Hogarth &
Ingham, 2009). Among emerging adult women,
childhood and adolescent masturbation has been
linked to positive later sexual experiences (Reynolds
& Herbenick, 2003), better self-image (J. L. Shul-
man & Home, 2003), romantic and sexual relation-
ship development, and positive sexual self-discovery
(Kaestle & Allen, 2011). Young women with a his-
tory of masturbation and noncoital orgasmic respon-
siveness had higher levels of sexual subjectivity, felt
more entitled to sexual pleasure through masturba-
tion, were more efficacious in achieving pleasure,
and reflected more on the sexual aspects of their
lives than those who had never experienced a non-
coital orgasm. Moreover, these women were more
expressive in their intimate relationships and more
resistant to gendered double standards (Horne &
Zimmer-Gembeck, 2005). Less is known about this
link in young or adult men.
Masturbation is also related to other sexual
behavior across the lifetime, either in lieu of other
behavior or in tandem with other behavior. For
example, among young people, solo masturbation
may serve as a method of sexual exploration for
those not wishing to experience other types of sex.
Likewise, masturbation may be one way of experi-
encing pleasure in the face of personal or partner
health issues that prevent other sexual behaviors. For
example, NSSHB data on people older than 65 have
suggested that men in poor health reported a higher
frequency of masturbation than men in good health
(Schick et al., 2010); additionally, solo masturbation
was highest across most age groups of adult men and
women older than 18 years who did not have a part-
ner (Herbenick et al., 2010b; Reece et al., 2010).
Moreover, solo masturbation may also occur as a
prelude to sexual intercourse (Laumann et al., 2000)
or as a follow-up to partnered sexual activities that
were not sexually fulfilling (Das, 2007), or it may be
introduced as part of an expanding set of dyadic sex-
ual behaviors. For example, among 14- to 17-year-
old adolescent men and women, those reporting
masturbation in the past year also reported higher
levels of giving and receiving oral sex, penile–
vaginal intercourse, and penile–anal intercourse
(Robbins et al., 2011). A study of postpartum
women found that solo masturbation plays an
important role in sexuality after birth, representing
the behavior to which women returned most quickly
and the behavior from which participants derived
the most sexual pleasure as compared to partnered
activities (Hipp, Kane Low, & van Anders, 2012).
In summary, we have suggested that although
often overlooked as a relevant sexual behavior, solo
masturbation is an important component of lifelong
sexual health. Despite a history of social stigmatiza-
tion, solo masturbation is widely reported in all life
stages, serving developmental and exploratory func-
tions in adolescence as well as substitutive and
enhancement functions in adulthood and during
later life. Although most research has focused on
oral sex organized around the penis or vagina,
emerging work has suggested that oral- and anal-
focused sex are also components of people’s sexual
behavior set.
Oral Sex
As with many other sexual behaviors, the term oral
sex can refer to one of a number of different prac-
tices and takes on different meanings depending on
the context in which it occurs. Broadly speaking,
oral sex invokes sexual contact involving genital
stimulation—to the vagina, penis, or anus—by the
use of the mouth, tongue, teeth, or throat (J.
Edwards & Booth, 1994). Although many oral sex-
ual behaviors are commonly practiced by individu-
als of different sexual orientations across all life
stages (Rye & Meaney, 2007), research has most
commonly focused on oral sex involving the vagina
or penis. As we suggest in this section, the absence
of shared meaning creates challenges for accurately
estimating both the prevalence of oral sex across
different life stages and disentangling the various
motivations by which people choose it alone or in
conjunction with other sexual behaviors (Hans,
Gillen, & Akande, 2010).
