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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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