Lisa Kirsten Hunter
Existing models of behavioral risk reduction used in understanding sexual risk behaviors have been hampered by the lack of attention to gender (Amaro, 1995). Amaro states that behavioral models of HIV risk reduction have failed to consider a host of social factors that shape the reality of sexual risk behaviors and the potential for sexual risk reduction for women. The impact of gender roles on communication regarding sexuality and negotiation of safer sex has been largely ignored, yet there is evidence that this may be one of the most important variables in predicting condom use, particularly for women.
If a woman is protected against pregnancy, she and her partner may still be at risk for STD's, especially when using oral contraceptives as the only birth control method. Although this method offers relatively good protection against pregnancy, it offers no protection against STD's. Therefore, health professionals advocate the use of condoms to protect against pregnancy and disease. According to the Center for Disease Control (CDC), condoms are the sole physical barrier to the sexual transmission of HIV infection from men to women. In light of the rising rate of HIV infection in women, condoms are an important means of preventing the spread of HIV. Women now constitute the demographic group among whom AIDS is spreading fastest in the United States. By the end of June 1994, 401,749 cases of AIDS, 51,235 of which were in women, had been reported to the CDC (CDC, 1994).
A 1990 study based on random testing of blood samples from over 16,000 students at 19 colleges and universities in the United States confirmed the presence of AIDS on college campuses (Gayle, Keeling, & Garcia-Turnon, 1990). This study reported an incidence rate of 2 per 1,000. Extrapolated to the U.S. college population, the CDC estimates that between 25,000 and 35,000 female and male college students are infected with HIV.
Studies of college students' knowledge and their use of condoms have suggested that, although students are knowledgeable about preventing STD's and HIV infection, they do not utilize that knowledge (Blonna, Hayden, & Milcetic, 1991). One possible explanation may be that they lack the skills they need to properly use condoms (Campbell, Peplau, & DeBro, 1992; Carroll, 1991).
Knowledge of gender differences is particularly
relevant to the study of condom use. Unlike many health behaviors, condom
use is inherently interpersonal, typically involving explicit and implicit
agreement by both partners. Literature on gender roles and gender differences
in social behavior (Eagly & Wood, 1991)
suggests that males and females may enter sexual relationships with differing
expectations, attitudes, and habits with respect to AIDS-relevant condom
use. Eagly and Wood's (1991) gender role theory asserts that prevalent
gender stereotypes are, in effect, culturally shared expectations for gender
appropriate behaviors. These expectations influence males and females to
behave consistently with their gender roles. Accordingly, the female role
is characterized by communal qualities including kindness, compassion,
concern for the welfare of others, avoiding physical harm to oneself, and
a willingness to be influenced by others. Young women tend to view sex
in emotional rather than physical terms, and regard sexuality in the context
of relationships. The male role, in contrast, is characterized by qualities
including chivalrous helping or heroic helping, a willingness to take risks,
aggressiveness, and resistance to being influenced by others. If these
stereotypes are an accurate reflection of young adults in this culture,
then differences in sexual behavior may occur.
Effects of Gender on Condom Use
Carroll (1991) examined knowledge about AIDS, sexual behaviors, and reported behavior change in college students. The data for this analysis were collected by means of a questionnaire distributed to 195 female and male students enrolled in a random sample of courses at the University of Rhode Island. The three dependent variables were frequency with which condoms were used in the preceding year, frequency of coitus in the past year, and number of different sexual partners in the past year. Self-reported change in sexual behavior was measured by asking, "Has concern about AIDS caused you to change your sexual behavior in any way during the past year?" Knowledge about AIDS was measured by a 10-item scale.
There was no discernible relationship between knowledge about AIDS and the frequency with which condoms were reportedly used. For women, there was a relationship in the expected direction between claiming to have begun use of condoms and the frequency with which they were reportedly used. For men, being in an exclusive relationship was negatively associated with frequency of condom use and condom use was also negatively associated with attitudes toward premarital sex, i.e., those who were permissive reported having used condoms less frequently than others.
Although there was substantial evidence to suggest that increased knowledge about AIDS had led to changes in the sexual behaviors of at least some men, the evidence suggested little change among women. Knowledge of AIDS was not associated with increased condom use, less frequent sex, or with fewer partners. Moreover, even women who claimed to have changed their behavior differed from others only in the extent to which they reported using condoms. That is, women who reported becoming more selective in partners or engaging in sex less frequently in the past year reported as many partners and coital frequency in the past year as women who claimed no change. Further research is necessary to interpret these gender differences, in particular to understand why there was apparently so little relation between knowledge about AIDS, reported changes in behavior, and independent measures of those behaviors among women when the relationships were substantial among men.