Among adolescents, the prevalence, frequency,
and timing of both behaviors differs with age (Brew-
ster & Tillman, 2008). Retrospective data from the
NHSSB (Fortenberry et al., 2010), which did not dif-
ferentiate partner gender, and other data from the
National Survey of Family Growth (NSFG; Copen,
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Hensel and Fortenberry
398
Chandra, & Martinez, 2012), which focused on
opposite-sex partners, have suggested that for young
people receiving oral sex is more common than giv-
ing oral sex. Within both of these studies, however,
notable gender patterns emerged, with fewer young
women receiving oral sex (NHSSB, 13.2%; NSFG,
28.3%) than young men (NHSSB, 17.3%; NSFG,
35.1%) and more young women giving oral sex
(NHSSB, 15.2%; NSFG, 27.4%) than young men
(NHSSB, 11.7%; NSFG, 24.2%). Prospectively col-
lected daily diary data collected from 14- to 17-year-
old adolescent women suggested a pattern opposite
that of the NHSSB and NSFG data: On days when
any oral sex was reported, more days were associ-
ated with receiving oral sex than with giving oral sex
(Hensel et al., 2008). A study of adolescent and
emerging adult gays, lesbians, and bisexuals sug-
gested the occurrence of both oral and oral–anal
behaviors in the past 3 months (Schrimshaw, Rosa-
rio, Meyer-Bahlburg, & Scharf-Matlick, 2006).
Another study of Australian male and female youths
suggested very few adolescents report any oral sex
with same-sex partners only or with opposite-sex
and same-sex partners (VandeCreek, Peterson, &
Bley, 2007). Little is known about oral–penile–anal
sex in young people.
The NSSHB (Herbenick et al., 2010b; Reece et al.,
2010) suggested that among adults ages 18 to 59 in
the past 90 days, about a fifth of men received oral
sex from a woman and fewer (10%–20%) gave
oral sex to a woman. Fewer women (2%–23%) gave
oral sex to men or received it (2%–15%) from men.
In the same NSSHB data, more men than women
older than age 50 had both given (37.1% vs. 25.8%)
and received (39.3% vs. 23.6%) oral sex in the past
90 days (Schick et al., 2010). Estimates among men
and women older than age 65 in Spain have sug-
gested lower prevalence of oral sex, but similar gen-
der patterns (Palacios-Ceña et al., 2012). Although
data explicitly examining oral–anal prevalence in
adults are scarce, one review (McBride & Forten-
berry, 2010) suggested that 51% of adult men and
43% of adult women had participated in at least one
act of oral–penile–anal sex.
Oral sex may serve different emotional, physical,
and social functions across the life span. For exam-
ple, oral sex is perceived as providing social status
enhancement, with nearly one quarter of adoles-
cents reporting elevated popularity as a reason to
participate in oral sex (Brewster & Tillman, 2008;
Cornell & Halpern-Felsher, 2006; Halpern-Felsher,
Cornell, Kropp, & Tschann, 2005). Young people
rate peers with oral sex experience as more popular
than those without such experience (Bersamin et al.,
2007; Prinstein, Meade, & Cohen, 2003). Teens
often perceive oral–genital sex as more acceptable
than penile–vaginal sex, with many adolescents
anticipating experiencing it in the future (Halpern-
Felsher et al., 2005). Some work has differentiated
motivations in terms of giving or receiving oral sex.
For example, in one study, although adolescent
women believed that male partners prefer to receive
fellatio over performing cunnilingus, they concur-
rently believed their male partners also desired,
wanted, and enjoyed cunnilingus as much as they
themselves did (Bay-Cheng & Fava, 2011).
In emerging adulthood, perceptions about oral
sex appear to shift away from a social emphasis
toward an emotional one. Women report signifi-
cantly more emotional and love motivations for oral
sex–only sexual encounters than do male peers
(Vannier & O’Sullivan, 2010). Most college students
rate oral sex as an intimate experience (Chambers,
2007); as confirmed in a qualitative study of college
women (Backstrom, Armstrong, & Puentes, 2012),
those with a positive evaluation of cunnilingus
dually emphasized the emotional aspects of oral sex,
particularly in its effectiveness in providing sexual
pleasure and orgasm.