Campbell et al. (1992) examined general favorability toward condoms and attitudes about specific features of condoms. Four aspects of condoms were selected: the effectiveness of condoms, the comfort and convenience of condoms, condom's interference with sexual pleasure, and the interpersonal consequences of discussing or using a condom. They hypothesized that men and women would differ on each of these four domains of attitudes about condoms. Participants were 393 undergraduate students (213 women, 180 men) from the University of California, Los Angeles. College students completed an anonymous 16-page questionnaire that included questions regarding demographic information, dating experiences, and sexual history.
Students' attitudes toward condoms were significantly related to gender. As predicted, women were consistently more positive about condoms than were men. Also as predicted, women were significantly more favorable than men about the comfort and convenience of condoms. Men were also more concerned than women about the effects of condoms on sexual sensations. Contrary to their predictions, women were more positive than men about the interpersonal aspects of condom use. Men were more concerned than women that condom use could create embarrassing or negative interpersonal exchanges. The gender differences obtained in this study suggest that men and women would respond differently to interventions designed to increase condom use.
Sacco, Rickman, Thompson, Levine, and Reed (1993) support the contention that men and women are still greatly constrained by traditional gender roles. They examined gender differences in AIDS-relevant condom attitudes, condom use behaviors, and relationships among attitudes and condom use behaviors. They recruited 248 undergraduates (65% females, 35% males) from introductory and advanced psychology courses and administered the Condom Attitude Scale (CAS) and Condom Use Questionnaire (CUQ). Despite having generally more favorable attitudes about condom use than did males on five of the eight CAS subscales, females had lower scores than males on Inhibition (i.e., were more inhibited about buying and possessing condoms). Consistent with their more inhibited attitudes, females reported being less likely than males to carry condoms, keep condoms at home, intend to carry condoms, and intend to keep condoms at home. It is noteworthy that females reported very low rates of these preliminary condom use behaviors, particularly with respect to past carrying and keeping of condoms.
The pattern of differences in attitude and preliminary condom use behaviors can be viewed from the perspective of gender role theory (Eagly, 1987), which argues that gender differences are due, in part, to the tendency for males and females to behave in accord with their respective gender roles. Females consistently reported more negative attitudes (i.e., greater inhibition) with respect to buying, carrying, and keeping condoms at home and were much less likely to engage in those behaviors. In contrast, females consistently exhibited more favorable scores on most other attitude subscales, including Self-Control, the subscale most predictive of condom use during intercourse. As suggested by gender role theory, these gender differences may reflect differing cultural expectations for male and female sexual behavior, which may play a role in AIDS-relevant condom use decisions among heterosexuals. As a result, females' more favorable attitudes about condom use are likely to have a muted effect on condom use decisions.
Jadack, Hyde and Keller (1995) further expanded on Eagly's (1987) articulation of social role theory as applied to gender roles. Participants were 141 women and 131 men enrolled in introductory psychology courses, who earned extra credit for participating. Participants completed an extensive survey that contained items regarding knowledge of HIV transmission and prevention, risk-taking behaviors with respect to HIV infection, and comfort with safer sex practices. Most of the items included in the questionnaire were developed as a result of a pilot study with a different group of college student volunteers (N = 122).
Gender differences measuring knowledge about sexual routes of transmission indicated a significant overall effect for gender. For most of the sexual behaviors listed, men reported less likelihood of transmission of HIV from risky sexual behaviors than women. That is, men were more likely to downplay the likelihood of transmission in comparison to women. Gender differences regarding transmission from intravenous routes were also significant. Men were more likely to downplay the likelihood of transmission in comparison to women.
The hypothesis predicting gender differences in frequency of sexual risk-taking behavior was supported. Of the risk factors listed, 43% of the women and 54% of the men reported either one or more risk factors. Three gender differences occurred. Consistent with the situational circumstances under which unprotected intercourse occurred, more women than men reported that intercourse without a condom occurred because of the presence of a long-term relationship. More men than women indicated that being under the influence of alcohol and other drugs, and running out of condoms were reasons for unprotected intercourse.
Testing for gender differences on the comfort with safer sex variables indicated a significant overall effect for gender. Women felt significantly more comfortable having sexual intercourse with only one partner, asking about past sexual history, and abstaining from sexual intercourse. Men felt more comfortable buying condoms. These results are consistent with recent related research (Sacco et al., 1993).
Hynie and Lydon's (1995) aim in studying the double standard (Men that have multiple partners are studs and women that have multiple partners are bad) was to investigate factors that might conflict with women's desire to use contraceptives. They hypothesized that women who provide a condom during an initial, casual sexual encounter and those who have unprotected sex will both be devalued, but in different ways. As a result of the double standard, Hynie and Lydon (1995) predicted that women who provide their own condom will be viewed less favorably. Women who have unprotected sex are breaking another social standard regarding sexuality, the importance of using contraception. However, women who violated this standard were predicted to be viewed as foolish, but not as immoral or unpleasant. Participants were recruited through classroom sign-up sheets that were distributed in several classes at McGill University. Analysis was based on 57 women who ranged from 17 to 30 years. Participants were informed they would read two diary entries, fill out some attitude questionnaires, and try to remember as much as they could about the entries. One entry was a distraught friend scenario. The other entry was a sexual encounter scenario about a young women named Anne-Marie. Three different contraceptive conditions of the sexual scenario were presented (women provided condom, man provided condom, no condom).
Participants assessed how appropriate the behaviors of Anne-Marie and her partner were. Anne-Marie's behavior was rated less appropriate if she had a condom than if her partner had a condom. Consistent with the double standard, women deemed the man's behavior as more appropriate when he provided the condom than when the woman provided the condom.
Participants then assessed how Anne-Marie, her partner, and they themselves felt about Anne-Marie's behavior after the evening's events. The woman-provided condom and man-provided condom condition revealed a tendency for participants to expect Anne-Marie to feel more negatively about her behavior if she provided the condom than if he did. Participants expected the male sex partner to feel less positively toward Anne-Marie when she provided the condom than when he provided the condom. Consistent with the other results, participants were less positive in the woman-provided condition than in the man-provided condom condition. No significant differences were found in the man-provided condition and no-condom condition. Thus, women may perceive more social pressure to appear sexually modest than to be sexually safe. As a result, women may acknowledge the importance of using condoms and actually wish to use them, but feel inhibited from initiating their use because of the double standard.
Gender differences in AIDS-related heterosexual concerns and sexual behavior with new sexual partners, with emphasis on condom use and subjective condom experiences, were assessed by a questionnaire entitled "Sexual Behavior Patterns", that was given to 155 heterosexual middle-class bar patrons (ranging in age from 18 to 51) in New York City (Juran, 1995). When asked how much they worried about AIDS in different partner situations, respondents answered that they worried most about acquiring AIDS when engaging in sex with a new partner. With new partners, women worried significantly more than did men.
Eighty-six percent of respondents reported that a concern about acquiring AIDS had an effect upon their sexual behavior in some way. More men than women stated that their sexual behavior had not been affected. The most frequent behavior strategies to avoid AIDS involved using condoms and decreasing casual sex. Comparing gender of respondents, more women reported working harder on relationships, giving up casual sex, not engaging in sex with new partners, and using spermicides. This can be explained by prevailing gender stereotypes about partner numbers and because women are at a greater risk of contracting AIDS, through intercourse.
Eighty-six percent of participants also reported that condoms gave them greater peace of mind, women more so than men. Although few people liked sex better with condoms, significantly more women stated this than men. Participants were also asked whether they expected to meet a new sexual partner at the bar and whether they were carrying a condom at the time. The results revealed that men had much greater expectations of meeting a new sexual partner than did women and men were more likely to carry a condom with them. This indicates that, although men like sex with condoms even less than women, men were more willing to carry condoms and presumably use them in order to engage in a new sexual encounter.
Taken together these studies suggest that women
are less likely to carry condoms, or to keep condoms at home and are less
comfortable than men buying condoms. Furthermore, women are likely to see
condom purchase and possession of condoms as more negative for women than
Intervention Studies With College Students
Franzini, Sideman, Dexter, and Elder (1990) employed behavioral techniques to teach assertive strategies designed to reduce the risk of contracting AIDS and to promote "safer-sex" behaviors. A total of 79 university students (38 male and 41 female) were included in the final data analysis. Control participants were required to attend a 50-min AIDS educational lecture and discussion conducted by a San Diego State University Health Service physician who specializes in preventative medicine. The experimental group attended the AIDS educational lecture and discussion and participated in three 1-hr training sessions which included assertiveness training, role playing, and behavior shaping.