The prevalence and evaluation of oral sex is also
strongly influenced by the type of relationship in
which it happens. For example, in the context of
casual relationships, oral sex is more likely to be
perceived as less intimate, but also as less risky, than
penile–vaginal sex (Dotson-Blake, Knoz, & Zusman,
2012). More emotional gain is typically expected
from oral sex within the context of committed rela-
tionships (Vannier & O’Sullivan, 2012). Indeed, a
sample of college women reported that because
relationships create a context of emotional and
physical comfort associated with sex, and because
this comfort was central to their sexual enjoyment,
committed or serious partnerships were therefore
preferable to hook-ups for receiving or giving oral
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Life-Span Sexuality Through a Sexual Health Perspective
399
sex (Backstrom et al., 2012). Among those in the
adult and aging adult life stages, across most age
groups the likelihood of receiving oral sex and giv-
ing it, for both men and women, was more likely
among those in a relationship (Herbenick et al.,
2010b; Reece et al., 2010). Additionally, increased
levels of physical health were associated with both
oral sex types among men 50 to 59 years old (Reece
et al., 2010).
Finally, some work has suggested that oral sex,
as does masturbation, may have important relation-
ships with other sexual behaviors. For example,
some data have suggested that oral sex increases for
young people as they also acquire experience with
penile–vaginal sex (Lindberg, Jones, & Santelli,
2008). The relationship of oral sex to vaginal sex
may differ by gender: Data from the NSFG have sug-
gested that more young men (10.3%) than young
women (9.8%) reported experiencing oral sex before
initiating vaginal sex, whereas more young women
(11.1%) than young men (8.4%) noted experiencing
vaginal sex before oral sex (Copen et al., 2012).
Hensel et al. (2008) found that adolescent women’s
daily diary reports of giving and receiving oral sex
were likely to occur apart from, as well as in con-
junction with, vaginal sex or penile–anal sex. One
study of college women found little consensus as to
whether women counted cunnilingus as sex or
whether it was more or less intimate than vaginal
sex (Backstrom et al., 2012). Moreover, having at
least one act of oral–anal contact in the past 30 days
was more likely among heterosexual men who had
also engaged in penile–anal sex with their female
partner (McBride & Fortenberry, 2010).
In summary, oral sex, which can be expressed in
a variety of different forms, remains prevalent across
the life span. Regarding the adolescent life stage,
research has focused on understanding the per-
ceived benefits young people associate with oral
sex—as a means of increasing social standing or
augmenting physical pleasure or, for some, as a sub-
stitute for penile–vaginal sex to maintain virginity.
Moving into adulthood, this emphasis shifts to the
emotional aspects of oral sex, with individuals inte-
grating it to increase intimacy or as one behavior in
a larger behavior set within relationships. For those
in the aging adult life stage, oral sex also remains
important, perhaps as a means of maintaining
aspects of a sexual relationship as they face changes
in physical health or partnership status.
Penile–Vaginal Sex
We begin this section by purposefully drawing attention
to the phrases penile–vaginal sex and vaginal sex.
Although these phrases are often used interchangeably
among heterosexuals, referring to the insertion of a
penis into a vagina, it is important to acknowledge that
vaginal sex may mean something entirely different for
women who have sex with women or for women who
have sex with both men and women. For the latter
groups, although some may have experienced penile–
vaginal sex at some point in their lifetime, for many,
vaginal sex may refer more broadly to stimulation of
the vagina in ways that do not involve any penetration
at all (Carpenter, 2001; Horowitz & Spicer, 2013; see
Chapter 20, this volume). Where possible, we draw
attention to these differences in the text that follows.
Perhaps more than any sexual behavior, penile–
vaginal sex is socially scripted as the sine qua non of
sexuality. That is, penile–vaginal sex is imbued with
intense cultural significance (see Chapter 25, this vol-
ume; Volume 2, Chapter 6, this handbook), from its
construction as the centerpiece of many young people’s
virginity; to its near-universal association, by hetero-
sexuals and by those in same-sex relationships, with
the definition of having sex (Horowitz & Spicer, 2013);
to its placement as the expected focus of heterosexual
sexual encounters (Simon & Gagnon, 2003). Penile–
vaginal sex is enacted both within gender and relation-
ship norms governing sexuality and also in deference
to challenges associated with each life stage.