There was a significant increase in rated assertiveness from pretest to posttest of the students who received the training compared to those who did not. Ratings of the assertiveness of the verbal content of the role plays revealed significant main effects for treatment on pretest and posttest. The experimental group scored significantly higher than the control group. A significant interaction effect was found for Gender x Scenario sequence at posttest. Regardless of treatment condition, and depending on which sequence they were asked to perform, the male subjects had a higher mean score on the posttest when given sequence BA (requesting the use of a condom, then requesting their partner's sexual history) than the female subjects. However, when given sequence AB (requesting their partner's sexual history, then requesting the use of a condom), the female subjects received a higher mean score than the males. On the assertive verbal component, the experimental male subjects performed better in sequence BA than the women and the women were rated more assertive in sequence AB than the men. These differences may be explained in terms of traditional gender roles. For example, condoms have historically been part of the male domain of responsibility, and women may not feel as comfortable or skilled with the issue.
Maslow, Corrigan, Pena, Calkins and Bannister (1992) evaluated the effectiveness of a psychoeducational treatment program for reducing high-risk human immunodeficiency virus (HIV) transmission behaviors as compared to an information-only group in a sample of 127 inpatients (gender not specified) in a drug abuse treatment unit. Subjects were randomly assigned to one of these interventions during the second week of the patients' program. The psychoeducation procedures included participatory modeling, goal setting, behavioral rehearsal (role playing), contracting, shaping and immediate reinforcement of positive responses, and practicing of coping responses to assist patients in recognizing, anticipating and preparing for cognitive, affective, and situational antecedents to HIV high-risk behaviors so that they may execute appropriate preventative action.
The information condition covered content similar to that provided in the psychoeducational condition. However, the information was presented by means of prerecorded audiovisual and printed materials with minimal patient-therapist interaction.
Interventions were assessed at pretest, posttest, and follow-up using the AIDS Risk Battery (ARB). The ARB assesses theoretically and empirically significant HIV risk, knowledge, attitudes, and behavioral dimensions associated with the Health Belief Model. The battery also included a hygienic needle sterilization demonstration and a condom use demonstration.
The effect of time was significant for all of the dependent variables at posttest and follow-up. These results indicate that both treatments promoted positive changes in reducing risk for HIV transmission at posttest that persisted over a 1-month period.
Regarding HIV knowledge, the psychoeducational group was significantly superior at follow-up but not at the posttest intervention. This suggests that the psychoeducational condition produces greater retention of factual material over time than the information condition. No gender differences were examined.
Cohen, Dent and MacKinnon (1991) developed, implemented and evaluated an intervention that focused on increasing familiarity and skills with condoms for women (N = 197) in a large urban STD clinic in Los Angeles. A condom skills education program was developed in which a health educator led a group discussion on condoms. The didactic portion emphasized three points about condoms: 1) that condoms should be made of latex, 2) that condoms should have a reservoir tip or space at end of condom, and 3) that condoms should be lubricated, preferably with spermicides. The health educator demonstrated how to put a condom on using her hand as a proxy phallus and stretched the condom in all directions to prove "one size fits all." Study participants consisted of all patients registered at the clinic for the session in which the health provider gave the presentation. Control subjects were those registered at the clinic on days when the presentation was not given.
One year after the presentation, medical records of the 192 subjects (97 treatment and 95 control) were reviewed. Risk factors for patient STD reinfection were examined by calculating the ratios of the odds for STD reinfection in the control and study group, as well as by demographic, historical, and contextual factors. Patients in the study group were only half as likely as control group patients to return to the clinic with a new STD. This study suggests that a group intervention promoting condom use among patients in an STD clinic may impact clinic return rates among patients with previous STD's. The strongest predictor of reinfection, those with prior STD infections, may be due to the establishment of high-risk sexual behaviors that are difficult to change. Because this group is at the highest risk for HIV infection, special efforts should be made to understand their sexual behaviors in order to help them make appropriate changes.
Maibach and Flora (1993) tested the social cognitive hypothesis that self-efficacy can be enhanced more effectively by symbolically modeling risk reduction information and by encouraging covert modeling/rehearsal than by the presentation of risk reduction information alone. One hundred and thirty-eight young unmarried women recruited from a number of sites in three California communities were randomly assigned to watch one of three videos: AIDS information only, information plus modeling, or information plus modeling with cognitive rehearsal. The information-only video consisted of scenes extracted from AIDS prevention videos available in commercial, government, and not-for-profit sector. The information plus modeling consisted of the same AIDS information plus 10 modeling episodes. The information plus modeling plus cognitive rehearsal included moderators that instructed the viewers on how to engage in cognitive rehearsal of the modeled information. They were told that at the end of each modeling episode, the clip would be followed by a 30-sec freeze-frame. During the freeze-frame participants were to covertly model/rehearse themselves in that scene.