As described earlier in this section, although a
number of behaviors can also be associated with loss
of virginity, penile–vaginal intercourse has long
been portrayed as the traditional way to lose one’s
virginity. In virtually every country, first penile–
vaginal sex is constructed as a socially and sexually
transformative moment, a rite of passage when
young people transition from childhood into adult-
hood, from virgin to nonvirgin, and from sexually
inexperienced to sexually experienced. Indeed, ret-
rospective accounts of virginity loss among male
and female college students have suggested that
most heterosexuals define this transition through
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Hensel and Fortenberry
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participation in penile–vaginal sex (Carpenter,
2001). In the same study, about two thirds of les-
bian women and one gay man also reported penile–
vaginal sex with an opposite-sex partner as a means
to virginity loss, whereas one lesbian noted virginity
loss through performing oral sex on another
woman. In the context of adolescent development,
first sex also symbolizes an important evolution in
the ability to engage in romantic and sexual rela-
tionships (O’Sullivan et al., 2007).
Traditional sex and gender norms script this sta-
tus change differently for young men and young
women. Some work has suggested a loss–gain
dichotomy in young people’s narratives: First sex
permits a young man to gain a step toward sexual
power, whereas young women experience a loss of
virginity, scripting them as passive participants in
the sexual process (Holland, Ramazanoglu, Sharpe,
& Thomson, 2010). Other studies have challenged
this dichotomy, suggesting a more complex process
by which young women can find agency balancing it
with other negative aspects.
For example, a retrospective study of virginity
loss among college students (Carpenter, 2002)
found that heterosexual college women were partic-
ularly empowered if they viewed first sex as one step
in a process toward greater sexual understanding of
themselves and of a partner. Also using a sample of
college students, Higgins, Trussell, Moore, and
Davidson (2010) examined retrospective accounts
of psychological and physical satisfaction at first sex
among White and Black men and women, finding
that higher psychological satisfaction was signifi-
cantly linked to physiological satisfaction for both
men and women across both racial groups. More-
over, although Black and White women’s satisfac-
tion was lower than that of their male counterparts,
being in a committed relationship and experiencing
less guilt were associated with increased psychologi-
cal satisfaction for both groups. Sexual agency has
been associated with intentions to engage in sexual
activity among early adolescent women (O’Sullivan
& Brooks-Gunn, 2005), with other work suggesting
that some young women find it difficult to navigate
away from social negativity even in the face of this
agency (Tolman, 2002). An event-level analysis of
adolescent women’s mood and partner attitudes
illustrates this balance, finding that sexual interest
and partner support peaked on the day of first sex,
with feelings of love peaking on the day before first
sex (Tanner, Hensel, & Fortenberry, 2010). These
findings lend support to the idea that first vaginal
sex can be a both physically and emotionally posi-
tive experience for young women.
One consequence of a cultural emphasis on het-
erosexuality and penile–vaginal sex is that little is
still known about early sexual experiences in LGBT
groups. Young women who first have sex with other
women appear to enjoy greater control over their
first sexual experiences than women whose first
partners are men; however, they face other chal-
lenges such as homophobic reactions from their par-
ents or peers (Carpenter, 2002; Thompson, 1996). In
a study of college men and women’s retrospective
accounts of virginity loss (Carpenter, 2002), a
greater number of lesbian women and gay men
(73%) than heterosexual men and women (46%)
evaluated their virginity loss as one step in a devel-
opmental process toward sexual health. Conversely,
half of heterosexual men and women but only a third
of gay or lesbian youths viewed their virginity as a
gift to their partner. Bisexual women and men vacil-
lated in their views, with two thirds ever interpreting
virginity as a gift and one third ever having perceived
it as a step in a larger developmental process.
Moreover, for many gay and bisexual participants,
virginity loss was constructed as a developmental
step because it closely intertwined with the process
of coming out (see Chapter 19, this volume).
After first sex, most studies have suggested that
vaginal sex is an uncommon event for young people.
Estimates from the NSSHB suggested that 13.7% of
boys and 16.0% of girls between ages 14 and 17 had
vaginal sex in the past 90 days (Fortenberry et al.,
2010). Diary data taken from primarily African
American adolescent women residing in areas of
high unintended pregnancy and sexually transmit-
ted infection (Hensel et al., 2008) supported these
patterns, showing that when sexual activity
occurred, noncoital behaviors were more prevalent
than vaginal sex. Prevalence of vaginal sex increased
with age among adolescent men and women, with
generally more boys reporting it than girls and
slightly more occurring in boyfriend–girlfriend
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Life-Span Sexuality Through a Sexual Health Perspective
401
relationships (Fortenberry et al., 2010). These statis-
tics contradict some risk framework assumptions
about the frequency of adolescent sexual decision
making (Fortenberry, 2005).
In the adult and aging adult stages, vaginal sex
becomes the most commonly reported partnered
sexual activity for men and women. In the United
States, the percentage of men and women reporting
this activity in the past 90 days peaks in the 25- to
29-year-old age group (men, 79.8%; women,
80.4%), occurring most frequently among those
who had a partner, but declining with age (Her-
benick et al., 2010c; Reece et al., 2010). In the aging
adult life stage, in a population of Spanish adults,
more than half of men and more than a third of
women age 60 and older reported vaginal sex in the
past year. Likewise, other work from the United
States has suggested that 75% or more of men and
women older than age 65 report they “usually or
always” have vaginal sex (Waite et al., 2009).
Some research has informed parallel processes in
LGBT individuals. With regard to quantity and type
of sexual behavior, lesbian couples engage in less
sex than do gay or heterosexual couples, but they
engage in more nongenital sexual behavior, such as
hugging, cuddling, and kissing than these two
groups (James & Murphy, 1998). Other studies
focusing on genital sexual activity have found that
adult lesbians report the lowest frequency of sex
compared with gay men and heterosexuals (Lau-
mann et al., 2000).
Aside from the cultural emphasis on its place in
the heterosexual sexual repertoire, there are a num-
ber of reasons why people choose to engage in vagi-
nal sex, and these reasons can change, or remain
equally important, across the life span. For example,
vaginal sex may be a means of expressing or enhanc-
ing love and affection within a relationship. The
frequency of vaginal sex increases over time in
established relationships, often in tandem with rela-
tionship quality and sexual satisfaction, both in ado-
lescent women’s relationships (Sayegh, Fortenberry,
Anderson, & Orr, 2005) and in early adult relation-
ships (Rostosky, Galliher, Welsh, & Kawaguchi,
2000). Likewise, relationship satisfaction is signifi-
cantly linked to a number of increased sexual behav-
iors, including vaginal intercourse, in the aging
adult life stage (DeLamater & Moorman, 2007). For
adults and aging adults, vaginal sex may increase in
new partnerships or may decline as individuals in
long-term relationships reprioritize other things
over sex (Hinchliff & Gott, 2008). Vaginal sex may
lessen after childbirth as time and sexual desire
change (Pauls et al., 2008). Similarly, as couples find
themselves moving from child rearing into becom-
ing empty nesters, vaginal sex may resume as they
spend more time together and worries about pre-
venting pregnancy diminish after menopause
(Dillaway, 2005).
Motivations for vaginal sex may also vary across
the life span as well as with gender. For example,
young women dually perceive higher pleasure
(Halpern-Felsher et al., 2005) but more emotional
consequences (Boekeloo & Howard, 2002) from
vaginal sex than other types of sex. Similarly, in a
study of adult men’s and women’s ratings of why
people have sex, men rated physical reasons, such as
stress reduction, and goal attainment, such as social
status, more highly than women as motivations for
sex (Meston & Buss, 2007). In the aging adult life
stage, this focus may be much more emotional. A
majority of men and women older than age 50
agreed that they “wouldn’t have sex unless they
were in love with their partner” and that “sex is
essential to maintaining a relationship” (Waite et al.,
2009, p. i60). This emotional connection may also
increase physical satisfaction for those still sexually
active in this life stage: Among men and women
older than age 50, reported arousal levels signifi-
cantly increased with age for men, and reports of
orgasm increased for both men and women (Schick
et al., 2010).
In summary, we have suggested the centrality of
penile–vaginal sex in the cultural organization of
sexual behaviors. For young people, vaginal sex is
scripted as a major transitional event in (hetero)sex-
ual development. Moreover, vaginal sex is an
expected component of many long-term relation-
ships in the adult and later life stages. We have illus-
trated the various reasons why individuals select
vaginal sex, noting that these reasons ebb and flow
with movement in and out of life stages and partner-
ships, but also with other life events, such as child-
birth or changes in physical health.