Participants in the cognitive rehearsal condition increased their self-efficacy significantly more than participants in the modeling condition, whereas modeling participants increased their self-efficacy more than the information participants did. Two behavioral indicators changed significantly in the anticipated direction: the acquisition of condoms and the number of conversations with other women about condom use. In response to the cognitive rehearsal video, 26% more participants acquired condoms during the month of follow-up than during the month before the pretest, compared to a 6% increase among the modeling participants and no increase among information-only participants. Similarly, rehearsal participants had 1.26 more conversations with women about condoms during the follow-up period as compared with pretest modeling participants who had 0.12 more, and information participants who had 0.06 fewer. These findings suggest that cognitive rehearsal can be used to help viewers organize symbolically modeled information. In this fashion, the impact of the symbolic-modeling is effectively enhanced in terms of its ability to create sustained changes in self-efficacy and, thus, presumably behavior as well.
Ploem and Byers (1997) assessed the effects of two AIDS risk reduction interventions on heterosexual college women's AIDS-related knowledge, attitudes toward condoms, and actual condom use during a 1-month follow-up period. Participants were 112 unmarried heterosexual female college undergraduates who ranged in age from 18 to 32 years. Participants were randomly assigned to one of three groups. The Information only group watched a 15-min videotape adapted from the video AIDS: The New Facts of Life as well as through informational pamphlets and handouts. The combination group consisted of the information dissemination plus condom eroticization, and communication skills training. The eroticization and communication skills components were presented through a 10-min audio taped erotic account of a heterosexual couple integrating condom use into their sexual script. The third group was a pretest-posttest control group. Participants individually completed the AIDS Knowledge Quiz (AKQ), the Background Questionnaire, the Sexual Opinion Survey (SOS), Perceived Social Norms Scale (PSNS), the Attitude Toward Condom Scale (ATCS), the Condom Utilization Scale (CUS), and the Post-Experimental Questionnaire prior to the intervention and at 1-month follow-up.
The AKQ, PSNS, ATCS, and SOS results showed that individuals who held more positive attitudes towards condoms and who perceived condom use as relatively more normative among peers had used condoms on a greater percentage of intercourse occasions. ATCS scores indicated that the combination group had significantly more positive attitudes toward condoms than the information and control groups. A significant interaction between intervention and change in percentage of condom use was found. Participants in the Information only group were more likely than those in the other groups to have maintained their pretest percent of condom use during the 1 month follow-up.
The impact of the interventions on actual safer
sex behaviors was also evaluated. Participants in the combination group
were significantly more likely than participants in the other groups to
have increased the percent of intercourse occasions in which they used
condoms. However, the information only intervention did not result in behavior
change, despite increased knowledge. Thus, it appears that without the
facilitative attitudes and necessary skills acquired through the combination
intervention, information was not sufficient to produce sustained behavioral
Purpose and Hypothesis
Gender difference findings indicate that females benefit less than males from interventions to increase condom use but little attention has been given to determining why this is true. Several studies suggest that women are less likely to buy, carry, or keep condoms at home than men (Jadack et al., 1995; Juran, 1995; Sacco et al., 1993). This difference may make women less likely to benefit from condom use interventions. Therefore, the main purpose of my study was to determine if women exposed to interventions supportive of buying and carrying condoms would have more favorable attitudes toward condoms and higher actual condom use than women only exposed to general information regarding condom use.
The secondary purpose of the present study was to compare the effectiveness of covert modeling/rehearsal with covert modeling/rehearsal + role playing as condom buying/carrying interventions. I therefore compared these conditions: information (general, no condom buying/carrying), covert modeling/rehearsal (information plus covert modeling/rehearsal of condom buying/carrying), role play (information plus covert modeling/rehearsal and role play of condom buying/carrying). I hypothesized that participants in the covert modeling/rehearsal group and in the role play group would have a more favorable attitude towards condoms (as measured by the Attitude Toward Condom Scale) and higher actual condom use (as measured by the Informational-Motivational-Behavioral Skills Model and the Sexual History Questionnaire) than the participants in the information group. I also hypothesized that participants in the modeling/rehearsal group and in the role play group would have higher self-efficacy (as measured by the Condom Use Self-Efficacy Scale) than those in the information group. Previous research did not clearly indicate whether differences between the modeling/rehearsal and role play groups could be expected.
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