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Hensel and Fortenberry
402
Penile–Anal Sex
As with many other sexual behaviors described in
this chapter, penile–anal sex has a long history of
both cultural fascination and cultural stigma. As
described in a recent review (McBride & Forten-
berry, 2010), although social visibility of penile–
anal sex has increased over the past decade, much of
the existing research still focuses on men who have
sex with men, rather than understanding how
penile–anal sex may be chosen by heterosexual indi-
viduals and individuals of other sexual orientations
as one piece in a larger sexual repertoire.
Within the larger cultural discomfort with
penile–anal sex, literature describing it among
young people is small but growing. A study of ado-
lescents and young adults ages 15 to 21 in three U.S.
cities found that 16% had reported it in the past 90
days (Lescano et al., 2009). One study of adoles-
cents found that 10.9% of females and 11.1% of
males reported any lifetime penile–anal sex experi-
ence, with Black adolescents less likely to report this
experience than White adolescents and Hispanic
males more likely than non-Hispanic White males to
report this experience (Lindberg et al., 2008). The
NSSHB data disagreed with these findings, with
more female adolescents than male adolescents
reporting past-90-day (female, 2.3%; male, 1.7%),
past-year (female, 4.3%; male, 4.4%), or lifetime
(female, 5.55%; male, 4.4%) experience with penile–
anal sex, with similar patterns at most recent sexual
event (Fortenberry et al., 2010). These same data
also illustrated that among adolescent men, at last
sexual event, 28.6% of penile–anal sex occurred
with a male partner (Fortenberry et al., 2010).
These estimates among adolescents are consider-
ably higher than reports of same-sex penile–anal sex
in adult male populations (Herbenick et al., 2010a),
although it has perhaps provided evidence of the
fact that same-sex experimentation may peak in
mid- to late adolescence (McCabe et al., 2011).
More adults than adolescents report lifetime penile–
anal sex: In the most recent NSFG, 35% of adult
women and 40% of adult men, all ages 18 to 44
years, reported engaging in heterosexual anal inter-
course in their lifetime (Mosher, Chandra, & Jones,
2005). Penile–anal sex typically occurs less often
than vaginal sex, for both men and women
(Herbenick et al., 2010b; Reece et al., 2010). Other
work has shown that adult Whites are more likely
than adult minority groups to engage in anal sex
(Leichliter, 2008; Lescano et al., 2009), whereas
other studies have demonstrated no association of
penile–anal sex with race/ethnicity (Gorbach et al.,
2009; Mosher et al., 2005). Penile–anal sex is least
common in the aging adult life stage: Fewer than 5%
of any men and women older than age 60 report any
penile–anal sex in the past 90 days (Herbenick et al.,
2010b; Reece et al., 2010), and its prevalence
declines with age (Schick et al., 2010).
Reasons why people choose penile–anal sex can
vary, with some patterns attributed to beliefs about
how penile–anal sex compares with vaginal sex.
Similar to perceptions of oral sex, most people are
less likely to consider penile–anal sex as having sex
(Sanders & Reinisch, 1999). In some instances, this
perception may catalyze young and emerging adults
to choose penile–anal sex out of the perception that
it is a “safer” alternative to vaginal sex, posing no
risk of pregnancy (Houston, Fang, Husman, & Per-
alta, 2007; Kaestle & Halpern, 2007). Penile–anal
sex is more likely in young women when vaginal
bleeding is present (Hensel, Fortenberry, & Orr,
2010), perhaps as a means of “not having sex” when
menstruation norms proscribe vaginal sex.
Additionally, sexual relationship characteristics
provide motivations for and perceptions of penile–
anal sex. For example, among at-risk adolescents
and emerging adults, imbalanced relationship power
(e.g., a history of forced sex) is associated with more
frequent penile–anal sex (Lescano et al., 2009).
Qualitative work has suggested that among adult
women, penile–anal sex occurs in the pursuit of
one’s own sexual pleasure, as an act of physical and
emotional intimacy with one’s partner, or in defer-
ence to one’s partner’s requests (Maynard, Carballo-
Diéguez, Ventuneac, Exner, & Mayer, 2009). A
sample of urban, ethnically diverse emerging adult
men and women reinforced these results, describing
penile–anal sex as a means of increasing sexual plea-
sure in serious relationships (Carter, Henry-Moss,
Hock-Long, Bergdall, & Andes, 2010). Moreover, a
study using daily diaries found that penile–anal sex
is more likely among young women with greater
sexual interest on a specific day (Hensel et al., 2008,
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Life-Span Sexuality Through a Sexual Health Perspective
403
2010), whereas retrospective reports of a male part-
ner’s being in love (reciprocated or not) have been
associated with penile–anal sex in young and emerg-
ing adult women (Kaestle & Halpern, 2007).
In terms of partnership type, a variety of studies
(Fortenberry et al., 2010; McBride & Fortenberry,
2010; Misegades, Page-Shafer, Halperin, & McFar-
land, 2001) have suggested that penile–anal sex typ-
ically occurs more often in the context of main or
exclusive relationships, perhaps as a means of rein-
forcing existing trust and intimacy or expanding
one’s sexual behavior repertoire. Another study
noted that penile–anal sex with a casual partner was
more likely among Puerto Ricans than among Blacks
and among respondents ages 22 to 25 than ages 18
to 21, but noted no gender differences (Carter et al.,
2010). In contrast, Leichliter (2008) found that
penile–anal sex was more likely with a nonmonoga-
mous sexual partner. Little to no qualitative research
has examined heterosexual men’s motivations for
penile–anal sex, but a study of Black gay men found
that younger and less masculine men wielded less
power in relationships, making them more likely to
be the receptive partner (Fields et al., 2012). Other
qualitative work has challenged this idea (Hoppe,
2011), describing the different ways in which gay
men understand sexual pleasure in specifically
choosing a receptive role. For some men, pleasure
was defined in terms of the mental or emotional
pleasure of providing their partner physical plea-
sure; for others, it was the physical pleasure they
themselves experienced from being a receptive part-
ner. Finally, some men defined sexual pleasure as a
combination of mental and physical pleasure from
opting for a receptive role.
Behavioral patterns within relationships can also
influence the occurrence of penile–anal sex. For
example, among adolescent women, penile–anal sex
is more likely when a young woman has also had
penile–anal sex within the past week (Hensel et al.,
2008, 2010). Among adult women, current reports
of penile–anal sex are also linked to having engaged
in recent penile–anal sex (Misegades et al., 2001).
Moreover, some penile–anal sex practices take place
around the occurrence of vaginal sex. For example,
among both young men and young women, the
likelihood of penile–anal sex increases as they move
further in time from their first vaginal sex (Lindberg
et al., 2008), perhaps reflecting increasing comfort
with sexuality and desire to explore more sexual
behavior. Among adolescent girls (Hensel et al.,
2008, 2010) and adult women (Misegades et al.,
2001), current penile–anal sex is linked to reporting
vaginal sex on that same day, suggesting that indi-
viduals may integrate penile–anal sex into a larger
set of sexual behavior choices. Among gay men, age
is an especially prevalent factor in addition to part-
nership traits. One study in Australia reported that
older men had a less extensive range of anal practices
than younger men but switched more frequently
between insertive and receptive roles with regular
partners (Van de Ven, Rodden, Crawford, & Kip-
pax, 1997). Several qualitative studies have shown
that sexual intimacy is an especially important moti-
vating factor for older gay men (Murray & Adam,
2001; Wierzalis, Barret, Pope, & Rankins, 2006).
In summary, we have suggested that despite cul-
tural discomfort with the idea of penile–anal inter-
course, adolescents, adults, and older adults do
participate in penile–anal sex, both those in hetero-
sexual relationships and those in same-sex relation-
ships. Penile–anal sex can take on multiple
meanings for individuals, used in some instances as
substitute for vaginal sex, particularly under the
assumption it is a safer alternative in terms of preg-
nancy risk, or in the event that one member of a
dyad is experiencing menstruation. Penile–anal sex
may also occur in conjunction with other sexual
behaviors, such as vaginal sex, particularly as a
means of expressing intimacy or sexual pleasure.
CONCLUSION
In this chapter, we have used sexual health as an
organizing paradigm for a life-span perspective on
sexuality. This paradigm pushes an understanding
of sexuality beyond a simple focus on aspects of
reproductive health or sexual function, positioning
sexual health as a lifelong process by which sexual-
ity remains a primary aspect of identity, as well as a
core element in health and well-being, during every
life stage. We have suggested that this life-span
approach to sexual health necessarily engages the
multiple dimensions in which sexuality is organized
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Hensel and Fortenberry
404
and acknowledges the salience of these dimensions
from youth to old age, the continuity and change in
these dimensions in the face of new experiences,
and the connectedness of these dimensions, because
past experiences inform current and future experi-
ences. We have considered this perspective within
the context of two important aspects of lifelong sex-
ual development—partnering and sexual behavior.
Although this chapter synthesizes only a small body
of the available literature on both topics, we have
forwarded the argument that the formation of
important relationships, as well as the types of sex-
ual behaviors that occur inside (and outside) of rela-
tionships, are two threads by which sexual health is
expressed across different life stages.
In describing the contribution of partnering to
sexual health across the life span, we began with the
assertion that there have been incredible changes in
both the nature of intimate relationship formation
and the literature that describes them. We now have
a better appreciation of how the partnering process
varies in timing, sequence, and duration across life
span, and more important, we have an emerging
understanding of how each relationship creates a
context for the (re)organization of sexuality. Rela-
tionships in adolescence represent diversification,
not only in terms of their progression from friend-
ship groups to later romantic dyads but also in terms
of the formative sexual health skills they provide for
future sexual health. We additionally described how
romantic partnerships remain equally salient, as well
as important to sexual health, in adulthood and in
later life. A volume of literature has evaluated how
committed relationships in adulthood are important
sources of intimacy, communication, and sexual sat-
isfaction in both heterosexual and same-sex couples.
Likewise, emerging knowledge has suggested that
aging individuals, much as their adult peers, choose
a variety of relationship forms, deriving positive
benefits from them.
We also presented evidence for an evolving view
of how researchers think about what constitutes sex,
as a means of thinking more broadly about the behav-
ioral ways in which people choose to express their
sexuality. Although much of the cultural discourse on
sexual behavior places emphasis on penile–vaginal
sex, we suggested that a life course perspective must
recognize that people participate in many different
types of intimate contact with partners, in ways that
both include and exclude their genitals and in ways
that may voluntarily or involuntarily exclude specific
behaviors. Moreover, we forwarded the idea that
behavior is inexorably linked to the context in which
it is given meaning, with the same behavior assuming
vastly different meanings at different points in time
(see also Volume 2, Chapter 6, this handbook).
This summary has invoked only a small amount
of the available research on partnering and sexual
behavior. We suggest that amid a growing under-
standing of how partnering and sexual behavior dif-
fer across different life stages, the more important
focus moving forward regards truly understanding
the ways in which they are connected. For example,
much remains to be learned about the dynamics of
sexuality in the aging adult life stage. We know very
little about varying motivations for sexual behavior,
particularly how patterns vary as a function of race/
ethnicity or sexual orientation. This information is
important in being able to situate sexual health
toward the end of life with sexual health in the
beginning and middle points in life.
We also argue that a life span approach to sexual-
ity opens up important possibilities to articulate what
a lifelong developmental model of sexuality looks
like. We advocate for research that pushes beyond
arbitrary boundaries between life stages, explicitly
modeling individual aspects of sexual health as they
intersect with lifetime changes in relationships, new
and old behaviors, and other biological and social
characteristics. This research may include questions
on how the content and nature of current experiences
links to the ways in which people interpret and make
decisions about future experiences, how individuals
longitudinally balance positive aspects of sexuality
with an understanding of risk management, how
early sexual socialization influences individual beliefs
and partnership events as individuals enter adulthood
and old age, how old experiences become new again
as individuals interpret them in new contexts, or how
positive sexuality specifically links in the long and the
short term to more global aspects of physical and
mental health. We suggest that this more integrative,
developmental approach is in fact a necessary step in
encouraging research that normalizes and honors the
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Life-Span Sexuality Through a Sexual Health Perspective
405
importance of sexuality at all points during one’s life-
time, not only as a defining characteristic of human
identity but also as a core constituent of lifelong
health and well-being.
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